700371314

240202

[Lab data]

2023-10-05 BM Cytogenetics Lab Report

  • Chromosome Analysis
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 400
    • Chromosome Counts: 45-(5)、46-(15)、47-()、Other-() Total-(20)
    • Karyotype: 46,XY[15]
  • Interpretation:
    • Analysis of this bone marrow sample shows a male having 46,XY[15] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 20 cells analyzed, five cells with abnormal karyotypes [45,X,-Y; 45,XY,-7; 45,XY,-8; 45,XY,-13 and 45,XY,-18, respectively] were observed. No clinical significance can be ascribed to these non-clonal findings at the present time.
  • Note
    • ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-08-30 Anti-HBc Nonreactive
2023-08-30 Anti-HBc-Value 0.36 S/CO
2023-08-30 Anti-HBs 14.93 mIU/mL
2023-08-30 HBsAg Nonreactive
2023-08-30 HBsAg (Value) 0.39 S/CO
2023-08-30 Anti-HCV Nonreactive
2023-08-30 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-12-26 CT - chest
    • Clinical diffuse large B-cell lymphoma.
    • Small right lower lung nodule, stastionary.
    • Post-op at lumbar spine.
  • 2023-12-26 CT - neck
    • Negative result.
  • 2023-12-25 SONO - neck (lymph node)
    • Prominent musular density in left neck. Suggest clinical correlation.
  • 2023-11-13 Nasopharyngoscopy
    • crust over max opening, R otalgia, “mass over R acromion”
  • 2023-09-11 Patho - bone marrow biopsy
    • Bone marrow, biopsy — No evidence of large B-cell lymphoma with bone marrow involvement
    • The sections show normocellular marrow (20%). M/E ratio = 4:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. IHC, scattered small CD3+ T-cells and CD20+ B-cells in interstitium without lymphoid aggregates.There is no evidence of large B-cell lymphoma with bone marrow involvement can be identified in the sections examined.
  • 2023-09-07 MRI - larynx
    • Indication: Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+),Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+)
    • Findings
      • Severe mucosal thickening and air-fluid level in right maxillary sinus, indicating sinusitis.
      • A cyst-like lesion, about 35 mm x 30 mm x 7 mm, with air-fluid level inside and rim enhancement at right posterior cervical space, associating with diffuse faint enhancement in surrounding soft tissue. C/W abscess formation.
      • Multiple lymph nodes at both sides of the neck, with larger ones at right retropharyngeal region (20 mm) and left level II (15 mm).
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • No abnormality at parotid, submandibular and sublingual glands.
    • IMP:
      • Right maxillary sinusitis. Abscess formation at right posterior cervical space. Enlarged lymph nodes at right retropharyngeal region and left level II.
  • 2023-09-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Concentric LVH; LV diastolic dysfunction, Gr 1
      • Mild MR and trivial TR
      • Preserved RV systolic function
  • 2023-09-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 60 dB HL, LE 40 dB HL
      • R’t normal to severe SNHL
      • L’t normal to moderately severe SNHL
  • 2023-08-30 CT - abdomen
    • History: Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck s/p Neck LND
    • Prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Follow up is indicated.
  • 2023-08-21 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Right paranasal sinuses, multiple sinusectomy — Chronic rhinosinusitis
      • Tumor, R’t maxillary sinus, excision — Diffuse large B-cell lymphoma
      • Nasopharynx, R’t, biopsy — Chronic inflammation
      • R’t neck level 3 LNs, dissection — Negative for malignancy (0/2)
      • R’t neck level IIa, IIb, Va and tumor, wide excision — Diffuse large B-cell lymphoma
        • Vessel, IJV, ditto — Free of tumor invasion
        • SCM Muscle, ditto — Free of tumor invasion
      • R’t neck level Ib LN, dissection — Fat only
      • R’t retropharyngeal lymph node, ditto — Nerve ganglia and one tiny lymph node
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: neck dissection + multiple sinusectomy + wide excision + biopsy
      • Main location: (A) R’t neck and (B) R’t maxillary sinus
      • Specimen Size: (A) R’t neck level IIa, IIb, Va and tumor: 6.3 x 5.2 x 4.5 cm and SCM muscle 5.3 x 3.7 x 3.3 cm (B) R’t maxillary sinus: 2 x 1.5 x 0.7 cm
      • Tumor Site: (A) R’t neck and (B) R’t maxillary sinus
      • Tumor Size: (A) R’t neck: multiple, up to 4.7 cm and (B) R’t maxillary sinus: one piece, 2 x 1.5 x 0.7 cm
      • Right paranasal sinus: multiple small pieces, up to 1.3 x 0.7 x 0.6 cm
      • Nasopharynx: 2 small pieces, up to 0.4 x 0.3 x 0.2 cm
      • R’t retropharyngeal lymph node: 1.9 x 0.9 cm
      • Representative sections as A: R’t paranasal sinuses, B: R’t maxillary tumor, C: nasopharynx, D: R’t neck level III LNs, E1-E3: IJV, E4-E13: main tumor, E14-E18: SCM muscle, F: R’t neck level Ib LN and G: R’t retropharyngeal lymph node
    • MICROSCOPIC EXAMINATION
      • R’t neck level IIa, IIb, Va and tumor: diffuse large B-cell lymphoma shows diffusely large atypical lymphoid cells with prominent nucleoli. Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes
      • Right paranasal sinuses: chronic rhinosinusitis and bone
      • Tumor at R’t maxillary sinus: diffuse large B-cell lymphoma
      • R’t nasopharynx: chronic inflammation
      • R’t neck level 3 LNs: negative for malignancy (0/2)
      • R’t neck level Ib LN: fat only
      • R’t retropharyngeal lymph node: nerve ganglia and one tiny benign lymph node at peripheral fat tissue
  • 2023-08-08 PET
    • A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
    • Glucose hypermetabolism in the left pulmonary hilar lymph nodes. Inflammatory process is more likely. Howver, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild hypermetabolism in some mediastinal and right pulmonary hilar lymph nodes. Inflammation may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiologcal FDG accumulation may show this picture.
  • 2023-07-31 CT - neck
    • Multiple enlarged right posterior neck LAPs, up to 4.7 cm.
    • No obvious nasopharynx, hypopharynx or larynx mass.
    • Relative prominent right tonsil?
    • Suggest clinical correlation.
  • 2022-05-02 CT - abdomen
    • History: 20220414 Sono abd: Moderate fatty liver with fat sparing area; Hepatic lesion, r/o hemangioma, S5/6; Renal stone, right
    • Findings
      • Abdominal CT with and without enhancement revealed:
      • Hypervascular hepatic tumor at S5 of liver about 1.58cm in largest dimension is found.
      • Two subpleural nodules are found at right lower lobe about 0.3cm and right middle lobe about 0.28cm in largest dimension is found.
    • Imp:
      • Hepatic hemangiomas.
      • Subpleural nodules at right lung. Suggest follow up.
  • 2022-04-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 29) / 89 = 67.42%
      • M-mode (Teichholz) = 67.1
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Trivial TR
  • 2021-12-03 Neck soft tissue
    • Osteoporosis. Loss of nature lordotic curve. Spondylosis, esp C4-5-6.

[MedRec]

  • 2023-09-06 ~ 2023-09-28 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right maxillary Diffuse large B-cell lymphoma, Immunohistochemistry shows Bcl-2(+), Bcl-6(+), c-myc(weakly +, 10%) and MUM-1(+) s/p chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) from 2023/09/18~
      • Essential (primary) hypertension
      • Insomnia, unspecified
      • Herpes Zoster at the L3~L4
      • Constipation, unspecified
    • CC
      • For diffuse large B-cell lymphoma study and chemotherapy with R-DA-EPOCH (C1).
    • Present illness
      • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted. Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
      • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
      • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg(80 -> 77kg) for 1 month from 2023/08~2023/09.
      • Now, he was admitted to ward for diffuse large B-cell lymphoma study and prepare chemotherapy with R-DA-EPOCH (C1).
    • Course of inpatient treatment
      • After admitted, Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
      • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
      • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
      • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
      • Ultracet 0.5# po Q6H for pain control.
      • Allegra 1# po BID and Mycomb cream BID use for neck skin redness rash.
      • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
      • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6)(C1) from 2023/09/18~2023/09/23.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Lenograstim 250mcg SC QD from D7 2023/09/24~2023/09/28, 2023/09/29, 2023/10/01.
      • Insomnia with Eurodin 0.5# po HS.
      • Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm–improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream(self pay) TID TOPI use from 2023/09/07~2023/09/28.
      • Constipation with Sennoside 2# po HS, MgO 2# po Q6H and Bisadyl supp 1pill RECT PRNQD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/28 and OPD followed up later.
    • Discharge prescription
      • Eurodin (estazolam 2mg) 0.5# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNQ6H
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
      • Ulstop (famotidine 20mg) 1# BID
      • Through (sennoside 12mg) 2# HS
      • MgO 250mg 2# Q6H
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Granocyte (lenograstim 250ug) SC on 2023-09-29 and 2023-10-01
  • 2023-08-29 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Regimen, R-DA-EPOCH
      • Admission for Chest/Abd/Pelvis CT and H&N MRI, BM study (A+B+C), Heart Echo, 24 hours CCr and Audiometry
      • Port-A insertion by CS Chief Hsieh
  • 2023-08-18 ~ 2023-08-23 POMR Ear Nose Throat Su WanYu
    • Discharge diagnosis
      • Right neck mass status post right neck dissection on 2023-08-18.
      • Right maxillary sinus benign tumor status post navigation guide endoscopic sinus surgery on 2023-08-18.(8/24 patho: Diffuse large B-cell lymphoma)
      • Enlarged prostate without lower urinary tract symptoms
      • Localized enlarged lymph nodes
    • CC
      • Hoarseness over 6 months, right neck palpable mass noted for 3 weeks.
    • Present illness
      • This 64-year-old man denied of having chronic disease before. The patient suffered from hoarseness for over 6 months. He had been to our ENT OPD for check up, where vocal atrophy was told. Due to right neck palpable mass noted for 3 weeks, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. The neck CT on 2023-07-31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm.
      • The whole body PET scan revealed: 1. A prominent glucose hypermetabolic lesion in the right maxillary sinus. Primary malignancy in this region should be watched out. 2. Glucose hypermetabolism in a right retropharyngeal lymph node and in some right neck level II lymph nodes. Metastatic lymph nodes may show this picture.
      • Under the impression of right nasal lesion, right neck mass and right oropharyngeal lesion suspect malignancy, surgery of right neck dissection, nasopharyngeal lesion biopsy and right tonsillectomy for tissue prof were suggested. After well explanation about the surgical details, he was admitted for the operation.
    • Course of inpatient treatment
      • After admission, pre-op evaluation was done. The patient underwent the operation of right neck dissection, right maxillary sinus tumor excision, right multiple sinusectomy and right nasopharyngeal biopsy. The whole procedure prformed smoothly, and the patient tolerated the whole procedure well. Post the operation, a hemo-vac drain tube was placed. Neck wound covered with steri-stip.
      • Prophylatic antibiotic with cephalexin 1# po q6h, pain control with Acetal 1# po q6h, anti-cough with Medicon-A 1# po tid. Under daily wound care and medication treatment, the hemo-vac drainage amount decrease day by day. The hemo-vac drainage tube was removed on post op day-5.
      • There was no wound infection or wound active bleeding noted.The surgical pathology was pending. Under relative stable condition, he was discharge today with OPD follow up.
    • Discharge prescription
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
      • cephalexin 500mg 1# QID
      • Allegra (fexofenadine 60mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# QID
  • 2022-04-28 SOAP Gastroenterology Li ZhongXian
    • Prescription x3
      • Dexilant (dexlansoprazole 60mg) 1# QD
  • 2022-04-26 SOAP Cardiology Liu GuanLiang
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 0.5# QD

[consultation]

  • 2023-12-28 Orthopedics
    • Q
      • For mass behind right shoulder, nature??
      • This 64-year-old man patient suffered from hoarseness in 2022/09. He had been to our ENT OPD for check up, where vocal atrophy was told. Right neck palpable mass noted in 2023/07, he came to our ENT OPD foe help. At our Ent OPD, fiberscope revealed bulggin of right lateral pharyngeal wall, right tonsillar asymmetric hypertrophy with granular surface, biopsy was done; right neck level II a 4cm mass without tenderness.
      • The pathology revealed suspicious malignancy, we arrange a series of image survey. No chills with fever, night sweat and body weight loss was noted.
      • Neck CT on 2023/07/31 which revealed multiple enlarged right posterior neck LAPs, up to 4.7 cm. Whole body PET scan on 2023/08/08 revealed right maxillary sinus of primary malignancy with right retropharyngeal lymph node and in some right neck level II lymph nodes metastatic.
      • Modified Radical neck dissection, right, type II, excision of maxillary sinus tumor, right, multiple sinusectomy, right, navigation-guided endoscopic sinus surgery, nasopharyngeal biopsy, right and sinoscopy on 2023/08/18 and right maxillary sinus excision patholoy showed Diffuse large B-cell lymphoma, Immunohistochemistry shows CD3(-), CD20(+), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), c-myc(weakly +, 10%), Ki-67(80-90%), CK(-) and MUM-1(+) for tumor, indicates a case of diffuse large B-cell lymphoma, non-germinal center B cell subtype. Besides, IJV and SCM muscle are free of tumor invasion as well as 18 reactive lymph nodes.
      • Abdominal CT on 2023/08/30 showed prior CT identified hemangioma 1.58 cm in S5 of the liver is noted again, decreasing in size to 1.28 cm and blurring of the tumor border. Body weight loss 3kg (80 -> 77kg) for 1 month from 2023/08~2023/09.
      • Port-A catheter insertion on 2023/09/06. Larynx MRI on 2023/09/07 showed right maxillary sinusitis. Abscess formation at right posterior cervical space, enlarged lymph nodes at right retropharyngeal region and left level II.
      • PTA on 2023/09/07 showed R’t normal to severe SNHL and L’t normal to moderately severe SNHL.
      • 2D echo on 2023/09/07 showed M-mode(Teichholz) = 75, 1. Adequate LV systolic function with normal resting wall motion 2. Concentric LVH; LV diastolic dysfunction, Gr 1 3. Mild MR and trivial TR 4. Preserved RV systolic function.
      • Check 24hrs CCr. on 2023/09/07 showed 103.5 mL/min.
      • Hold chemotherapy with Herpes Zoster at the L3~L4 (rigth lower back skin redness rash 6cm - improving) with Valaciclovir 500mg 2# po TID from 2023/09/07~2023/09/18 and Acyclovir cream (self pay) TID TOPI use from 2023/09/07~2023/09/28.
      • Bone marrow study on 2023/09/11 showed no evidence of large B-cell lymphoma with bone marrow involvement.
      • Chemotherapy with R-DA-EPOCH (Rituximab 375mg, D1, Etoposide 50mg/m2 + Doxorubicin 10mg/m2 + Vincristine 0.4mg/m2 D2~D5, Prednisone 60mg/m2 po D1~D5, Cyclophosphamide 750mg/m2 D6) (C1 from 2023/09/18~2023/09/23, C2 on 2023/11/1, C3 on 2023/11/23). Now, he was admitted for chemotherapy with R-DA-EPOCH (C4).
      • We sincerely need your professional assistance!!
    • A
      • Dx: Diffuse large B-cell lymphoma
      • PE:
        • right shoulder bony prominence over the right superior border of scapular, nontender (discovered soon after the surgery)
        • ROM: intact
        • No skin lesions
      • CXR: No bony lesion over the scapular or clavile
      • CT: no visible bony lesion, osteolytic lesion over the CT
      • Plan:
        • Arrange OPD f/u at ORTH OPD
        • Active survillance, may arrange imaging again if persisited symptoms or enlargement
        • Conservative treatment with symptomatic treatment

[surgical operation]

  • 2023-08-18
    • Surgery
      • Modified Radical neck dissection, right, type II
      • Excision of maxillary sinus tumor, right
      • Multiple sinusectomy, right
      • Navigation-guided endoscopic sinus surgery
      • Nasopharyngeal biopsy, right
      • Sinoscopy
    • Finding
      • tumor over Right maxillary sinus
      • NP biopsy, right
      • huge neck mass with adheion to internal jugular vein and SCM muscle (unkown primary neck cancer? Occult metastasis from NPC? primary malignancy was from right maxillary sinus?)
      • Will check EBV and HPV status in the pathological specimen
  • 2021-10-12
    • Surgery
      • Arthroscopic rotator cuff repair, acromioplasty + biceps tenodesis        
    • Finding
      • left rotator cuff tear, 3x2 cm, over supraspinatus tendon
      • type II acromion with subacromial spur
      • significant synovitis and bursitis        
      • biceps tendon subluxation with partial tear

[immunochemotherapy]

  • 2024-02-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2024-01-12 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-12-22 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-11-23 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 40mg/m2 75mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1000mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-11-01 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2
  • 2023-09-18 - rituximab 375mg/m2 700mg NS 500mL 12hr D1 + etoposide 50mg/m2 90mg doxorubicin 10mg/m2 18mg vincristine 0.4mg/m2 0.7mg NS 500mL 24hr D2-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 + prednisolone 60mg/m2 100mg QD D1-5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + acetaminophen 500mg PO D1 + palonosetron 250ug D2 + aprepitant 125mg PO D1-3 + NS 250mL D1-2

Dose-adjusted R-EPOCH – (da)-R-EPOCH: Infusional etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) for non-Hodgkin lymphoma - 20231006 - https://www.uptodate.com/contents/image?imageKey=ONC%2F88411

  • Cycle length: 21 days.
  • Regimen
    • Rituximab
      • 375 mg/m2 IV
      • Dilute in NS or D5W to a final concentration of 1 to 4 mg/mL. Initial infusion: Start at 50 mg/hour; escalate in 50 mg/hour increments every 30 minutes to a maximum of 400 mg/hour, as tolerated. In the absence of an initial infusion reaction, for subsequent infusions, administer 20% of the total dose over the first 30 minutes and the remaining 80% over 60 minutes, as tolerated. The 90-minute infusion schedule should NOT be used in patients who have clinically significant cardiovascular disease or have a circulating lymphocyte count ≥5000/microL.
      • Day 0 or 1
    • Etoposide
      • 50 mg/m2 per day IV
      • Dilute a 24-hour supply of etoposide, doxorubicin, and vincristine in 500 mL NS and administer as continuous infusion over 24 hours per day through central venous line. Solution must be protected from light to maintain stability.
      • Days 1 to 4 (96 hours)
    • Doxorubicin
      • 10 mg/m2 per day IV
      • (together with etoposide)
    • Vincristine
      • 0.4 mg/m2 per day IV (dose not capped)
      • (together with etoposide)
    • Cyclophosphamide
      • 750 mg/m2 IV
      • Dilute with 250 mL NS or D5W and administer over 30 minutes.
      • Day 5
    • Prednisone
      • 60 mg/m2 orally twice daily
      • Administer first dose 30 minutes prior to chemotherapy on day 1.
      • Days 1 to 5
    • Granulocyte colony stimulating factor (G-CSF)
      • Start day 6
  • Pretreatment considerations:
    • Hydration
      • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day) and void frequently to reduce risk of hemorrhagic cystitis.
    • Emesis risk
      • MODERATE.
    • Prophylaxis for infusion reactions
      • Premedicate with acetaminophen and diphenhydramine, with or without an H2 receptor blocker, 30 minutes prior to at least the first and second infusions of rituximab.
    • Vesicant/irritant properties
      • Doxorubicin and vincristine are vesicants; avoid extravasation. Etoposide is an irritant.
    • Infection prophylaxis
      • Primary prophylaxis with hematopoietic growth factors is an essential component of this regimen. Regular or pegylated G-CSF may be used according to center policy. In addition, due to the risk of developing Pneumocystis jiroveci pneumonia and other opportunistic infections, consider the use of antimicrobial prophylaxis.
    • Dose adjustment for baseline liver or renal dysfunction
      • Adjustment of initial cyclophosphamide, doxorubicin, etoposide, and vincristine doses may be needed for preexisting liver dysfunction. In addition, dose adjustment of etoposide and cyclophosphamide may be required for renal dysfunction.
    • Hepatitis screening
      • Patients should be screened for hepatitis B and C prior to starting rituximab, and, if positive, considered for antiviral prophylaxis.
    • Cardiac screening
      • Doxorubicin is associated with cardiomyopathy, the incidence of which is related to cumulative dose. Assess baseline LVEF prior to initiation of therapy. Dose alterations should be considered for LVEF <50%, and doxorubicin therapy is contraindicated in patients with LVEF <30% at initiation, those with recent myocardial infarction, severe myocardial dysfunction, severe arrhythmia, or previous therapy with high cumulative doses of doxorubicin or any other anthracyclines.
    • CNS prophylaxis
      • The need for CNS prophylaxis is determined based upon the aggressiveness of the tumor reflected in the histology, organ involvement, and presence or absence of high risk features.
    • HIV screening
      • Patients should be screened for HIV prior to starting therapy. Consider reducing the initial dose of cyclophosphamide to 187 mg/m2 if CD4 <100/microL at diagnosis.
    • Neurotoxicity
      • Vincristine may cause constipation, and in severe cases, paralytic ileus. A routine prophylactic regimen against constipation is recommended in all patients receiving vincristine.
  • Monitoring parameters:
    • CBC with differential and platelet count twice weekly during treatment.
    • Assess basic metabolic panel (creatinine and electrolytes) and liver function prior to each subsequent treatment cycle.
    • Monitor cumulative doxorubicin dose. Reassess LVEF periodically during dose-adjusted EPOCH-R therapy, as clinically indicated.
    • Carriers of hepatitis B or C should be monitored for clinical and laboratory signs of active infection during and following completion of therapy. Rituximab should be discontinued if reactivation occurs.
  • Suggested dose modifications for toxicity:
    • Myelosuppression
      • Each new cycle should be delayed until ANC is >1000/microL and platelet count is >100,000/microL. Doses of etoposide, doxorubicin, and cyclophosphamide are adjusted based upon the nadir ANC and platelet counts:
        • If nadir ANC ≥500/microL, increase doses by 20% over preceding cycle.
        • If ANC <500/microL on one or two measurements, doses remain the same as preceding cycle.
        • If ANC <500 on ≥3 measurements or platelets <25,000/microL on one measurement, doses reduced by 20% from preceding cycle. Doxorubicin and etoposide doses are not reduced below starting dose.
    • Neuropathy
      • Dose adjustment of vincristine may be necessary if the severity of neuropathy persists or worsens. No specific guidelines are available for dose adjustments.
    • Hepatic dysfunction
      • Dose adjustments of vincristine may be necessary in the setting of liver toxicity.

==========

2024-02-02

Lab results from 2024-01-29 and 2024-02-01, along with vital signs readings in the TPR panel during the current hospital admission, remained predominantly normal. Examination of the HIS5 and PharmaCloud databases disclosed no medication discrepancies.

2024-01-15

[etoposide dose increase back to standard recommended]

If no other issues or reasons for caution are identified, increasing the etoposide dose back to the standard level of 50mg/m2 (from the current 40mg/m2) is recommended.

2023-12-25

[etoposide back to standard? clear coast, time to increase dose]

Recent lab tests (2023-12-22) show no obviously abnormalities.

While the etoposide dose has been reduced since 2023-11-23 (40mg/m2 75mg instead of the standard 50mg/m2 90mg), no adverse reactions of grade 2 or higher have been documented in the latest progress notes (2023-12-06 and current admission). In the event that absence of other concerns or contraindications, it is recommended to increase the etoposide dose back to the standard level.

2023-11-02

The R-DA-EPOCH regimen was initiated on 2023-09-18 (cycle 1) and continued on 2023-11-01 (cycle 2). Lab values for LDH and B2 microglobulin were not particularly elevated at the time of diagnosis with DLBCL and have remained relatively stable, showing no significant changes after administration of one cycle of R-DA-EPOCH.

  • 2023-10-27 B2-Microglobulin 2119 ng/mL

  • 2023-08-31 B2-Microglobulin 1899 ng/mL

  • 2023-10-26 LDH 179 U/L

  • 2023-10-03 LDH 299 U/L

  • 2023-09-06 LDH 200 U/L

During this hospitalization, the patient received the 2nd cycle of treatment. To date, there are no updated PET/CT imaging results following the initiation of therapy. The WBC DC in early Oct after the first cycle had shown single digit percentages of metamyelocytes, myelocytes, promyelocytes and atypical lymphocytes. However, in the most recent data from 2023-10-26, these numbers have dropped to zero.

WBC DC 2023-09-06 2023-09-18 2023-09-24 2023-09-26 2023-09-28 2023-10-03 2023-10-04 2023-10-09
Band 0.0 0.0 0.0 4.1 0.0 4.5 0.0 2.0
Neutrophil 73.5 54.5 57.2 92.9 80.4 53.9 66.7 59.4
Lymphocyte 16.7 34.6 38.3 2.0 15.7 22.5 18.2 24.7
Monocyte 8.1 7.7 1.0 1.0 1.9 6.7 10.1 9.9
Eosinophil 1.4 3.0 3.5 0.0 0.0 1.1 1.0 0.0
Basophil 0.3 0.2 0.0 0.0 1.0 0.0 0.0 0.0
Metamyelocyte 0.0 0.0 0.0 0.0 1.0 2.2 1.0 2.0
Myelocyte 0.0 0.0 0.0 0.0 0.0 4.5 3.0 2.0
Promyelocyte 0.0 0.0 0.0 0.0 0.0 2.3 0.0 0.0
Atypical Lymphocyte 0.0 0.0 0.0 0.0 0.0 2.3 0.0 0.0

No drug discrepancy is detected.

2023-10-06

No medication inconsistencies were identified in the review of both PharmaCloud and HIS5 records. Prophylactic G-CSF was prescribed after the patient’s first R-DA-EPOCH treatment on 2023-09-18, and only a brief period of leukopenia was observed.

700531243

240201

[exam findings] (not completed)

  • 2024-01-15

    • LVEF = (LVEDV - LVESV) / LVEDV = (37 - 13) / 37 = 64.86%
      • LVEF (%) = 64
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Mild AR; mild MR; moderate TR.
      • Sinus tachycardia during exam.
  • 2024-01-10 MRA - brain

    • Indication: Just receive C/T and discharged on 2024-01-09
      • General weakness, dizziness, vomiting, and left hand weakness started from 2024-01-09
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • foci with high SI on DWI and low SI on ADC in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere
      • some white matter gliosis in the bilateral frontal lobes; old lacunar infarction in the right basal ganglion; mild bilateral periventricular leukoaraiosis.
    • IMP:
      • recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere without evidence of acute hemorrhagic transformation.
  • 2024-01-10 CT - brain

    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • mild bilateral periventricular leukoaraiosis.
    • IMP
      • no acute intracranial hemorrhage
  • 2024-01-03 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 1400ml of yellow ascited were aspirated.
  • 2023-12-19 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 600ml of yellow ascites was aspirated.
  • 2023-12-05 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000ml of yellow ascites were aspirated
  • 2023-11-27 Body fluid cytology - asictes

    • 20 cc orange turbid ascites — Positive for malignancy
  • 2023-11-27 Ascites tapping

    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000 ml light orange color ascites was drained.
  • ……….

  • 2023-11-01 Patho - peritoneum biopsy

    • Peritoneum, biopsy — Consistent with metastatic ovarian serous adenocarcinoma
    • Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.5 x 1.5 x 0.6 cm. All for section in one cassette.
    • Sections show metastatic adenocarcinoma in fibrous tissue.
      • The immunohistochemical stain reveals PAX8(+). The result is consistent with metastatic ovarian serous adenocarcinoma.
  • ……….

  • 2023-09-14 Patho - ovary

    • Diagnosis:
      • Ovary, left, salpingo-oophorectomy —- high grade serous adenocarcinoma.
        • IHC stains: p53 (aberrant type), Napsin-A (-), WT-1 (focal +), ER (+, 5%, strong intensity), PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
      • Fallopian tube, left, salpingo-oophorectomy — free
      • if capsule intact during surgery pT1a pNx (if cM0), FIGO stage: IA, at least
      • if capsule ruptured during surgery pT1c1 pNx (if cM0), FIGO stage: IC1, at least
      • if capsule ruptured before surgery pT1c2 pNx (if cM0), FIGO stage: IC2, at least
    • Gross description:
      • Procedure - Left salpingo-oophorectomy: ovary: 11 x 9 x 2.3 cm opened. Tube: 5 x 0.3 x 0.3 cm intact.
      • Specimen Integrity-
        • Specimen Integrity of Right Ovary- no right ovary submitted.
        • Specimen Integrity of Left Ovary -Capsule opened. See comment.
        • Specimen Integrity of Right Fallopian Tube- no right fallopian tube submitted.
        • Specimen Integrity of Left Fallopian Tube- left tube intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement- Absent
      • Fallopian Tube Surface Involvement - Absent
      • Tumor Size - Greatest dimension (centimeters): 11 cm
        • Additional dimensions (centimeters): 9 x 3 cm
      • Sections are taken and labeled as: A1: tube; A2: ovarian wall; A3-6: solid part of left ovarian tumor.
    • Microscopic Description:
      • Histologic Type: Serous carcinoma
      • Histologic Grade - High grade
      • Implants (required for advanced stage serous/seromucinous borderline tumors only) - Not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not applicable
      • Largest Extrapelvic Peritoneal Focus (required only if applicable) - no tissue submitted
      • Peritoneal/Ascitic Fluid - Not submitted
      • Regional Lymph Nodes: No lymph nodes submitted
      • Additional Pathologic Findings - None identified
      • Comment(s) - Please correlate with operation note.
  • ……….

[MedRec]

  • 2024-01-11 ~ 2024-01-17 POMR Neurology Xu BoRen
    • Discharge diagnosis
      • Multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere, TOAST:4. Specific etiology, suspect cancer type
      • Modified ranking scale 1
      • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
      • Postprocedural pelvic peritoneal adhesions
      • Reflux esophagitis LA Classification grade A
      • Urinary tract infection (U/C no grew)
    • CC
      • generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday.
    • Present illness
      • This 68 y/o woman has a history of
        • left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
        • Postprocedural pelvic peritoneal adhesions
        • Reflux esophagitis LA Classification grade
        • Hypokalemia
        • Toxicoderma
        • Acute embolism and thrombosis of unspecified deep veins of right lower extremity under Eliquis 5 mg 1 tab BID.
        • massive ascites S/P abdominal tapping on 2023/11/27, 2023/12/5, 2023/12/19,
        • Cachexia.
      • She had received chemotherapy and was discharged on yesterday. However generalized weakness, vertigo, nausea and vomiting with left limbs clumsiness noted since yesterday. Hence she came to our for help 2024/01/10 afternoon.
      • Conscious remain clear, GCS E4V5M6, CNs: intact, MP: upper 5/4 lower 5/5, mild left dysmetria. NIHSS 000 000 1000 10000 (2).
      • Lab showed hyponatremia (Na 131), elevated D dimer 9414, CA-125 392.8 on 2023/12.
      • Brain CT showed no ICH.
      • Brain MRI showed multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
      • Thus she was admitted to our ward for further eveluation.
    • Course of inpatient treatment
      • After admisison, adequate hydration and continuted previous NOAC with Eliquis for DVT history.
      • Empirinic antibiotic with Flumarin day 7 for urinary tract infection, culture no grew.
      • PPI with Nexium for GERD, Hemoptysis since before, n’t progressive, high risk for ulcer.
      • Stroke risk factor survey showed No HTN, DM or Hyperlipidemia.
      • TCD/CCCD showed Increased PI in bilateral MCA, indicating distal stenosis.
      • Adequate total VA flow volume (280 ml/min).
      • 2D echo showed LVEF 64%, Mild AR; mild MR; moderate TR.
      • Sinus tachycardia during exam. Pending 24 hours holter.
      • We also maintenance rehab. program and well tolerance.
      • Only mild left hand clumsiness with weakness.
      • Regular schedule the chemotherapy also done during this admission on 2024/01/16.
      • Under the general condition stable, she is discharge on 2024/01/17 and will be followed up at OPD.
    • Discharge prescription
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Eliquis (apixaban 5mg) 1# BID
      • Eurodin (estazolam 2mg) 0.5# PRNHS if insomnia
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Uroprin (phenazopyridine 100mg) 1# TID
      • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 1# Q3D EXT
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • diphenidol 25mg 1# TID
      • morphine 15mg 1# PRNQ6H if pain
  • 2023-09-21, -06-15, -03-23, 2022-12-29, -10-06, -07-05, -04-12 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Insomnia, unspecified [G47.00]
      • Anxiety disorder, unspecified [F41.9]
    • Prescription x3
      • Valdoxan (agomelatine 25mg) 1# QN
      • Rivotril (clonazepam 0.5mg) 1# QN
  • 2023-09-13 ~ 2023-09-17 POMR Obstetrics and Gynecology Zen LunNa
    • Discharge diagnosis
      • Left ovarain tumor post Left salpingo-oophorectomy on 2023/09/13
      • Abdominal pain
    • CC
      • Lower abdominal pain since two months ago   - Present illness
      • This is a 68 y/o female paitent with the past histories of:
        • Anxiety disorder, unspecified
        • Insomnia, unspecified
        • Senile cataract s/p Intraocular lens on 2022/03/28 amd 2022/06/13
        • Age-related osteoporosis
        • Bilateral primary osteoarthritis of knee
        • Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee
        • Benign neoplasm of liver
      • She has felt lower abdominal pain since the middle of July. She first seeked for help at TuCheng Hospital and she was informed there was a uterine cyst that caused the pain. Under conservative treatments, she was in relatively stable conditions. Hereafter, on 09/11 she seeked for second help at TuCheng hospital due to the intermittent abdominal pain and the CT was done and revealed as the followings:
        • Uterine mass lesion ~11 cm in diameter with compression forward and causing bladder compression
        • Mild R’t hydroureter, RUQ surgical clip retension
      • This time, she sufferred from acute lower abdominal pain this morning and she was sent to our ER for help. At that time PE performed and showed without nauseau, vomitting, diarrhea, constipation, and fever.
      • Additionally, GYN Dr. Tseng was consulted with the first impression: pelvic mass 126*93mm, r/o teratoma or endometrioma with torsion. Hence, the patient is now under urgent surgical interventions to control her pain.
      • Menstrual histories:
        • G2P2A0 (NSD*2)
        • menopause at age of 48 years old.
    • Course of inpatient treatment
      • The patient was admitted on 2023/09/13 from ER with the symptom acute lower abdominal pain. After the consultation with Dr. Saing, a pelvic mass with 126x93mm was observed under the sonography and left salpingo-oophorectomy was scheduled on the same day under the impression of teratoma or endometrioma with torsion.
      • She underwent left salpingo-oophorectomy on 2023/09/13 and her postoperative course was uneventful. Her appetite was fine and she can void well.
      • The patient complained of intermittent abdominal wound pain and constipation. The analgesic medications and stool softener were given accordingly.
      • The vital sign was stable after surgery. She is discharged on 2023/09/17 and she will have her OPD follow-up next week.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Keto (ketorolac 10mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Rivotril (clonazepam 0.5mg) 1# QN
      • Valdoxan (agomelatine 25mg) 1# QN

[consultation]

  • 2024-01-12 Rehabilitation

    • A
      • Assessment
        • Recent ischemic infarction in the bilateral frontal lobes, left temporal lobe and left cerebellar hemisphere on 2024/01/10 with left hemiparesis
        • Left ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV, status post Left salpingo-oophorectomy on 2023/09/13 + Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01, immunohistochemical stain reveals PAX8(+)
      • Plan
        • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
        • Goal: Ambulation without device smoothly indoor; BADL ID.
        • Suggest tracking the food and water intake for 2-3 days. If there are issues with inadequate food or water intake or frequent choking, please notify CR 羅元廷(69028). Swallowing therapy would be arranged to increase swallowing ability and NG tube insertion is recommended.
        • The patient was educated about oral hygiene and safe eating, including proper positioning (must be seated upright), consuming small amounts at a time and ensuring no wet voice before taking the next bite.
  • 2024-01-10 Neurology

    • Q
      • General weakness, dizziness, vomiting , and left hand weakness started from 2024-01-09
    • A
      • O
        • Brain CT: no ICH
        • Brain MRI: multifocal cerebral infarcts involved cerebellum and bilateral cerebral hemisphere.
      • impression: multifocal cerebral infarcts, favor embolic stroke or Trousseau syndrome
      • suggestion:
        • give IV NS 40ml/hr, keep current medication including eliquis ( give eliquis 1# stat for evening dose)
        • give symptomatic treatment including promeran and cephadol
        • arrange neurology ward admission (Dr. Xu BoRen)
        • monitor vital signs/GCS/MP at least Q4H
        • tight control SBP < 220 or DBP < 120, tight control BS < 180
  • 2023-11-10 Dermatology

    • Q
      • for skin rash & icthing (2023/11/08 C/T with Abraxance/Carboplatin)
      • This 68-year-old woman, a patient of ovary cancer with peritonal seeding and liver mets S/P C/T on 2023/11/08. intermittent skin rash, icthing over whole body for days. anti-histamin was given but did not improve. We need expertise to evaluate her condition thanks!
    • A
      • This patient suffered from generalized erytematous papules on trunk and 4 limbs for days
      • Imp: Toxicoderma
      • Suggestion:
        • Zaditen (ketotifen) 1 / Bid
        • Xyzal (levocetirizine) 1 / Hs
        • Mycomb (triacinolone, neomycin, nystatin) 2 tubes / bid
  • 2023-11-02 Hemato-Oncology

    • A
      • This 68 year old woman is a case of newly diagnosis Ovarian high-grade serous adenocarcinoma with peritoneal carcinomatosis and liver metastases, pTxNxM1, Stage IV s/p Left salpingo-oophorectomy on 2023/09/13 and Diagnostic Exploratory Laparoscopy, peritoneal biopsy and ascites drainage on 2023/11/01. We are consulted for further treatment (neoadjuvant therapy).
      • Suggestion:
        • Consult GS for port A insertion if patient agree further treatment
        • Check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
        • Consider commercial gene test for HRD, BRCA (self pay) for further study
        • Carboplatin + Paclitaxel +/- avastin is indicated for this patient
        • We had well explaint to patient and her husband this afternoon. Patient also said she and her children will discuss with Dr Gao tomorrow morning.
  • 2023-10-26 Obstetrics and Gynecology

  • 2023-09-13 Obstetrics and Gynecology

[surgical operation]

  • 2023-09-13 - Op Method: Diagnosis: Left ovarian mass
    • Surgery: Left salpingo-oophorectomy
    • Finding:
      • Uterus: Avfl, normal size, grossly normal.
      • RAD: grossly normal.
      • LAD: one 1086 cm cystic lesion in the LOV with mucinous content, mild adhesion to left pelvic wall.
      • CDS: free of adhesion. No ascites.
      • Estimated blood loss: 50cc.
      • Blood transfusion: nil
      • Complication: nil

[chemotherapy]

  • 2024-01-16 - nab-paclitaxel 100mg/m2 137mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2024-01-09 - nab-paclitaxel 100mg/m2 137mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2024-01-02 - bevacizumab 15mg/kg 700mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 140mg 30min + carboplatin AUC 5 550mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-20 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-12-13 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-12-06 - bevacizumab 15mg/kg 800mg NS 100mL 1.5hr + nab-paclitaxel 100mg/m2 150mg 30min + carboplatin AUC 5 750mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-22 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-15 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-08 - nab-paclitaxel 100mg/m2 150mg 30min
    • dexamethasone 4mg + NS 250mL
  • 2023-11-07 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2024-02-01

[evaluating Avastin’s risks: cerebral infarcts and bleeding concerns]

Avastin (bevacizumab) has been linked to venous thromboembolism (grades 3/4: 5% to 11%; 2024-01-31 D-dimer 7060 ng/mL FEU) and hemorrhage (grades >=3: <=7%; including major hemorrhage). Given that this patient recently experienced multifocal cerebral infarcts affecting the cerebellum and bilateral cerebral hemispheres in early to mid-January 2024, it is crucial to exclude the possibility that these infarcts may have been induced by the medication prior to next administration.

Additionally, recent lab data indicated rising CA125 and CA199 levels, warranting close observation and subsequent follow-up.

  • 2024-01-30 CA125 (NM) 719.6 U/ml

  • 2024-01-02 CA125 392.8 U/mL

  • 2023-12-13 CA125 159.2 U/mL

  • 2024-01-30 CA199 (NM) 1468.90 U/ml

  • 2023-12-13 CA199 333.96 U/mL

  • 2023-11-27 CA199 161.03 U/mL

700941015

240131

[MedRec]

  • 2024-01-30 SOAP Medical Emergency Li XuanQing
    • O
      • Abdomen: soft, RLQ tenderness, hyperactive bowel sounds
    • A
      • Preliminary impression: K35.80 Unspecified acute appendicitis
    • Prescription
      • Laston (ketorolac) 30mg ST IVP
      • Flumarin (flomoxef sodium) 1000mg ST IVD
      • Laston (ketorolac) 30mg ST IVD slow drip > 10 min
      • Despas (hyoscine-N-butylbromide) 20mg ST IVD slow drip > 10min
      • NS 500mL ST IVD
  • 2023-10-27 SOAP Metabolism and Endocrinology Qiu QuanTai
    • S: T2DM since about 35 Y/O
    • Prescription x3
      • Jardiance (empagliflozin 10mg) 1# QD
      • Uformin (metformin 500mg) 2# BIDAC
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QDAC
      • Blopress (candesartan 8mg) 1# QD
  • 2019-12-26 SOAP Metabolism and Endocrinology Zhang YaLi
    • Diagnosis
      • Type 2 diabetes mellitus without complications [E11.9]
      • Hyperlipidemia, unspecified [E78.5]
    • Prescription x3
      • Jardiance (empagliflozin 25mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Amepiride (glimepiride 2mg) 0.5# QDAC
      • Uformin (metformin 500mg) 1# BID

[surgical operation]

  • 2024-01-30
    • Surgery
      • laparoscopic appendectomy        
    • Finding
      • diated appendix
      • pus ccumulation in appendix
      • rupture (-)
      • fecalith (-)
      • ascites (-)

==========

2024-01-31

[reconciliation]

No medication discrepancy identified in Stazolin (cefazolin) 1000mg Q8H IVD and metronidazole 500mg Q6H IVD after appendectomy.

701340072

240131

[exam findings]

  • 2024-01-29 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
      • Modereate ascites is found.
      • Several low density lesions are found at both lobes of liver with marginal enhancement and loss of surface integrity at S5. Multiple metastatic tumor with probably previous tumor rupture is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • The portal vein and IVC are patent.
      • The stomach, colon and pancreas are intact.
    • Imp:
      • Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
  • 2024-01-29 KUB
    • Compression fracture of L1 vertebral body
    • marginal spurs of multiple vertebral bodies due to spondylosis.
    • increased air in nondistended loops of small bowel over RUQ, could be paralytic ileus

[MedRec]

  • 2024-01-29 SOAP Medical Emergency Li XuanQing
    • S
      • Abdominal distension and pain 1 week
      • constipation in the first 2-3 days then few stools noticed
      • no fever, no chest pain, no back pain
      • no N/V, no diarrhea, no tarry stool, no dysuria
      • Past History: HBV carrier
      • Surgical history: denied abd OP
      • Drug allergy: NKDA
    • O
      • Vital signs: BP:134/80; HR:106; BT:35.7’C; RR:18;
      • Con’s:E4V5M6
      • SpO2:99%
      • Conscious: clear and oriented
      • HEENT: pink conjunc, anicteric sclera
      • BS: bil. symmetric expansion
      • Heart: RHB
      • Abdomen: distended, diffuse tenderness, no rebound tenderness, no muscle guarding
      • Ext: freely movable, no pitting edema
    • A/P
      • Preliminary impression: R10.9 Unspecified abdominal pain
      • 2024/01/29 09:04 WBC = 10.38 x10^3/uL;
      • 2024/01/29 09:16 Bilirubin total = 2.11 mg/dL;
      • 2024/01/29 09:16 CRP = 11.3 mg/dL;
      • 2024/01/29 09:16 Creatinine = 0.62 mg/dL;
      • 2024/01/29 09:16 ALT = 54 U/L;
      • 2024/01/29 10:43 Bilirubin direct = 1.11 mg/dL;
      • 2024/01/29 10:43 r-GT = 1054 U/L;
      • 2024/01/29 10:43 Alkaline phosphatase = 402 U/L;
      • 2024/01/29 10:43 AST = 56 U/L;
      • 2024/01/29 CT: ABD — whole abdomen, Pelvis (with and without contrast)
        • Imp: Multiple hepatic tumors with bone meta, the origin should be further investigated. HCC is less likely.
    • Prescription
      • TaiTa No.5 Inj (electrolyte solution) 1000mL ST IVD
      • Flumarin (flomoxef sodium) 1000mg ST & Q8H IVD
      • NS 1000mL ST IVD
      • Tramtor (tramadol) 100mg ST IVD
      • Imperan (metoclopramide) 10mg ST IVD

==========

2024-01-31

[reconciliation]

The patient presented to our emergency department with a week-long history of abdominal distension and pain. CT imaging revealed multiple hepatic tumors and bone mets, necessitating further investigation to determine the primary source. Lab tests highlighted abnormalities in liver function.

  • 2024-01-29 Bilirubin direct 1.11 mg/dL
  • 2024-01-29 r-GT 1054 U/L
  • 2024-01-29 Alkaline phosphatase 402 U/L
  • 2024-01-29 AST 56 U/L
  • 2024-01-29 Bilirubin total 2.11 mg/dL
  • 2024-01-29 CRP 11.3 mg/dL
  • 2024-01-29 ALT 54 U/L

Ongoing management includes hydration, analgesics, electrolyte supplementation, diuretics, and gastrointestinal motility-enhancing agents. A review of the PharmaCloud database found no discrepancies in medication administration.

701507492

240130

[lab data]

2024-01-22 HBV DNA PCR (Quantitative) 246 IU/mL

2024-01-20 HBeAg Nonreactive 2024-01-20 HBeAg Value 0.361 S/CO

2024-01-11 HBsAg (NM) Positive 2024-01-11 HBsAg Value (NM) 1660.000 2024-01-11 Anti-HCV (NM) Positive 2024-01-11 Anti-HCV Value (NM) 57.800 2024-01-11 Anti-HBc (NM) Positive 2024-01-11 Anti-HBc Value (NM) 0.007 2024-01-11 Anti-HBs (NM) Negative 2024-01-11 Anti-HBs value (NM) <2.000 mIU/mL

[exam findings]

  • 2024-01-04 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2024-01-04 SONO - abdomen
    • Indication: Cancer evaluation
    • Symptoms:
      • Liver
        • Coarse liver parenchyma with uneven surface.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • Splenomegaly
    • Diagnosis:
      • Liver cirrhosis
      • Status post cholecystectomy
      • Splenomegaly
    • Suggestion:
      • Check HBsAg, anti-HBc, anti-HCV, a-fetoprotein
      • Regular GI OPD follow up after discharge
  • 2024-01-03 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the lower L- spine, bilaterla shoulders, S-I joints, hips, and knees.
  • 2023-12-25 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei and syncytial growth pattern. Keratin formation is absent. Tumor necrosis and inflammatory exudate are present.
  • 2023-12-22 CT - temporal bone HRCT (without contrast)
    • Indication: left otorrhea on and off for one year
    • Without-contrast high-resolution CT scan of temporal bones with 1-mm axial and coronal images reveals:
      • Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM.
      • Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC.
      • Tubular calcification along bilateral intracranial ICAs.
    • IMP:
      • Suspected advanced NPC. Suggest further evaluation.
      • Left COM and mastoiditis.
  • 2023-12-22 Nasopharyngoscopy
    • Findings
      • left facial tender
      • HRCT showed left NP swelling
    • Diagnosis/Conclusion
      • Npscope: left NP swelling tumor, s/p biopsy
  • 2023-12-11 Ear Nose Throat Hearing Test
    • Tymp:
      • RE type Ad; LE perforation?
    • ART:
      • RE ipsi absent, contra CNT.
      • LE ispi CNT, contra absent.
    • PTA:
      • Reliability FAIR
      • Average RE 45 dB HL; LE 85 dB HL.
      • RE normal to profound HL.(1k,4k Hz masking dilemma)
      • LE severe mixed type HL.

[MedRec]

  • 2024-01-10 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S
      • pre-RT dental extraction
    • O: the patient came for dental evaluation before RT of NPC.
      • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
      • A: Tooth 11,14,15,32: retained root
      • P: Suggest extraction of tooth 11,14,15,31,32 and 41 before RT.
    • A
      • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
    • Plan:
      • Explain the risk/benefit of the treatment to the patient
      • Sign informed consent.
      • Block anesthesia of anterior mandible.
      • Complicated extraction of tooth 31,32 and 41
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and Amoxicillin.
      • Teach the patient how to do home care and OPD follow-up.
      • Next visit for stitches removal.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • Actein (acetylcysteine 200mg) 1# TID
      • amoxicillin 250mg 2# Q8H
  • 2024-01-02 ~ 2024-01-05 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Nasopharyngeal squamous cell carcinoma, stage cT4N1M0, undifferentiated type.
    • CC
      • Intermittent left otorrhea for 1 year.
    • Present illness
      • This is a 68-year-old man with underlying hypertension, coronary artery disease and diabetes mellitus. he had noticed left otorrhea on and off for about one year. The patient visited local clinic, but the symptom didn’t subside despite medical treatment. The patient then visited our OPD where initial local finding showed right intact eardrum left tympanic membrane perforation with acute infection.
      • Antibiotic of Curam and Earflo were given with mild improvement.
      • Also, audiometry revealed left side mixed type hearing loss.
      • Microscope revealed left chronic otitis media with middle ear polyp.
      • Hence HRCT was arranged to evaluate the middle ear condition. However, the report showed not only left COM with mastoiditis but also diffuse soft tissue at left nasopharynx and density associating multiple bony subsite destruction.
      • Subsequent nasopharynoscope revealed left nasopharynx swelling tumor of which the biopsy report showed nasopharyngeal carcinoma.
      • Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up. 
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up.
      • Nasopharynx MRI showed cT4N1MX.
      • Abdominal sonography showed no prominent metastasis.
      • Whole body bone scan showed faint hot spots in both rib cages, and increased activity in the right femoral shaft which suggested further follow-up.
      • OS, radio-oncologist, hematologist were consulted for evaluation.
      • Under relative stable condition, the patient was dishcarged with OPD follow up.

[consultation]

  • 2024-01-05 Hemato-Oncology
    • Q: same content in the consultation to Radiation Oncology
    • A
      • Dear doctor: This 68 year old man is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA). We are consulted for CCRT.
      • Please arrange port A insertion. And check HBsAg, Anti HBc, Anti HBs, Anti HCV. Thanks for your consultation.
      • Arrange our OPD after discharge.
  • 2024-01-05 Radiation Oncology
    • Q
      • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma.
      • He had undergone several study for tumor staging.
        • Bone scan survey report was currently pending. (Initial interpretation seemed to be fair.)
        • MRI showed cT4N1Mx disease with intra-cranial invasion.
        • Abdominal echo showed no evidence of liver metastasis.
      • For the above impression, we would like to ask your expertise to guide our CCRT treatment plan. Thx!!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to nasopharyngeal carcinoma.
        • PI: According to the patient’s statement, he suffered fro diplopia, left facial focal numbness, occasional stuffy nose, or epistaxis, and hearing impairment for an uncertain period.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (+)
        • Previous RT Hx: (-)
      • O: ECOG: 0
        • PE: neck and bil SCF: neg; left lateral eye fixation; left facial focal numbness, left side hearing impairment.
        • NP scopy (2023-12-22): left NP swelling tumor , s/p biopsy
        • CT scan of temporal bone (2023-12-22): 1. Soft tissue opacification in left mastoid air cells and right middle ear cavity, indicating mastoiditis and COM. 2. Diffuse soft tissue density associating bony destruction involving left nasopharynx, clivus, sphenoid sinuses, pterygopalatine fossa, inferior orbital fissure, foramen ovale and foramen lacerum. R/O advance NPC. 3. Tubular calcification along bilateral intracranial ICAs. Imp: (1)Suspected advanced NPC. Suggest further evaluation. (2)Left COM and mastoiditis.
        • Pathology (S2023-25765, 2023-12-26): Nasopharynx, left, biopsy – Non-keratinizing squamous cell carcinoma, undifferentiated type.
        • CXR (2024-01-02): No cardiomegaly. No active lung lesion. Tortuosity of the aorta. Degenerative joint disease of T-spine with marginal osteophytes.
        • Bone scan (2024-01-03): Faint hot spots in both rib cages, and increased activity in the right femoral shaft, U/3, the nature is to be determined (post-traumatic change or other nature ?),
        • Abd sono (2024-01-04): Liver cirrhosis. Status post cholecystectomy. Splenomegaly.
        • MRI of nasopharynx (2024-01-04): T4 (intracranial, cranial nerves involvement; N1M0, stage IVA
      • A: Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, stage cT4N1M0 (stage IVA)
      • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4N1M0 (stage IVA)
        • Goal: curative
        • Treatment target and volume: nasopharyngeal tumor, peripheral involved, and bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor and involved nodal lesions. The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of pre-RT dental evaluation and management.
  • 2024-01-04 Oral and Maxillofacial Surgery
    • Q
      • Dear doctor, this patient was a newly-diagnosed case of nasopharyngeal carcinoma, he was admitted for tumor staging and would receive examination schedule as following: Bone scan: 1/3 1200, Abd sono: 1/4 1030, MRI: 1/4 1240.
      • Since the patient would receive radiation therapy as primary treatment modality, we would like to sincerely ask for your expertise to evaluated the patient’s dental condition and perfomed tooth extraction if needed. Thx!!
    • A
      • Dear doctor, the patient came for dental evaluation before RT of NPC.
      • O: Tooth 11,14,15,32: retained root, food deposition with local inflammation, poor prognosis
      • A: Tooth 11,14,15,32: retained root
      • P: Suggest extraction of tooth 11,14,15,32 before RT.

[radiotherapy]

[chemotherapy]

==========

2024-01-30

[prophylactic nucleoside analogues prescribed for this HBV carrier, silymarin may also be considered.]

The presence of detectable HBV DNA PCR, positive HBsAg, and anti-HBc positivity in recent lab results warrants consideration of pre-emptive antiviral nucleoside analog therapy before commencing chemotherapy to mitigate the risk of HBV reactivation. Self-carried Vemlidy (tenofovir alafenamide) has been prescribed with no discrepancy identified.

Since elevated AST, ALT and direct bilirubin were also noted, the addition of BaoGan (silimarin) could be considered optionally if no contraindication exists.

701511954

240130

{donor}

[MedRec]

  • 2024-01-29 ~ 2024-01-30 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Other blood donor, stem cells
    • CC
      • for Peripheral blood stem cell collection
    • Present illness
      • This is a 37-year-old female without any past medical history. She had been selcected for HSCT donor at almost one year ago.
      • This time, she was admitted for Peripheral blood stem cell, and DLI to the recipient.
    • Course of inpatient treatment
      • After being admitted, consult Anesthesia Department for A-line catheter inserting at left radial artery, Vitacal kept injection for prevention Hypocalcemia first. And she received the peripheral blood was circulated and collected the stem cells. After 16+6 liters of peripheral blood was circulated and collected the stem cells, adequate number of CD34+ cell were collected according to the recipient weight (Total CD34+ cell: 152.419*10^6). She was discharged at today with no specific condtion.
  • 2024-01-16 SOAP Hemato-Oncology He JingLiang
    • S
      • BMT/HSCT donor for pre-donation evaluation.
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: no medicine allergy history.
      • Travel history: no recent travel history.
    • O
      • Skin: unremarkable.
      • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
      • Neck: soft and supple, no jugular vein engorgement
      • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
      • Heart: regular heart beat, no murmur
      • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
      • Back and spine: no deformity, no knocking pain at both CV angles
      • Extremity: free movable, no deformity, warm and pink in color
      • Digital examination: not done
    • Diagnosis
      • Bone marrow donor [Z52.3]

701513098

240130

{bone marrow donor}

[MedRec]

  • 2024-01-30

  • 2024-01-23 SOAP Hemato-Oncology He JingLiang

    • S
      • BMT/HSCT donor for pre-donation evaluation.
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: no medicine allergy history.
      • Travel history: no recent travel history.
    • O
      • Skin: unremarkable.
      • HEENT: no deformity, no icteric sclera, no anemic conjunctiva, no visual or auditory deficit
      • Neck: soft and supple, no jugular vein engorgement
      • Chest: symmetrical, no deformity, clear breathing sound, bilaterally
      • Heart: regular heart beat, no murmur
      • Abdomen: soft and flat, no palpable liver and spleen, no inguinal LN enlargement
      • Back and spine: no deformity, no knocking pain at both CV angles
      • Extremity: free movable, no deformity, warm and pink in color
      • Digital examination: not done
    • Plan
      • arrange admission
    • Diagnosis
      • Bone marrow donor [Z52.3]

700146860

240129

[exam findings] (not completed)

  • 2023-12-14, -10-25, -04-06 EGD
    • Findings
      • Esophagus
        • Minimal mucosa break < 5mm was noted at EC junction.
      • Stomach
        • A huge ulcerative, fungating tumor with necrotic tissue and ozzing at distal stomach, almost occupied whole antrum, s/p hemostasis with Argon plasma coagulation.
        • Coffee ground content was noted at stomach.
    • Diagnosis:
      • Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
      • Reflux esophagitis LA Classification grade A (minimal)
    • Suggestion:
      • PPI usage
  • 2023-05-17 SONO - abdomen
    • Findings
      • Liver
        • Homogeneous echotexture of liver parenchyma. A 0.8 cm hyperechoic mass at rt ant seg.
        • A 0.45cm anechoic lesion was noted at S2.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • No splenomegaly
    • Diagnosis:
      • Liver cyst
      • Hepatic tumor R/O hemangioma
  • 2022-11-21 PD-L1 IHC
    • Cellblock No. S2022-19870
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
      • Combined Positive Score (CPS): 5%
  • 2022-11-21 PD-L1 (22C3)
    • Cellblock No. S2022-19870
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= 1 and < 10
      • Combined Positive Score (CPS): 5%
  • 2022-11-21 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Tumor type: adenocarcinoma
    • Tumor location: stomach
    • Testing assay: SP142 Assay (Ventana)
    • Testing platform: BenchMark ULTRA
    • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
    • Control slide result: [V]Pass, [ ]Fail
    • Adequate tumor cells present (>= 50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC >= 5% and < 50%
        • Percentage of PD-L1 expressing tumor cells (%TC): 5%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >= 1% and < 5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-11-11 Patho - stomach biopsy
    • Stomach, low body and antrum, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of tubular adenocarcinoma of the gastric tissue characterized by tumor cells arranged in tubular, fused glandular or subtle cribriform pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma.
  • 2022-11-11 EGD
    • Indication: UGI bleeding
    • Findings
      • Esophagus
        • Mucosa break < 5mm was noted at EC junction.
      • Stomach
        • One large semi-annular ulcerative tumor with elevated and nodular margin was noted at low body and antrum. One hemoclip was in-place. One exposed vessel was noted on the ulcer base, s/p hemostasis with argon coagulation plasma, s/p biopsy*8.
    • Diagnosis:
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with APC and biopsy*7
      • Reflux esophagitis LA Classification grade A
    • Suggestion:
      • High dose PPI*3 days
  • 2022-11-10 CT - abdomen
    • History and indication: suspect gastric cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of gastri antrum and lower gastric body with a big ulcer, adjacent fat stranding and regional LAP.
      • Liver and renal cysts (up to 1.4cm). Left liver hemangiomas (6mm, 7mm). Accessory spleen at LUQ.
      • Hyperplasia of left adrenal gland.
      • A nodule (2.5mm) at LUL.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P NG tube indwelling.
      • Degeneration and spondylosis of L-S spine.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N3a(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
  • 2022-11-10 SONO - abdomen
    • Findings
      • Liver
        • Homogeneous echotexture of liver parenchyma.
        • A 0.45cm anechoic lesion was noted at S2.
      • Kidney
        • A 1.91cm anechoic lesion was noted at right kidney.
        • A 0.86cm anechoic lesion was noted at left kidney.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
    • Diagnosis:
      • Liver cyst, S2
      • Renal cyst, both kidney
  • 2022-11-08 EGD
    • Diagnosis:
      • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
      • Reflux esophagitis LA Classification grade A
      • Incomplete study
    • Suggestion:
      • High dose PPI*3 days
      • NG tube for decompression
      • Admission for UGI care and malinancy work-up

[MedRec]

  • 2023-12-13 ~ 2023-12-18 POMR Gastroenterology Chen JiangHua

    • CC
      • tarry stool passage for days
    • Course of inpatient treatment
      • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
      • Blood was transfused for the management of anemia.
      • Upper G-I panendoscopy was performed and revealed Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC; Reflux esophagitis LA Classification grade A (minimal).
      • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/12/18 and GI OPD Follow-up would was arranged later.    
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Trand (tranexamic acid 250mg) 1# BID
  • 2023-10-20 ~ 2023-10-26 POMR Gastroenterology Chen JiangHua

    • CC
      • tarry stool passage for days
    • Present illness
      • This time, she suffered from tarry stool passage for days. General malaise was noted. She denied chest tightness/pain, diarrhea/constipation, dysuria/frequency found. No TOCC history was noted. She was brought to our GI OPD for help. At GI OPD, the laboratory data showed anemia (Hb: 5.8 g/dL -> 6.4g/dL post LPRBC 2 Units), no leukocytosis. PE showed pale conjunctiva, no icteric sclera, soft abdomen, no leg pitting edema.
      • Under the impression of favor gastric cancer with bleeding. She was admitted to our GI ward for management and further survey.
    • Course of inpatient treatment
      • After admission, NPO with adequate IV fluid supplement, IV form PPI agent and IV transamin were administered.
      • Blood was transfused for the management of anemia.
      • Upper G-I panendoscopy was performed and revealed Reflux esophagitis LA Classification grade A (minimal); Gastric adenocarcinoma, Borrmann type III, tumor bleeding, s/p hemostasis with APC.
      • There was no more tarry stool passage after treatment, oral intake trying was administered. PPI agent and Transamin was shifted to oral form. Under stable condition, she was discharged on 2023/10/26 and GI OPD Follow-up would was arranged later.    
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Transamin (tranexamic acid 250mg) 1# BID
  • 2023-05-15 ~ 2023-05-17 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Gastric adenocarcinoma T4aN3aM1, stage IVB
      • post bleeding Anemia
    • CC
      • Tarry stool passage 7 times since yesterday
    • Present illness
      • This is a 92-year-old male with underlying disease of:
        • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding, with Chinese herbal decoction management.
        • Chronic anemia
        • Old CVA
        • CKD stage III
        • HTN
        • DM
        • HLD
      • This time, he suffered from tarry stool passage 7 times since yesterday. He was brought to our GI OPD for help. He denied fever, URI sympyoms, chest tightness, epigastric pain, abdominal pain found.
      • At GI OPD, blood test showed mild anemia (Hb:10 g/dL). PE showed no icteric sclera, soft abdomen, no leg pitting edema. Under the impression of favor gastric cancer with bleeding. He was admitted to our GI ward for management and further survey.
    • Course of inpatient treatment
      • After admission, we gaved IV PPI for suspect UGIB control. LPRBC was transfusioned for anemia. Since there was no tarry or bloody stool passage, she started oral diet as toleravle. Under relative stable condition, she was discharged on 2024/05/17.  
  • 2023-04-05 ~ 2023-04-08 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Malignant neoplasm of stomach with bleeding
      • Acute posthemorrhagic anemia
    • CC
      • tarry stool for 3 times for a day.
    • Present illness
      • This is a 92-year-old male with underlying disease of:
        • Gastric adenocarcinoma T4aN3aM1,stage IVB, with bleeding
        • Chronic anemia
        • Old CVA
        • CKD stage III
        • HTN
        • DM
        • HLD
      • He was admitted on 2022/11/08 for GIB. PES revealed:
        • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3
        • Reflux esophagitis LA Classification grade A
      • Abdomonal CT reported gastric carcinoma T4aN3aM1, stage:IVB. Further biopsy showed adenocarcinoma. The patient and his family preferred to palliative care.
      • Recurrent tarry stool and anemia was noticed after admission. This time, the patient was found tarry stool for 3 times since 2023/04/05 morning. Accompanied symptoms included productive cough with whitish sputum for 2 days and chronic bilateral legs pitting edema for 5-6 years. There was no fever, chillness, nausea, vomiting, abdominal pain, dyspena, orthopnea, PND or chocking history recently.Due to the above problem, he was sent to our ER.
      • At ER, his consciousness was E4V5M6, vital signs were BP:143/63; HR:78; BT:36.5’C; RR:20; SpO2:97%. PE showed chronic weak ill-looking, moderate anemia conjunctiva, pitting edema(+).
      • Lab data revealed severe normocytic anemia (Hb 6.2, 4/3 Hb: 8.1) and impaired renal function (Cr: 1.31).
      • CXR showed Ground glass opacity in RLL.
      • Pantoprazole was given.
      • Under the impression of UGI bleeding, he was admitted for further care and management.
    • Course of inpatient treatment
      • After admission, we gaved use PPI pump for UGIB control. Also, we arranged PES to survey the lesion. LPRBC was transfusioned for anemia.
      • As times went by, the patient regained fair spirit, Lab data follow up showed health status improved. Under stable status of health, we discharged the patient on 2023/04/08.
  • 2022-12-21 SOAP Psychosomatic Medicine Chen YiQian

    • Diagnosis
      • Unspecified dementia, unspecified severity, with behavioral disturbance [F03.91]
    • Prescription x3
      • Risperdal (risperidone 1mg) 1# HS
      • Exelon Patch (rivastigmine 4.6mg/24h, 9mg/patch) 1# QD EXT
      • Anxiedin (lorazepam 0.5mg) 1# PRNHS
  • 2022-11-08 ~ 2022-11-21 POMR Gastroenterology Chen JiangHua

    • Discharge diagnosis
      • Gastric adenocarcinoma T4aN3aM1, stage IVB
      • Gastric cancer with one exposed vessel bleeding status post hemostasis with submucosal epinephrine injection and hemoclips on 2022/11/08
      • Reflux esophagitis Los Angeles grade Classification grade A
      • Osteoarthritis of right knee with acute inflammation
      • Type 2 diabetes mellitus
      • Hypertension
      • Chronic kidney disease, stage 3
      • Chronic obstructive pulmonary disease
    • CC
      • tarry stool for a period of time (Family doesn’t know the exact duration)
    • Present illness
      • This 92-year-old female has histories of hypertension, diabetes mellitus, hyperlipidemia, coronary arteriosclerosis under plavix control, dementia, old CVA and COPD for years under regular medication control. She COVID-19 was confirmed on 2022/09/23.
      • This time, she suffered from tarry stool for a period of time (Family doesn’t know the exact duration). She visited ER for help.
      • At ER, vital sign BT 36.4C, HR 96/min, RR 18/min, BP 125/61 mmHg, SpO2 94% under room air, consciousness was clear (GCS:E4V5M6).
      • Blood test showed leukocytosis (11.11*10^3/uL), but no left shift, anemia (Hb:7.1 mg/dL), renal dysfunction (BUN/Cr:46/1.38mg/dl), no electrolyte imbalance.
      • EGD was performed and revealed
        • Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3.
        • Reflux esophagitis LA Classification grade A.
      • Medical treatment with Hemoclot 500mg IVD, blood transfusion with LPRBC, pantoloc 80mg IVD and 200mg in NS 500ml IVD 21ml/hr.
      • There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain.
      • Under impression of gastrointestinal bleeding with anemia,she was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission to GI ward, NPO with adequate IV fluid supply, NG with decompression and high dose PPI for Gastrointestinal bleeding.
      • Anemia was corrected using blood trnasfusion with LPRBC.
      • EGD on 2022/11/08 was reported 1.Highly suspected gastric malinancy, Borrmann type III, Forrest classification type IIa, s/p hemostasis with hemoclips and biopsy*3. 2.Reflux esophagitis LA Classification grade A.
      • The pathology was showed ulcer with intestinal metaplasia and atypical glands.
      • Abdominal sonography was reported 1.Liver cyst,S2. 2.Renal cyst, both kidney.
      • Abdomonal CT was reported gastric Carcinoma T4aN3aM1, STAGE:IVB.
      • Second look EFD was performed on 2022/11/11 for gastric biopsy.
      • The pathology was showed adenocarcinoma.
      • Family meeting on 2022/11/11 with her family talk about operation and palliative care, that her family need discuss.
      • Oncologist was consulted and who suggested 1. Well discussion with patient and family. 2. Please check HBV and HCV status. 3. Please check the biopsy with MMR (Mismatch Repair), Her2, PD-L1. 4. May consider NGS.
      • Family meeting with oncologist Dr. Xia on 2022/11/18 with her family talk about chemotheraphy, that her family need discuss.
      • Oral intake trying was administered since 2022/11/10 and there was no tarry stool nor coffee ground.
      • IV PPI shifted to oral form with Nexium.
      • Right knee swelling with local heat was found on 2022/11/15. Orthologist was consulted and who suggested 1. Conservative treatment with activity restriction and avoid excessive knee flexion. 2. May consider joint aspiration if progressive painful swelling noted, but carries risk of infection. But still complaint right knee swelling, we contact Orthologist and who suggested if worse may need right knee aspiration and steroid injection. The right knee swelling with local heat was improved.
      • Under the stable condition,she was discharge on 2022/11/21 and GI OPD was arranged leater.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Bisacodyl supp 10mg 1# PRNQOD RECT if constipation
      • Ultibro Breezhaler (indacaterol 100mug, glycopyrronium 50ug) 1# QD INHL
      • Atanaal (nefedipine 5mg) 1# PRNQ6H if SBP > 170
  • 2022-09-23 ~ 2022-09-27 POMR Integrative Medicine Chen HengXiang

  • 2021-08-27 ~ 2021-08-28 POMR Nephrology Hong SiQun

  • 2020-11-02 ~ 2020-11-10 POMR Ear Nose Throat Su WanYu

  • 2019-06-05 SOAP Urology Xie ZhengXing

    • Diagnosis
      • Unspecified urinary incontinence [R32]
      • Neuromuscular dysfunction of bladder, unspecified [N31.9]
    • Prescription
      • Wecoli (bethanechol chloride 25mg) 1# BID
  • 2017-08-14 SOAP Cardiology Zhang HengJia

    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.50]
      • Acute cystitis [N30.01]
      • Cardiac dysrhythmia, unspecified [I49.9]
      • Chest pain,unspecified [R07.9]
      • HCVD, unspecified, without CHF [I11.9]
    • Prescription x3
      • Norvasc (amlodipine besylate 5mg) 1# BID
      • Uretropic (furosemide 40mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Olmetec (olmesartan medoxomil 20mg) 1# BID
  • 2017-07-27 SOAP Chest Medicine Huang JunYao

    • Diagnosis
      • Chronic airway obstruction (COPD), NEC [J44.9]
      • GERD [K21.9]
      • Allergic rhinitis [J30.0]
      • bilateral lung nodules [R91.1]
    • Prescription x3
      • Pulmicort (budesonide 64ug/dose) 1 puff QD perNA
      • Ultibro (indacaterol 110ug, glycopyrronium 50ug) 1# QD INHL
      • Allegra (fexofenadine 60mg) 1# BID
      • Welizen (famotidine 20mg) 1# BID
      • Shitan (bromhexine 8mg) 1# BID
      • Fucou (dextromethorphan, cresolsufonate, lysozyme) 1# BID
  • 2017-06-12 SOAP Metabolism and Endocrinology Yu LiJiao

    • Diagnosis
      • Right pons infarction on 2016/11/30 with left hemiparesis [I63.8]
      • Hypertension [I10]
      • Type 2 diabetes mellitus with hyperglycemia [E11.65]
      • Pure hypercholesterolemia [E78.0]
    • Prescription x3
      • Tulip (atorvastatin 20mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Grumed (glimepiride 2mg) 0.5# QDAC
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# QD

[surgical operation]

  • 2020-11-03 - Op Method:
    • Emergent incision and drainage of deep neck infection, right
    • Finding:
      • abscess over right submental deep neck
      • pus culture done
      • DM, HT, HCVD, angina, COPD, hyperlipidemia, senile = thus LA operation was advised by the superintendent

==========

2024-01-29

[addressing continuous high glucose readings]

During this hospital stay, 4 serum glucose measurements consistently showed values around 300 mg/dL despite the administration of regular insulin and oral antihyperglycemic agents. If hyperglycemia persists, consideration may be given to adding basal insulin to the regimen.

700185693

240129

[exam findings]

  • 2023-11-29 Patho - soft tissue tumor, extensive resection
    • Diagnosis:
      • Ovary, left, laparoscopic debulking surgery — clear cell carcinoma, and endometrioma
      • Ovary, right, laparoscopic debulking surgery — negative for malignancy
      • Fallopian tube, bilateral, laparoscopic debulking surgery — negative for malignancy
      • Cervix, laparoscopic debulking surgery — severe dysplasia (CIN3) with glandular involvement
      • Myometrium, laparoscopic debulking surgery — adenomyosis
      • Endometrium, laparoscopic debulking surgery — negative for malignancy
      • Lymph node, left iliac, dissection — negative for malignancy
      • Lymph node, left obturator, dissection — negative for malignancy
      • Lymph node, right iliac, dissection — negative for malignancy
      • Lymph node, right obturator, dissection — negative for malignancy
      • Omentum, laparoscopic debulking surgery — negative for malignancy
      • AJCC 8th edition pathology stage: pTIc1N0(if cM0); FIGO stage: IC1
    • Gross description:
      • Procedure (select all that apply)
        • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
      • Specimen size:
        • Uterus: 8x 6x 6X 5 cm, 63-g
        • Ovary, left: 8x 8 cm
        • Ovary, right: 3x 2x 1 cm
        • Fallopian tube, right: 5 cm in length and 0.4 cm in diameter
        • Fallopian tube, left: 5 cm in length and 0.4 cm in diameter
        • Omentum: 10x 3x 1 cm
        • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
        • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site:
        • Note: Please select the primary tumor site only
        • Left ovary
      • Ovarian Surface Involvement (required only if applicable):
        • Absent
      • Fallopian Tube Surface Involvement (required only if applicable):
        • Absent
      • Tumor Size
        • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Greatest dimension (centimeters): 5 cm
        • Additional dimensions (centimeters): 3 x 2 cm
      • Sections are taken and labeled as: F2023-536FSA1-2 and A1-6:left ovarian tumor, F2023-527A5: left tube, A1-2:right adnexae, A3:cervix, A4-5:coprus, A6:omentum, A7:left iliac LN, A8:left obturator LN, A9: right iliac LN, A10:right obturator LN
    • Microscopic Description:
      • Histologic Type:
        • Clear cell carcinoma
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System
        • Not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
        • Not applicable
      • Other Tissue/ Organ Involvement (select all that apply):
        • Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)
        • Not applicable
      • Peritoneal/Ascitic Fluid
        • Negative for malignancy
      • Regional Lymph Nodes:
        • Left iliac — negative for malignancy (0/3)
        • Left obturato — negative for malignancy (0/13)
        • Right iliac — negative for malignancy (0/3)
        • Right obturator — negative for malignancy (0/10)
      • Additional Pathologic Findings
        • Cervix: severe dysplasia (CIN3) with glandular involvement
        • Myometrium: adenomyosis
      • Immunohistocehncial stains — Napsin A (+), p16: negative( weak, < 5%), p53: wild type (weak to moderate, 50%).
  • 2023-11-10 SONO - thyroid
    • Autoimmune thyroid disease
  • 2023-10-11 CT - abdomen
    • Indication: p0, SEX (-). r/o chocolate cyst and adenomyosis
    • Findings:
      • There is a cystic mass in left adnexa with mild wall thickening and enhancing mural nodule, measuring 7.8 cm in size (the largest dimension).
        • Cystic adenocarcinoma of left ovary is highly suspected.
        • The differential diagnosis includes cystic adenoma.
    • Impression:
      • Cystic adenocarcinoma of left ovary 7.8 cm is highly suspected.
      • The differential diagnosis includes cystic adenoma.
  • 2023-10-09 Gynecologic ultrasonography
    • IMP: R/O LT Ovarian cystic mass: 75mmx73mm, papillary: (37mmX27mm), no blood flow
  • 2023-10-09 ENT Hearing Test
    • Tymp bil type A
    • ART RE contra 2000-4000 Hz and LE contra 500 ,4000 Hz absent
    • PTA:
      • Reliability FAIR
      • Average RE 11 dB HL; LE 16 dB HL
      • bil WNL except LE 4000 Hz absent
  • 2023-08-07 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 8 dB HL, WNL
      • L’t : 16 dB HL, normal to mild SNHL
    • Tymp
      • R’t : Type As
      • L’t : Type A
    • ART
      • Bil contra absent.
  • 2021-09-24 Neurosonograpy
    • Adequate total VA flow volume (154 ml/min).
    • Normal extracranial carotid, vertebral arterial flows.
  • 2021-09-24 ENT Hearing Test
    • Tymp:
      • Bil type A
    • ART:
      • Bil WNL.
    • PTA
      • Reliability FAIR
      • Average RE 9 dB HL; LE 20 dB HL.
      • R’t WNL.
      • L’t normal to mild SNHL.
  • 2021-09-24 OVEMP
    • cVEMP: Interaural Amplitude Asymmetry ratio : 11.17%, <35%, WNL.
    • oVEMP: Bil show no response.

[MedRec]

  • 2024-01-26 SOAP Gastroenterology Xiao ZongXian
    • S: Bowel irritability after meal.
    • A: Possible chemotherapy-induced GI sx
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Dicetel (pinaverium bromide 100mg) 1# BID
      • Ulstop (famotidine 20mg) 1# BID
  • 2024-01-16 SOAP Infectious Disease Yang QinHui
    • S: referred from Onco for URI
      • sorethroat, running nose, sneezing and ocugh for days
      • hx of ovary cancer under C/T
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# QD
      • Actein Effervescent (acetylcisteine 600mg) 1# BID
      • ZCough (benzonatate 100mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever BT > 38’C
  • 2024-01-16 SOAP Cardiology Liu ZhiRen
    • S
      • Cystic adenocarcinoma of left ovary s/p first chemotherapy, palpitation off andon for 2 days just after C/T
      • improved now
      • Hx of MVP, COVID-19(+) 2023-03
      • occasionally cough
      • exertional dyspnea, mild, no chest pain
      • insmonia and anxiety
    • O
      • BP: 145/72; HR: 89;
      • 2024-01 ECG: Normal
      • 2023-12 CXR: Normal
      • 2023-11 Normal thyroid function
      • DM-
      • HTN-
      • asthma-
      • smoking-
      • NKA
      • RHB, no mur
      • BSclear
      • no leg edema
    • Prescription
      • Pronolol (propranolol 10mg) 1# PRNTID
  • 2024-01-16 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Unspecified Anxiety Disorder [F41.9]
      • Major Depressive Disorder, Single Episode, Moderate [F32.1]
    • Prescription
      • Lexapro (escitalopram 10mg) 0.5mg QN
      • Anxiedin (lorazepam 0.5mg) 1# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNBID
      • Eurodin (estazolam 2mg) 1# PRNHS
  • 2023-12-29 SOAP Gastroenterology Xiao ZongXian
    • S
      • For HBV prophylaxis
      • Dyspeisia recently
    • A: Resolved HBV - On prophylaxis of antiviral therapy for chemotherapy since 2023/12/29
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
  • 2023-11-27 ~ 2023-12-03 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Left ovarian cancer, post laparoscopic debulking surgery (laparoscopic total hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + omentectomy) and laparoscopic fulguration of pelvic endometriosis on 2023/11/28
      • Endometriosis of pelvic peritoneum
      • Pelvic peritoneal adhesions
    • CC
      • Progressive LY ENLARGINHG left ovarian cystic mass for six months.
    • Present illness
      • This is a 60 years old female, G0P0, sex(-), menopause at 52 years old, with A past history of breast cancer stage II status post left partial mastectomy with chemotherapy and radiation therapy 20+ years ago at Cardinal Tien Hospital, and hyperthyroidism 20+ years ago with regular follow-up without medication. She denied food or drug allergy, and denied hormone and illicit drug usage.
      • According to the patient, she had regular follow-up of breast cancer at Cardinal Tien Hospital, where sonography showed ovarian mass and the doctor suggested follow-up after 3 months. She then came to our OPD for consultation. She denied abdominal pain, increased vaginal discharged, urinary incontinence, dyuria, diarrhea or constipation. GYN Sonography on 2023/10/09 showed uterus size 49x26mm, endometrium thickness 5.5mm, but progression in size of the left ovarian cystic mass: 75x73mm, and papillary content 37x27mm without blood flow, and no ascites. Abdominal CT showed that cystic adenocarcinoma of left ovary 7.8 cm is highly suspected with the differential diagnosis including cystic adenoma. Tumor markers were within normal range (CA125 5.1 U/mL, CEA 1.42 ng/mL).
      • After discussing with the doctor, she asked for surgical intervention. The operation and complication had been fully explained to the patient and her family.
      • She was then admitted to the ward on 2023/11/27 for preparation of Laparoscopic Left salpingo-oophorectomy + frozen section or debulking depending on the frozen pathology report, and further management.
    • Course of inpatient treatment
      • The patient was admitted on 2023/11/27. She underwent laparoscopic Left salpingo-oophorectomy during the operation, and frozen section pathology of the left ovary showed malignant tumor. The debulking surgery (laparoscopic total hysterectomy and bilateral salpingo-oophorectomy + omentectomy + bilateral pelvic lymph node dissection) + laparoscopic fulguration of pelvic endometriosis + enterolysis were then done on 2023/11/28.
      • We gave her Cefazolin and Gentamycin IV form for 3 day and then shifted her antibiotics to Cephalexin oral form.
      • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/11/28 also showed elevated WBC without fever. Her condition was stable without fever and special complaints since 3 days after the debulking surgery. After flatus, her eating, self voiding and defecation were all ok. The JP drain was removed on 2023/12/2 smoothly. Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/12/03 for her for further OPD follow up of her recovery status and surgical wound conditions.
    • Discharge presciption
      • Acetal (acetaminophen 500mg) 1# QID
      • Alpraline (alprazolam 0.5mg) 1# TID
      • cephalexin 500mg 1# QID
      • diphenidol 25mg 1# TID
      • Eurodin (estazolam 2mg) 1# PRNHS
      • MgO 250mg 1# QID
      • Through (sennoside 12mg) 2# HS
  • 2021-11-22, -09-20 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • Nontoxic goiter, unspecified [E04.9]
      • Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm [E05.00]
    • Prescription x3
      • Cardiolol (propranolol 10mg) 1# QD
      • methimazole 5mg 2# QD
  • 2020-04-17 SOAP Metabolism and Endocrinology Zhang YaLi
    • Diagnosis
      • Nontoxic goiter, unspecified [E04.9]
    • Prescription x3
      • Polupi (propylthiouracil 50mg) 1# QW14
      • propranolol 10mg 1# PRNQD

[surgical operation]

  • 2023-11-28
    • Op Method:
      • laparoscopic debulking surgery (total hysterectomy + bilateral salpingo-oophorectomy + BPLND + omentectomy) and laparoscopic fulguration of pelvic endometriosis
    • Finding:
      • Uterus: 7x6x5cm, normal-looking
      • LOV and tube
      • tumor rupture due to severe adhesion
      • LOV: 8x8cm cystic tumor with septums, mural part and chocolate fluid inside, suspected ovarian endometrioma
        • Frozen section pathology of left ovary: malignancy
        • left fallopian tube – grossly normal
      • ROV: 2x2cm, grossly normal
        • right fallopian tube – grossly normal
      • omentum, peritoneum, liver and bowels – seemed free of cancer invasion
      • CDS: no fluid but severe pelvic endometriosis (AFS score > 40) and pelvic adhesion were noted between post uterus, left adnexum, left pelvic wall, US ligament, sigmoid colon and rectum and s/p laparoscopic fulguration of pelvic endometriosis and lysis
      • After the surgery, optimal debulking was achieved
      • A 7 mm JP drain was placed in CDS

[chemotherapy]

  • 2024-01-29 - paclitaxel 175mg/m2 257mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2024-01-08 - paclitaxel 175mg/m2 258mg NS 250mL 3hr + carboplatin AUC 5 825mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2024-01-29

[reconciliation]

Medications prescribed by specialists in family medicine and gastroenterology on 2024-01-26, and by cardiologists and psychosomatic medicine experts on 2024-01-16, are generally listed in the current active medication roster without issues noted.

700214839

240129

[exam findings]

  • 2024-03-16 MRI - L-spine

    • Indication: left breast cancer with liver, bone matestasis, stage IV, s/p left partial mastectomy, axillary lymph node on 2018-01-31 s/p Epirubicin/Endoxan/Fluorouracil x4 (2018/02/22 ~ 04/27), tyrosine hydroxylas s/p Nolbaxol/Herceptin (2018/05/19-07/02). Recurrent multiple spine metastases in 2023-09. s/p C6 corpectomy, reconstruction with VDRS artificial bone, C5-7 plating on 2023/09/21, s/p radiotherapy (2023/10/06 - 11/15), liver, T-spine metastsis s/p radiotherapy with TPH (2023/12/04 ~).
    • Findings:
      • Multiple bone lesions in vertebral column, either enhancing (T8, T9 and T12), T1 and T2-hypointensity and non-enhancing (L1-5 and S1), or T2-hyperintensity (bilateral iliac bones). C/W Multiple bony metastases s/p radiochemotherapy.
      • No intramedullary lesion.
      • Bilateral pleural effusion, more prominent on right side.
    • IMP:
      • Multiple bony metastases involving vertebral column, s/p treatment.
  • 2024-03-06 Nasopharyngoscopy

    • rt vocal palsy, minimal gap, LPR
  • 2024-03-04 Tc-99m MDP bone scan with SPECT

    • Several new lesions of increased radioactivity in both rib cages, and some of previous old lesions in the sternum, spines, left S-I joint, left acetabulum, and right femoral trochanters become more evident, indicating metastatic bone disease in progression.
    • Suspected benign lesions at bilateral shoulders, right S-I joint, and knees.
  • 2024-03-01 CT - chest

    • Diagnosis: Invasive carcinoma of no special type of the left breast, ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), AJCC Pathologic Stage — pT2N1a(3/4)(cM0), stage IB, s/p partial mastectomy and axillary lymph nodes dissection, adjuvant chemotherapy, radiotherapy, Herceptin, and s/p endocrine therapy. Bone mets noted in Sep 2023. s/p spine C6 mets resection.
    • Chest CT with and without IV contrast ehnancement shows:
      • Mild atelectatic change at right lower lobe is found.
      • S/P mastectomy at left chest.
      • Mild right pleural effuison is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Very tiny nodules at right lower lobe is found. Lung meta is favored and the lesions regressed markedly.
      • Low density lesions are found at both lobes of liver. Liver meta is considered. In comparison with CT dated on 2023-11-20, the lesions decreased in size.
      • Low density change at pancreatic body is noted. Pancreas meta is considered.
    • Imp:
      • Left breast cancer s/p op. with lung, liver and bone meta. In much regression.
  • 2024-03-01 SONO - breast

    • Diagnosis
      • Bil. fibroadenomas
      • s/p left breast operation
    • BI-RADS: 2. benign finding
  • 2023-12-13 Nasopharyngoscopy

    • rt vocal palsy, LPR
  • 2023-12-05 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (77 - 20) / 77 = 74.03%
      • M-mode (Teichholz) = 75
  • 2023-11-20 CT - chest

    • Indication: Invasive carcinoma of the left breast s/p partial mastectomy and axillary lymph nodes dissection, adjuvant chemotherapy, radiotherapy and s/p endocrine
    • Findings comparison made with CT on 2023/10/06
      • Lungs: numerous randomly distributed pulmonary nodules of varying sizes due to metastases.
        • newly developed small Lt pleural effusion.
      • liver: multiple tumors of variable sizes in both lobes of liver due to metastases in progression as compared CT on 2023/10/06.
      • mediastinum: regression of meastatic lymphadenopathies in the visceral space and left anterior prevascular space, and both hila.
      • Thoracic aorta and central pulmonary arteries: normal caliber. Heart: normal size of cardiac chambers.
      • Visible abdominal-pelvic contents: mild dilatation of CHD and CBD that may be secondary to S/P cholecystectomy
      • Rt Lt bilateral renal cysts stone measuring up to cm (longest axial diameter)
      • a hepatic cyst multiple hepatic cysts measuring up to
      • Visualized bones: destructive lytic change in spine and manubrium of sternum
    • Impression:
      • Lt breast cancer s/p op. with lung, mediastinal and hilar LNs hepatic, and bones metastasis, in progression of hepatic metastassis and regression of mediastinal and hilars LNs metastases as compared with CT on 2023/10/06.
  • 2023-11-17 Bronchodilator Test, BCT

    • There is mild restrictive lung defect.
    • The bronchodilator test is boderline.
    • Small airway disease was suspected.
  • 2023-11-10 CXR erect

    • Multiple nodules of in both lungs due to metastases.
    • Enlargement of hila and superior mediastinal widening due to lymph node enlargement
    • Osteolytic metastasis spine
  • 2023-10-06 CT - chest

    • Indication: Breast cancer with multiple bone mets
    • Chest CT without IV contrast ehnancement shows:
      • Tiny(< 1.0cm) nodules at bilateral lung fields are found. Lung meta is considered.
      • Some homogeneous soft tissue lymph nodes are found in the mediasitnum is found.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Necrotic tumors at both lobes of liver up to 5.0cm in largest dimension. Liver meta is considered.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Diffuse lung and liver meta. Mediastinal lymphadenopathy. Bone meta.
  • 2023-09-27 Tc-99m MDP bone scan

    • Highly suspected multiple bone metastases in some C-, T- and L-spine, sternum, left sternoclavicular junction, left pelvic bones, left S-I joint, left acetabulum, and right femoral trochanters.
    • Suspected benign lesions in both rib cages, bilateral shoulders, right S-I joint, and knees.
  • 2023-09-25 MRI - L-spine

    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
    • Findings
      • Multiple bone destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
      • After IV contrast administration shows well or heterogenous enhancement of the masses or tumors.
    • IMP:
      • Multiple bone metastases/destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
  • 2023-09-21 Patho - bone resection

    • C6 vertebrae and C56/C67 disc, C6 corpectomy — Metastatic invasive carcinoma, consistent with breast primary
    • The specimen submitted consists of multiple pieces of yellow gray bondy tissue, labeled C6 vertebrae and C56/C67 disc, measuring up to 0.5 x 0.4 x 0.3 cm and weighing 0.3 gm. All for section after decalcification.
    • The sections show a picture consistent with metastastic breast invasive carcinoma of no special type, composed of bony tissue and cartilaginous tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Extensive tumor necrosis is present.
    • IHC, the tumor cells show following features:
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Positive (score= 3+)
      • GATA3: Focally positive
  • 2023-09-16 MRI - C-spine

    • Acute compression fracture of C6 vertebra. R/O pathologic fracture.
    • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
    • Retrolisthesis of C5 on C6, grade I.
  • 2023-09-15 KUB + L-spine Lat

    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • r/o Bone metastasis in left pubic bone.
  • 2023-09-14 C-spine AP + Lat

    • Degenerative change of the cervical spine with narrowed intervertebral disc spaces,narrowed neuroforamina and spurs formation.
  • 2023-02-17 Mammography

    • Impression:
      • Dense breast.
      • Post-op with breast tissue reduction in left breast. Benign calcifications in right breast.
    • BI-RADS: Category 2: benign findings.-annual screening.
  • 2023-02-17 SONO - abdomen

    • Right liver calcification (0.47cm).
    • Bil. liver cysts (up to 1.55cm).
    • Left renal angiomyolipoma (0.44x0.46cm).
  • 2023-02-17 SONO - breast

    • Diagnosis
      • Bil. fibroadenomas
      • s/p left breast operation
    • BI-RADS: 2. benign finding
  • ….-..-..

  • 2018-01-31 Surgical pathology Level VI

    • Clinical diagnosis: Malignant female breast neoplasm, NOS;
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy —- Invasive carcinoma of no special type, grade 2
      • Resection margins, ditto — Free of tumor invasion
      • Skin, ditto — Free of tumor invasion
      • Nipple, ditto — not received
      • Lymph node, level I — Positive for tumor metastasis (3/4) with extracapsular extension (1/3)
      • Lymph node, level II — No lymph node (0/0)
      • AJCC Pathologic Stage — pT2N1aMx, stage IB at least
    • MACROSCOPIC EXAMINATION
      • Breast: 7 x 6.5 x 4.2 cm
      • Skin: 7 x 1.4 cm
      • Nipple: not received
      • Tumor: 3.7 x 2.6 x 2.2 cm
      • Resection Margins: Free of tumor invasion, 1.4 cm to “down”, 2.1 cm to “up”, 2.3 cm to “in”, 2.5 cm to “out”, and 0.5 cm to base
      • Lymph node: axillary LN (level I and level II)
      • Representative sections: A1-A5: breast tumor and skin; B1-B3: level I; C: level II.
        • Reference: frozen: S2018-01971: FSA1-FSA2: down margin (1 piece, 3.5 x 2 x 0.5 cm); FSB: inner margin (1 piece, 2.5 x 2 x 0.5 cm)
    • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.7 x 2.6 x 2.2 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6)
          1. Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 2
      • Margins: Free of tumor invasion, 1.4 cm to “down”, 2.1 cm to “up”, 2.3 cm to “in”, 2.5 cm to “out”, and 0.5 cm to base
      • Nodal status: Positive for tumor metastasis (3/4) with extracapsular extension (1/3)
      • Treatment Effect: not applicable
      • Immunohistochemistry: refer to S2018-01044
  • 2018-01-25 Tc-99m MDP bone scan

    • Increased activity in the lower C-spine and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, bilateral S-I joints and hips, compatible with benign joint lesion.
  • 2018-01-17 SONO - breast

    • Diagnosis
      • Highly suspicious of malignancy, with sonographic positive axillary LAP, multifocal, left 1/3 and 1.5/4 lesions.
    • BI-RADS:
      • 4B - intermediate suspicion of malignancy Biopsy Should Be Considered.
  • 2018-01-17 Surgical pathology Level IV

    • Breast, left, core biopsy — Invasive carcinoma, NST (no special type). An addendum report of the result of ER, PR, Her2/neu, Ki-67, and p53 will be followed.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration. An addendum report of the result of ER, PR, Her2/neu, Ki-67, and p53 will be followed.
    • IHC stain: ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), 95%; Ki-67: 40%; p53: 75%.

[MedRec]

  • 2023-10-05 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Treatment course:
        • s/p partial mastectomy and axillary lymph nodes dissection
        • Adjuvant chemotherapy (since 2018/02/22 AC follow by TH)
        • Adjuvant R/T (2018-09-18 ~ 2018-10-31: 5000cGy/25 fractions of the left breast to left SCF, and 6000cGy/30 fractions of the left breast tumor bed (scar) area.)
        • Adjuvant Herceptin (until 2019/05)
        • Adjuvant endocrine therapy (tamoxifen since 2018/09- (? or 2019-06-12) to 2023-06-14)
      • Recurrence over C3, C6 and T1 and L (MRI an Bone scan) vertebral bodies, favor
        • s/p C6 corpectomy to remove cervical spine metastasis
        • reconstruction with VDRS artificial bone+ C5-7 plating
        • R/T 30 Gy/ 10 fx to the multiple mets region, C-spine and sternoclavicular region
    • P
      • Arrange Chest/Abd/Pelvis CT in 2023-10
      • Breast sono Q1Y, next in 2024-01
      • Mammo Q1Y, net in 2024-03
      • Apply CDK4/6 + letrozole
  • 2023-10-03 SOAP Radiation Oncology Wang YuNong
    • O
      • 2023/09/27 Tc-99m MDP whole body bone scan
        • Highly suspected multiple bone metastases in some C-, T- and L-spine, sternum, left sternoclavicular junction, left pelvic bones, left S-I joint, left acetabulum, and right femoral trochanters.
      • 2023/09/25 MRI: L-spine
        • Multiple bone destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3.
      • 2023/09/21 PATHO - bone resection
        • C6 vertebrae and C56/C67 disc, C6 corpectomy — Metastatic invasive carcinoma, consistent with breast primary
      • 2023/09/16 MRI: C-spine
        • Acute compression fracture of C6 vertebra. R/O pathologic fracture.
        • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
    • P:
      • CT-simulation for L-spine mets and pelvic and femoral mets will be done today.
      • Plan to deliver 30 Gy/ 10 fx to the multiple mets region. RT will start aorund 2023/10/09.
      • RT for the C-spine and sternoclavicular region will be arranged the the current Tx completes.
  • 2023-09-15 ~ 2023-09-28 POMR Neurosurgery Hong LiWei
    • Discharge diagnosis
      • Acute compression fracture of cervical 6 vertebra, metastatic invasive carcinoma status post C6 corpectomy to remove cervical spine metastasis and reconstruction with VDRS artificial bone + C5-7 plating on 2023-09-20
      • Secondary malignant neoplasm of bone
      • Cervicalgia
      • Radiculopathy, cervical region
      • Malignant neoplasm of unspecified site of left female breast
    • CC
      • Neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks.
    • Present illness
      • This 56 years old female patient had left breast cancer s/p left partial mastectomy + axillary lymph node dissection on 2018-01-31. Adjuvant chemotherapy with Epirubicin 90mg/m2 + Endoxan 600mg/m2 + Fluorouracil 500mg/m2 x4 course erery three weeks since since 2018/02/22 to 2018/04/27, then tyrosine hydroxylase (Nolbaxol 75mg/m2+ Herceptin 6mg/m2) since 2018/05/19-2018/07/02.
      • She was suffered from neck soreness about 5 months, severe recurrent trapezius region pain brachialgia has been persistent for months, more sever of right side, associated with numbness in right hand a weeks. Pain got worse at early morning and just awakened from sleep. She also complained itchy throat and frequent coughing, she visited to Orthopedics clinic first, but owing to ineffective conservative treatment and frequent recurrences. She visited our clinic, X-ray showed C5-6 vertebrae osteolytic picture, r/o metastasis. Then, she was admitted to neuro ward for further survey and treatment.
      • No trauma history
    • Course of inpatient treatment
      • Upon admission, C-spine MRI with contrast showed:
        • Acute compression fracture of C6 vertebra. R/O pathologic fracture;
        • Enhancing lesions over C3, C6 and T1 vertebral bodies, favor metastases.
        • Retrolisthesis of C5 on C6, grade I.
      • We also consulted Radiology and Oncology for further evaluation, who suggestion:
        • Please check CEA, CA-153, LDH, serum EP, albumin/globulin, ALK-P;
        • C-spine surgery biopsy for tissue proof.
      • After well explained to the patient about MRI findings. We informed that operation is a treatment option for cervical spine metastasis with cord compression and unstable spine. But the patient hesitated. Finally she decided operation.
      • Postoperative course was uneventful. Analgesic agents were used for wound pain control. One JP drain was inserted and record amount Q8H. Her neck and right shoulder pain got improved. C-spine X-rays showed good positions of implants.
      • She complained of right thigh sorness. L-spine MRI with contrast was performed on 2023/09/25 and revealed multiple bone metastases/destructions at thoraco-lumbar spine and bil. pelvic bones, especially at T12, L1, L3. JP drain was removed on 2023/09/25.
      • Dentistry was consulted for dental evaluation prior to Xgeva use.
      • The wounds were clean and dry. She was discharged and outpatient follow-up was mandatory. Sutures would be removed at outpatient.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# BID
      • Kentamin (Vit B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Sindine (povidone iodine aq soln) ASORDER EXT
  • 2023-09-14 SOAP Neurosurgery Hong LiWei
    • S
      • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, for 1 month
      • s/p left partial mastectomy and axillary LN dissection on 2018/01/31, pT2N1aM0, stage IB, ER: (+, 75%); PR (+, 25%); Her2/neu: Positive (score=3+), 95%; Ki-67: 40%; p53: 75%
      • menopausal after chemotherapy
      • phx: breast ca.
    • O
      • E4V5M6
      • pupil: 3+/3+
      • MP R L
      • UE 5 5
      • LE 5 5
      • paresthesia
      • SLRT
      • patrick test
      • tineal test
      • x ray showed C56 vertebrae osteolytic picture, r/o metastasis
    • A
      • neck pain, radiate to bil. shoulder pain (R>L) and right upper arm, x ray showed C56 vertebrae osteolytic picture, r/o metastasisneed MRI c+-
      • 9/15 admission, arrange MRI C+- of C-spine
      • h/s hydration+acetylcysteine 1pc bid for renal protection

[consultation]

[surgical operation]

  • 2023-09-21
    • Surgery
      • C6 corpectomy to remove cervical spine metastasis
      • reconstruction with VDRS artificial bone+ C5-7 plating
      • C-arm and microscope assisted
    • Finding
      • under c-arm localization
      • split platysma muscle
      • split to pre-vertebral space via medial side of carotid sheath
      • dissect bilateral longus coli muscle
      • set retraction screws on C5 and C7 body
      • do C56, C67 discectomy first
      • do C6 corpectomy to remove spinal metastasis, send pathology
      • insert VDRS artificial bone, length: 2.15cm
      • do C5-7 plating with screws fixation
      • plate: 4.2cm, screws: 1.4cm*4
      • well hemostasis
      • set vacuum ball*1
      • close wound layer by layer

[immunochemotherapy]

  • 2024-05-25 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-05-03 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-04-09 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-03-15 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-02-17 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-27 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-30 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 1min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-04 - docetaxel 60mg/m2 80mg NS 250mL 1hr + trastuzumab 600mg SC 2min + pertuzumab 420mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

Xgeva (denosumab 120mg)

  • 2024-05-24 Xgeva (denosumab 120mg) SC ST IPD
  • 2024-04-22 Xgeva (denosumab 120mg) SC Q1M OPD
  • 2024-03-15 Xgeva (denosumab 120mg) SC ST IPD
  • 2023-12-02 Xgeva (denosumab 120mg) SC ST IPD

==========

not posted yet

[Bard]

Missing the loading dose of Pertuzumab (840mg) and instead using a 420mg dose requires careful consideration, as its impact on treatment efficacy and potential risks depends on several factors:

  1. Timing of missed dose:

Early in the treatment course: Missing the loading dose early on can significantly impact initial drug exposure and potentially weaken treatment efficacy. In this case, resuming with the recommended maintenance dose (420mg every 3 weeks) might not be sufficient to compensate. Later in the treatment course: If several loading doses have already been administered, the impact of missing one dose might be less significant, offering more leeway for resuming with the maintenance dose.

  1. Reason for missing the dose:

Accidental: If the omission was accidental and unlikely to occur again, resuming with the maintenance dose may be acceptable after discussing it with your doctor.

[cGPT]

Missing the full loading dose of 840 mg and instead using a 420 mg dose could have implications for the effectiveness of the treatment, especially in the initial stages. Here are some potential considerations and impacts:

Reduced Initial Drug Levels:

The purpose of the loading dose is to quickly achieve effective drug levels in the body. Using only half of the intended loading dose may result in lower drug concentrations initially, which might reduce the effectiveness of the treatment during the early phase. Delayed Therapeutic Effect:

It might take longer to reach the therapeutic levels of pertuzumab in the bloodstream, potentially delaying the onset of the drug’s therapeutic effects. Adjustment of Subsequent Doses:

If the loading dose is missed or reduced, healthcare providers might need to adjust subsequent doses to achieve the desired drug levels. This could involve administering an additional dose or modifying the maintenance doses, though such adjustments should be based on clinical judgment and the specific circumstances of the treatment.

Clinical Decision and Monitoring:

In cases where the loading dose is not administered as recommended, it’s important for healthcare providers to closely monitor the patient’s response to treatment and adjust the dosing regimen as necessary. This might include more frequent assessments of tumor response and monitoring for side effects.

701494845

240129

[exam findings]

  • 2023-12-07 CT - chest
    • Indication: Peripheral T-cell lymphoma, stage IV, CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+)
    • Chest CT with and without IV contrast ehnancement shows:
      • Tiny nodule at url measuring 0.26cm in largest dimension. (Se202 IM37).
      • One ground glass nodule at right middle lobe measuring 0.2cm is also found. (Se202 Im99). Suggest follow up
      • Very small lymph nodes are found at paraaortic region. The findning in non-specific
    • Imp:
      • No evidence of lymphadenopathy in the study
      • Tiny lung nodules at right lung. Suggest regular follow up.
  • 2023-09-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88.6 - 21.9) / 88.6 = 75.28%
      • M-mode (Teichholz) = 63.1
      • 2D (M-Simpson) = 62.8
    • Conclusion:
      • Normal AV/MV, no AR, No MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
  • 2023-09-11 PET
    • Glucose hypermetabolism lesions in bilateral neck regions, SCF, left axilla, mediastinum, celiac lymph nodes, bilateral para-aortic space, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the spleen and in skeleton including scapulae, left rib, pelvic bones, and femurs, highly suspected lymphoma with involvement of spleen and bone marrow.
    • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-31 Patho - lymph node region resection
    • Lymph node, neck, left, excision — Malignant lymphoma — Peripheral T cell lymphoma, NOS (addendum)
    • Operation procedure: Excision; Topology: left neck; Specimen size and number: 1 piece, 5.2x 4.4x 3.6 cm in size
    • Immunohistochemical stain profiles: CD3 (+, diffuse), CD20 (focal+ at background B cells), CK(-), CD4(+, diffuse), CD8(+), CD56(focal+, 1%), Ki-67 index: 50%, EBV (+), ALK1(-), CD10(-), TdT(-), Granzyme B(-), CD15 & CD30 ( focal+), EBER(+).
    • Special stain: Acid-fast stain: Negative for TB bacilli, PAS stain: negative for microorganism.
  • 2023-08-26 CT - abdomen
    • History and indication: fever unknown and neck lymphma
    • Non-contrast CT of abdomen-pelvis revealed:
      • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
      • Some calcifications at pelvic cavity.
      • Collapse of gallbladder.
    • IMP:
      • Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions.
  • 2023-08-25 Nasopharyngoscopy
    • Findings: Smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
    • Dx/Conclusion: No finding of mucosal lesion in the study.
  • 2023-08-22 CT - neck
    • Diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space.
    • Multiple LAPs also were noted in left supraclavicular space.
    • After IV contrast administration shows well or heterogenous enhancement of those LNs.
    • Suggest clinical correlation.

[MedRec]

  • 2023-08-25 ~ 2023-09-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites, Lugano stage IV
      • Acute lymphadenitis of face, head and neck
      • Hepatomegaly with splenomegaly, not elsewhere classified
      • Nonspecific mesenteric lymphadenitis
      • Acute lymphadenitis of other sites
      • Unspecified adrenocortical insufficiency
    • CC
      • fever off and on for 6 months and left neck palpable lymph nodes for 4 months.
    • Present illness
      • The 23-year-old male patient has history of Covid-19 infection and influenza A infection. He has suffered from fever off and on for 6 months and left neck palpable lymph nodes for 4 months, since this April. He went to ShuangHe Hospital for with suspect malignancy by needle aspiration at ShuangHe Hospital on 2023-08-08. CT was scheduled on Aug 29, so he came to our Oncology OPD for help on 8/18 and Neck CT was done on Aug 22. CT report showed diffuse multiple enlarged left neck LNs, mainly in the posterior cervical space. Multiple LAPs also were noted in left supraclavicular space. After IV contrast administration shows well or heterogenous enhancement of those LNs.
      • He came to our ER yesterday due to fever again and skin rashes after contrast medium injection. At ER, fever noted with BT 39.7’C. Lab data showed normal white count WBC:8160, and elevated CRP level 17.5. Urinalysis showed no UTI and CxR film showed no pneumonia. Empirical antibiotic Augmentin was given for infection control at ER. Under the impression of Fever and left neck lymphadenopathy, cause unknown, he is admitted to our Infection ward for further evaluation and management on 2023-08-25.     
    • Course of inpatient treatment
      • After admission, patient received antibiotic with Cravit iv for infection control and cover possible atypical infection, fever off and on after admission under antibiotic treatment, check laboratory data with virus infection EMB, CMV, HIV all showed negative result, the abdominal CT scan showed Hepato-splenomegaly. Enlarged LNs at retroperitoneum and bil. inguinal regions and mass lestion over nack, the ENT was consulted and Impression of suspect lymphoma. the excisional biopsy for the patient was done on 8/30 and pending phathology.
      • The TB qauntiferon was check and report showed indeterminate, we will keept follow phathology report. Due to persisted fever the antibiotic Gentamicin was added since Aug 29 and check coartisol level showed 0.48 only, added Hydrocortisal 50mg Q8H and the Meta was consulted due to possbile medical effect, or possible related with stress caused adrenal insufficiency, and if the patient performs less adrenal insufficiency symptoms, suggested downgrade steroid dose gradually and check ACTH and corstisol level for evaluation.
      • No more fever and more stable condition, follow up laboratory data on Sep 05, with noraml WBC and CRP 1.7 mg/dL. Pending phathology report if negative finding, he can be discahrge in this week. However, the phathology report showed T- cell Lymphoma, so he was trasfer to Hematologist for continue care and treatment.    
      • After transferred to Hemalogy ward, we arranged heart echo, PET/CT scan, and bone marrow biopsy for the patient. Port-A insertion was arranged and done on 2023-09-11.
      • Lab data was then followed up, and as PET/CT reported Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), the patient has started his chemotherapy on 9/12 with CHOEP.
      • After chemotherapy started, we followed up the patient’s blood data every day, and there was no more fever noted. We added Feburic, Promeran and Famotidine for symptom prevention, and the patient had no elevation of uric acid and LDH noted. The patient’s first session of chemotherapy was finished on 2023-09-15, and we followed up his lab data on renal function, electrolyte, uric acid and LDH every day.
      • There was no abnormal lab data noted in each follow up, and there was no discomfort or fever noted. Under stable condition, the patient was discharged on 2023-09-18, with OPD follow up arranged on 2023-09-22.
  • 2023-08-18 SOAP Hemato-Oncology Gao WeiYao
    • S
      • He received needle aspiration over neck and lymphoma was suspected at ShuangHe Hospital.
      • Fever for 6 months and Neck tumor were noted since April, 2023.
      • Nonsmoker

[chemotherapy]

  • 2024-01-26 - cyclophosphamide 750mg/m2 1430mg NS 500mL 30min D1 + doxorubicin 50mg/m2 95mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 190mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-12-27 - cyclophosphamide 750mg/m2 1420mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 189mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-12-09 - cyclophosphamide 750mg/m2 1410mg NS 500mL 30min D1 + doxorubicin 50mg/m2 94mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 188mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-11-13 - cyclophosphamide 750mg/m2 1390mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-10-23 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-10-02 - cyclophosphamide 750mg/m2 1350mg NS 500mL 30min D1 + doxorubicin 50mg/m2 90mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 180mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3
  • 2023-09-12 - cyclophosphamide 750mg/m2 1330mg NS 500mL 30min D1 + doxorubicin 50mg/m2 88mg NS 100mL 10min D1 + vincristine 1.4mg/m2 2mg NS 50mL 10min D1 + etoposide 100mg/m2 177mg NS 500mL D1-3 + prednisolone 50mg BID D1-5 (CHOEP)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D1-3

Initial treatment of peripheral T cell lymphoma - INDUCTION THERAPY - 2023-11-24 - https://www.uptodate.com/contents/initial-treatment-of-peripheral-t-cell-lymphoma

  • Fit, younger patients
    • For medically fit, younger patients with CD30-negative PTCL, we suggest CHOEP rather than CHOP or more intensive regimens. Compared with CHOP, CHOEP is associated with better clinical outcomes and moderately increased toxicity; other intensive regimens are associated with similar outcomes but substantially greater toxicity.
    • CHOEP administration - Many experts limit use of CHOEP to medically fit patients <=60 or 65 years because of toxicity.
    • In CHOEP, intravenous etoposide 100 mg/m2 on days 1 through 3 of each 21-day cycle is added to the CHOP regimen. An alternate version of CHOEP administers intravenous etoposide 100 mg/m2 on day 1 of CHOP, followed by oral etoposide 200 mg/m2 on days 2 and 3 of each 21-day cycle. The higher oral dose of etoposide is necessary due to poor bioavailability with oral administration.
    • PET3 is performed after the first three cycles of CHOEP in order to decide whether to give three additional cycles of induction or treat for refractory PTCL (as described above for BV+CHP).
  • Older or less-fit patients
    • For older or less medically fit individuals of any age with CD30-negative PTCL, we favor CHOP induction therapy to avoid the increased toxicity associated with CHOEP.
    • CHOP administration - CHOP is given every three weeks for three cycles, followed by PET3 to guide completion of six total cycles of CHOP (for patients with CR or PR) versus management for refractory disease.

==========

2024-01-29

[reconciliation]

Lab results on 2024-01-25 indicated normal liver and kidney function tests, with serum uric acid levels at 9.0 mg/dL, suggesting hyperuricemia. This condition is being managed with Feburic (febuxostat), and there are no discrepancies in medication.

700374777

240126

[exam findings] (not completed)

  • 2023-05-10 PET
    • Increased FDG uptake in the middle third of esophagus, compatible with the primary esophageal cancer.
    • Increased FDG uptake in lymph nodes in bilateral upper mediastinum and in the left supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    • Increased FDG uptake in bilateral pulmonary hilar and right lower mediastinal lymph nodes, probably reactive nodes.
    • Increased FDG uptake at the left shoulder, probably benign in nature.
    • Increased FDG accumulation in bilateral kidneys and colon, physiological uptak of FDG is more likely.
    • Esophageal cancer, cTxN2M0, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-05-09 Patho - esophageal biopsy
    • Esophagus, 20 cm below incisor, biopsy — No significant pathologic change
    • Esophagus, 21-24 cm below incisor, biopsy — severe squamous dysplasia
    • Microscopically, section A shows bland squamous mucosal epithelium and no significant pathologic change. Section B shows severe squamous dysplasia with high grade nuclear atypia of the squamous cells and loss of polarity.
  • 2023-05-09 MRI - brain
    • No evidence of brain metastasis.
  • 2023-05-08 Miniprobe Endoscopic Ultrasound
    • Advanced esophageal SCC, middle esophagus, EUS staging T3Nx
    • Suspected esophageal dysplasia, 20 cm below incisors, s/p biopsy (A)
    • Suspected early esophageal SCC, 21-24 cm below incisors, uT1a, s/p biopsy (B)
    • Esophageal inlet patch, c/w heterotopic gastric mucosa
  • 2023-05-08 SONO - abdomen
    • Renal stones, both
  • 2023-05-05 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-05-05 CXR
    • Rt-sided convexity of the azygoesophageal recess interface, due to esophageal tumor
  • 2023-04-28 CT - chest
    • Indication: 20230418 EGD: Esophageal mass like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy; Stenosis at 30cm below
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at left lower neck and bilateral paratracheal is found.
        • Long segmental wall thickening at esophagus up to 6.7cm is found. Esophageal cancer is considered.
      • Visible abdomen:
        • Bilateral renal stones are found.
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp: Esophageal cancer with mediastinal lymph nodes and left lower neck.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression ( Imaging stage ): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-27 Tc-99m MDP bone scan
    • Increased activity in the L3 spine. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Mildly increased activity in the lower T-spines, L4-5 spines and bilateral S-I joints. Degenerative change is more likely.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, right knee, bilateral ankles and feet, compatible with benign joint lesions.
  • 2023-04-19 Patho - esophageal biopsy (Y2)
    • Esophagus, 25 cm to 30 cm below incisor, biopsy — moderate differentiated squamous cell carcinoma
    • Microscopically, section shows moderate differentiated squamous cell carcinoma consisting of invasive irregular squamous epithelial tumor nests arranged in solid architecture. The tumor cells display nuclear pleomorphis, hyperchromasia, high N/C ratio and prominent nucleoli.
  • 2023-04-18 Esophagogastroduodenoscopy, EGD
    • Esophageal mass-like lesion, 25cm to 30cm below incisors, s/p biopsy, R/O malignancy
    • Stenosis at 30cm below incisors

[chemotherapy]

  • 2024-01-26 - docetaxel 75mg/m2 120mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-30 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 137mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1800mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-07-03

  • According to the PharmaCloud database, our hospital was the sole provider for this patient’s healthcare needs. In addition to the hemato-oncology department, the patient had an appointment with our gastroenterologist on 2023-04-24 who prescribed a 28-day course of a PPI Pariet (rabeprazole) for his gastroesophageal reflux disease with esophagitis. This prescription is currently invalid and the symptoms are no longer listed on the active medical problem list. As a result, no problems were identified during the medication reconciliation process.

701507856

240126

[lab data]

2023-12-22 HBV-DNA-PCR Target Not Detected IU/mL
2023-12-21 Anti-HCV Nonreactive
2023-12-21 Anti-HCV Value 0.15 S/CO
2023-12-21 HBsAg Nonreactive
2023-12-21 HBsAg (Value) 0.49 S/CO
2023-12-21 Anti-HBs 267.16 mIU/mL
2023-12-21 Anti-HBc IgM Nonreactive
2023-12-21 Anti-HBc IgM Value 0.09 S/CO
2023-12-21 Anti-HBc Reactive
2023-12-21 Anti-HBc-Value 6.93 S/CO

[exam findings]

  • 2024-01-22 CT - brain
    • Imp: Brain atrophy. Multiple bil. brain and right cerebellar metastases with hemorrhages.
  • 2023-12-26, -12-21 CXR erect
    • A mass opacity projecting in left middle lung is noted that is c/w primary lung cancer after correlate with CT.
  • 2023-12-25 ALK IHC (EGFR positive should be self-paid)
    • Cellblock No. S2023-24780
    • RESULT: Positive
  • 2023-12-21 ECG
    • Sinus bradycardia
    • Nonspecific ST abnormality
  • 2023-12-18 Peripheral Vascular Test - Artery, upper limbs
    • Findings
      • Atherosclerosis: Mild
      • Doppler: Decreased flow velocity at L’t Subclavian A., Axillary A., Brachial A., Radial A., Ulnar A.
    • Conclusions:
      • Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery.
      • Patent right upper limbs arteries.
  • 2023-12-15 Tc-99m MDP bone scan
    • Increased activity in the middle C-spine, L2-3 spines and bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips and knees, compatible with benign joint lesions.
  • 2023-12-14 ROS1 IHC
    • Cellblock No.: S2023-24780
    • RESULTS: Negative
  • 2023-12-14 PD-L1 IHC
    • Cellblock No.: S2023-24780
    • RESULTS:
      • Tumor cell (TC) staining assessment: TC: >= 5% and <10%
      • Percentage of PD-L1 expressing tumor cells (%TC): 5%
  • 2023-12-14 PD-L1 (22C3)
    • Cellblock No.: S2023-24780
    • RESULTS:
      • Tumor Proportion Score (TPS) assessment: TPS <1%
      • Tumor Proportion Score (TPS): 0%
  • 2023-12-14 EGFR
    • Cellblock No.: S2023-24780
    • No mutation was detected at exons 18,19, 20, 21 of EGFR gene in this specimen
  • 2023-12-14 PET scan
    • A glucose hypermetabolic lesion in the upper lobe of the left lung near left pulmonary hilum. Primary lung malignancy may show this picture.
    • Glucose hypermetabolism in some left mediastinal lymph nodes. Metastatic lymph nodes should be watched out.
    • Multiple glucose hypermetabolic lesions in bilateral cerebral and cerebellar hemispheres, suggesting multiple cerebral and cerebellar metastases.
    • Glucose hypermetabolism in the stomach. Inflammation may show this picture. please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-12-11 Patho - brain biopsy
    • Brain tumor, frozen + biopsy — Metastatic pulmonary mucinous adenocarcinoma
    • The specimen submitted consists of some small pieces of sticky brain tumor tissue measuring 1.5 x 1.0 x 0.2 cm in aggregate, fixed in formalin. Grossly, they are gray in color and sticky mucus in consistency. All mbedded for section. Reference: frozen section, F2023-00562 some sticky mucoid tumor tissue, all embedded.
    • Microscopically, the section shows a picture of metastatic pulmonary adenocarcinoma characterized by atypical tumor cells arranged in papillary or tubular patterns with intracytoplasmic mucin.
    • Immunohistochemistry shows TTF-1(+), CK7(+), Napsin-A(+), PAX-8(-) and CK20(-) for tumor.
  • 2023-12-11 Frozen Section
    • Brain tumor, frozen — Mucinous adenocarcinoma, metastatic
  • 2023-12-09 CT - brain
    • Indication: brain meta, for navigator
    • With and without-contrast CT of brain shows:
      • Multiple mass lesions, up to 32mm, in bilateral cerebral and right cerebellar hemispheres. Enhancement after contrast administration.
      • Minimal midline shift to left, 4mm.
    • Impression
      • Multiple brain metastasis
  • 2023-12-08 CT - chest
    • Indication: brain metastasis for tumor survey
    • Chest CT with and without IV contrast ehnancement shows:
      • One ground glass nodule at left upper lobe measuring 0.6cm in largest dimension is found. (Se202 Im24).
      • Soft tissue mass at left upper lobe measuring 2.73cm in largest dimension is found. The lesion attached to left hilar region
      • Some lymph nodes are found at bilateral paratracheal region.
      • Cystic change at left ovary up to 2.86cm is found.
    • Imp:
      • left upper lobe lung cancer with brain meta. and mediastinal lymphadenopathy.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-12-07 MRI - brain
    • Indication: Brain metastasis for survey
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Numerous intra-axial tumors with heterogeneous enhancement and perifocal edema involving bilateral cerebral and cerebellar hemispheres, and pons, with the largest one about 33 mm at right anterior frontal lobe. Midline shift to left side for 8 mm also noted.
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
    • IMP:
      • Multiple brain metastases (with the largest one about 33 mm at right anterior frontal lobe causing mass effect).
  • 2023-12-07 ECG
    • Prolonged QT
    • Nonspecific T wave abnormality
  • 2023-12-06 CXR erect
    • A lobulated left parahilar lung tumor mass.

[MedRec]

  • 2024-01-17 SOAP Hemato-Oncology He JingLiang
    • S: CDDP + Gemzar C1D8, ALK positive, apply Alectinib
    • O: Cancer multidisciplinary team meeting conclusion, Meeting date: 2023-12-26
      • RT to brain lesions
      • pending ALK, ROS1, PD-L1.
    • Prescription
      • Hepac Lock Flush (heparin sodium) ST IRRI
      • Norvasc (amlodipine 5mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
      • Through (sennoside 12mg) 2# HS
      • Ulstop (famotidine 20mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
  • 2024-01-04 ProgressNote Gao ZhenYi
    • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
      • Assessment:
        • Chest CT:
          • LUL nodule, 0.6cm
          • Soft tissue mass at LUL 2.73cm
          • Some lymph nodes are found at bilateral paratracheal region.
      • Plan:
        • Carefully monitor vital signs and closely track the neurological status.
        • Administer Keppra at a dose of 500mg twice daily for anticonvulsant therapy.
        • Anti-brain swelling Mannitol 75ml QD then taper off
        • Prescribe an H2 blocker to prevent stress ulcers.
        • Administer pain relief as necessary (using Paran).
        • Administer dexamethasone 1 tablet twice daily, to alleviate brain swelling.
        • 8th RT on 1/3 for brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring. Much improved consciousness & verbal response. Impaired recent memory noted by her son.
        • Follow up lab data on 1/1 showed mild leukocytosis with WBC:12K, nuu:94%, CRP:0.1 and hypocalcemia with Ca:1.93.
        • Plan to start chemotherapy
  • 2024-01-03 ProgressNote Zhang YouKang
    • Subjective
      • 8th RT fraction to metastatic brain tumors today.
      • Much improved consciousness & verbal response.
      • Impaired recent memory noted by her son.
      • Acceptable appetite and oral intake.
      • On wheel chair use.
    • Objective
      • RT dose: 2640cGy/8 fractions (6 MV photon) to metastatic brain tumors (sparring bilateral hippocampi), 2023/12/22 to 2024/01/03.
      • Date of evaluation, 2024/01/03: Radiation dermatitis, grade 0; N/V, grade 0; IICP, grade 1.
      • EGFR mutation: wild type; PD-L1: 5 % (IHC); 1% (22C3).
      • Radiotherapy Adverse Reactions (2024-01-03)
    • Problem #2: Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1c, stage IVB
      • Assessment:
        • Lung cancer, LUL, mucinous adenocarcinoma, with multiple brain metastasis s/p stereotactic brain tumor biopsy on 2023/12/11; ECOG = 2.
        • RT response: partial response.
      • Plan:
        • Local RT (planning dose: 3960cGy/12 fx, sparring bilateral hippocampi); 4 more fx to finish.
    • Attending doctor comments
      • Keep dexamethasone 4mg 1# QD.
      • Walking slowly as rehabilitation.
  • 2023-12-06 ~ 2024-01-11 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy, cT3N2M1, stage IVA
      • Brain metastasis status post stereotactic Brain tumor biopsy on 2023-12-11
      • Severe left subclavian artery stenosis
    • CC
      • intermmitent dizziness in recent one year, and worsened since this 2023 May.
    • Present illness
      • This is a 72-year-old female patient with no significant medical history. Over the past year, she has experienced intermittent episodes of dizziness, which worsened notably since May 2023. Additionally, she has reported disorientation, forgetfulness, and a tendency to become easily lost. Seeking medical attention, she initially visited Yonghe Cardinal Tien Hospital, where a brain CT scan revealed multiple intracranial lesions, raising suspicion of brain metastasis. Subsequently, she sought a second opinion at our neurosurgery clinic. During her outpatient visit, the patient presented with clear and responsive consciousness, with intact cranial nerve function, muscle strength, and deep tendon reflexes. Nevertheless, the brain CT scan again indicated the presence of multiple intracranial lesions, further heightening the suspicion of brain metastasis. Consequently, the patient was admitted to undergo additional evaluations, including brain MRI, chest and abdominal CT scans, and tumor marker testing.
    • Course of inpatient treatment
      • Upon admission, the anticonvulsant medication Keppra was prescribed. Elevated levels of tumor markers CEA and CA199 were detected, prompting preoperative examinations.
      • A lobulated left parahilar lung tumor mass was identified through a chest X-ray, and brain MRI revealed multiple brain metastases, with the largest one measuring about 33 mm, causing mass effect in the right anterior frontal lobe.
      • A whole-body CT scan indicated the presence of left upper lobe lung cancer with brain metastasis and mediastinal lymphadenopathy.
      • A brain CT scan for navigation purposes was performed on 2023-12-09.
      • After thoroughly explaining the imaging findings to the patient and family, a brain biopsy was scheduled for 2023-12-11. The patient underwent a stereotactic brain tumor biopsy, which resulted in a frozen report indicating mucinous adenocarcinoma with metastatic properties. The post-operative course proceeded without complications, and analgesic agents were utilized to manage wound pain.
      • During the hospitalization, elevated blood pressure (systolic BP > 20 mmHg) was observed in both arms. The patient reported mild dizziness while ambulating after surgery, and a cardiovascular specialist was consulted. The assessment revealed a weak left radial pulse (1+) with no accompanying symptoms. Recommendations included:
        • Scheduling an upper extremity Duplex study.
        • Checking the lipid profile, including total cholesterol, LDL, HDL, and triglycerides, and prescribing rosuvastatin if LDL levels exceed 100.
        • Considering the addition of aspirin (100mg daily) if there are no contraindications.
      • A consultation with a hematologist-oncologist was also sought regarding the left upper lobe lung cancer, which involved brain metastasis and mediastinal lymphadenopathy, categorized as T3N2M1.
      • Further evaluation was requested, including:
        • Coordinating a bronchoscopy to obtain tissue proof of the left upper lobe lung cancer.
        • If the bronchoscopy results are inconclusive, considering a CT-guided biopsy.
        • Arranging a bone scan and PET/CT scan for a comprehensive assessment.
        • Pending the pathology results of the brain tumor, considering a colonoscopy if mucinous adenocarcinoma with an origin from the colon is identified.
        • As of the current status, the patient remains conscious with an E4V4M6 score. Head wounds are clean and dry, and continuous monitoring of the clinical condition is being conducted.
      • On 2023/12/20, Anticonvulsant Keppra was maintained.
      • Anti-swelling Mannitol was prescribed and tapper off.
      • Steroid prednisolone 2# TID was prescribed.
      • The final pathology reported metastatic pulmonary mucinous adenocarcinoma. EGFR. PD-L1, PD-L1 IHC and ROS1 IHC were conducted.
      • Oncology radiologist was consulted. RT to brain tumor for 3960cGy/12 fx for tumor control with hippocampal sparring if feasible.
      • CT simulation on 2023/12/20 13:30 will be arranged. RT will be initiated 2-3 days later.
      • Steroid dexamethasone 4mg oral BID was switched at least during brain RT.
      • Peripheral Vascular Test : Artery. upper limbs duplex was performed on 2023/12/20, which revealed 1. Decreased flow spectrum from left subclavian artery, consider severe left subclavian stenosis. Patent left axillary, brachial, antebrachial, raidal and ulnar artery; 2. Patent right upper limbs arteries.
      • We added aspirin 100mg qd for severe left subclavian stenosis.
      • We checked lipid profile and was within normal limit. As of the current status, she remains conscious with an E4V4M6 score. Head wound with stitches were clean and dry.
      • After trasnfered to Oncology ward, we consulted GS for port-A implantation for further chemotherapy.
      • Radiotherapy started on 2023/12/25 for brain metastasis. 12 times RT was done from 2023/12/22 to 2024/01/09 for metastatic brain tumors with hippocampal sparring. Much improved consciousness and verbal response were noted after RT.
      • Follow up lab data on 2024/01/01 showed mild leukocytosis with WBC 12K, nuu 94%, CRP 0.1 and hypocalcemia with Ca 1.93.
      • Follow up lab data on 2024/01/09 showed no leukocytosis and normal PCT. Chest xray showed no pneumonia patch.
      • We start chemothrapy of Gemcitabine 1000mg + cisplatin 35mg on 1/10. Vena, decan, and aloxi were given for vomitting prevent.
      • There were no nausea, vomitting, diarrhea after chemotherapy.
      • Under stable condition of no fever, no dyspnea, no nausea, no diarrhea, she was discharged and turned to OPD follow-up.
    • Discharge prescription
      • Norvasc (amlodipine 5mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC if nausea or vomiting
      • Through (sennoside 12mg) 2# HS
      • Keppra (levetiracetam 500mg) 1# BID
      • Ulstop (famotidine 20mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNQD RECT
      • Acetal (acetaminophen 500mg) 1# PRNQID if pain
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Limeson (dexamethasone 4mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
  • 2023-12-06 SOAP Neurosurgery Xu XianDa
    • S
      • Female patient with recurring dizziness since the previous year.
      • Dizziness worsened significantly in May and reached a peak in November.
      • Symptoms include disorientation, forgetfulness, and a tendency to become lost.
      • No history of hypertension (H/T) or diabetes mellitus (DM).
      • Patient has a 30-year history of smoking one pack of cigarettes per day.
    • O
      • BP:148/73; HR:94;
      • Female patient with clear and responsive consciousness.
      • Normal cranial nerve function.
      • Muscle power (MP) rated at 5 in all limbs with no spasticity.
      • Brisk deep tendon reflexes (DTR) observed in limbs.
      • No signs of dysmetria in finger-nose-finger (FNF) testing.
      • Brain CT reveals multiple intracranial lesions.
      • Impression: Brain metastasis.
    • Plan:
      • Admit the patient for a comprehensive assessment, which will include brain MRI, chest and abdominal CT scans, as well as tumor marker testing.

[chemotherapy]

  • 2024-01-17 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-01-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min + NS 250mL 2hr (before cisplatin) + cisplatin 25mg/m2 35mg NS 350mL 3hr + NS 250mL 60min (after cisplatin) (Gemzar applied twice and omitted once)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-26

[alectinib administration via tube feeding]

The administration of Alecensa (alectinib) typically involves swallowing the capsule whole, as indicated in the Taiwan package insert, which advises against opening the capsule or dissolving its contents.

Despite this, there have been clinical cases where Alecensa was administered via tube feeding in patients with NSCLC, leading to positive outcomes. For instances:

  • A Stage IV NSCLC patient reliant on ventilator support showed tumor shrinkage and improved respiratory status after receiving dissolved Alecensa through a nasogastric tube (NGT). [1]
  • A patient with NSCLC and leptomeningeal carcinomatosis, experiencing drowsiness and difficulty swallowing, also benefited from NGT-administered Alecensa. [2]
  • A Stage IV NSCLC patient with disease progression on crizotinib and tracheostomy for tumor-related airway obstruction responded well to Alecensa dissolved in an olive oil-based solution, administered via a percutaneous endoscopic gastrostomy (PEG) tube. [3]
  • A Stage IV NSCLC patient showed improvement after Alecensa treatment but developed a Grade 3 maculopapular rash after three weeks. The medication was temporarily stopped for steroid treatment. Two weeks later, treatment resumed with Alecensa dissolved in olive oil, starting at 37.5 mg/day and gradually increasing to 300 mg BID. The patient’s rash did not recur, and no other significant adverse reactions were observed. After three weeks, the disease did not worsen. Once the patient’s appetite improved and weight increased, the PEG tube was removed, and they continued on Alecensa 300 mg BID. [4]

Pharmacologically, alectinib hydrochloride is a white to off-white powder containing insoluble particles, formulated into immediate-release capsules. Opening the capsules may lead to dispersion and inhalation of the contents, potentially altering the active ingredient’s concentration. Laboratory tests have shown that Alecensa capsules can dissolve in 40’C warm water within 10 minutes utilizing Simple Suspension Method (SSM), although the resulting suspension may appear cloudy, making it difficult to ascertain complete dissolution. This suspension remains stable for up to 6 hours at 25’C but may turn gel-like after 24 hours. [5]

A Phase I clinical trial assessed the relative bioavailability and pharmacokinetics of an oral suspension of Alecensa compared to its capsule formulation in healthy participants. The study found higher individual peak levels and overall systemic exposure to Alecensa and its metabolite M4 in the oral suspension group, both under fed and fasting conditions, compared to the capsule group. The bioavailability of Alecensa and M4 significantly increased post-administration in the oral suspension group, but there was no significant difference in the incidence or severity of treatment-emergent adverse events (TEAEs) between the two formulations. [6]

Ref: 1. Watanabe Y et al., Ann. Cancer Res. Ther. 2016; 24:47-51. https://www.jstage.jst.go.jp/article/acrt/24/2/24_47/_article 2. Kanai O et al., Clin. Case Rep. 2017; 26:927-930. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458002/ 3. Bejarano MT et al., J Oncol Pharm Pract 2019;25:1722-1725. https://pubmed.ncbi.nlm.nih.gov/30124125/ 4. Anderson BE et al., J Oncol Pharm Pract 2020. https://journals.sagepub.com/doi/abs/10.1177/1078155220918644 5. Manufacturer inhouse data 6. Liu S et al., Clin Transl Sci 2023;16:1085-1096. https://pubmed.ncbi.nlm.nih.gov/36978270/

2024-01-25

[analyzing post-granocyte WBC recovery and left-shifted distribution]

Following the administration of Granocyte (lenograstim), the episode of leukopenia observed on 2024-01-22 resolved.

  • 2024-01-25 Band 21.5 %
  • 2024-01-25 Neutrophil 58.0 %
  • 2024-01-25 Metamyelocyte 10.3 %
  • 2024-01-25 WBC 12.91 x10^3/uL
  • 2024-01-22 WBC 1.37 x10^3/uL **
  • 2024-01-17 WBC 3.76 x10^3/uL
  • 2024-01-09 WBC 8.74 x10^3/uL
  • 2024-01-01 WBC 12.18 x10^3/uL

Subsequent lab results showed no further evidence of leukopenia and indicated a left-shifted distribution, consistent with ongoing G-CSF effect. The blood cell differential on 2024-01-25 revealed increased band cells, neutrophils, and metamyelocytes, alongside mild elevated WBC counts.

This left shift, often linked to rapid blood cell production in response to infections or inflammation, coincides with the CXR on 2024-01-22 showing patchy density in the left pulmonary hilar region. The current empirical use of Brosym (cefoperazone, sulbactam) aligns with these indications.

2024-01-23

[ALK rearrangement discovered: targeted therapy options]

For this patient, who tested positive for ALK on immunohistochemistry IHC on 2023-12-25, consideration might be given to using alectinib, brigatinib, or lorlatinib. If alectinib is the chosen medication, the recommended dosage is 600mg taken twice daily with food.

[hypokalemia - serial serum potassium monitoring and intervention]

The serial data of serum potassium levels indicate a continuing development of hypokalemia. Consequently, Const-K 10mEq TID has been recently initiated to address this condition.

  • 2024-01-22 K(Potassium) 2.8 mmol/L
  • 2024-01-17 K(Potassium) 3.3 mmol/L
  • 2024-01-09 K(Potassium) 3.8 mmol/L
  • 2024-01-01 K(Potassium) 4.2 mmol/L
  • 2023-12-29 K(Potassium) 4.5 mmol/L

When increased sympathetic tone is thought to play a major role, the administration of a nonspecific beta blocker, such as propranolol, might be considered.

2024-01-05

[carboplatin, pemetrexed, pembrolizumab as NSCLC treatment]

For this patient, tests have not detected EGFR or ROS1 mutations, and the PD-L1 22C3 Tumor Proportion Score (TPS) is less than 1%, with Immunohistochemistry (IHC) Tumor Cells (TC) at 5%.

If the patient recovers to ECOG PS 0-1, a potential treatment regimen could include a combination of either carboplatin or cisplatin, along with pemetrexed and pembrolizumab.

700161986

240125

[exam findings]

[MedRec]

  • 2024-01-24 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Generalized anxiety disorder [F41.1]
      • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
      • Malignant neoplasm of unspecified site of left female breast [C50.912]
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# QN
      • Zoloft (sertraline 50mg) 1# QN
  • 2024-01-08 SOAP Hemato-Oncology Gao WeiYao
    • Prescription
      • Femara (letrozole 2.5mg) 1# QD
  • 2023-12-29 ~ 2024-01-01 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Infiltrating ductal carcinoma of the left breast, stage pT1N3(31/34)M0, ER(-), PR(+, 60%), Her-2/neu (-, 1+), s/p partial mastectomy and axillary lymph nodes dissection, with bone metastases
      • Mixed hyperlipidemia
      • Generalized anxiety disorder
    • CC
      • for Anti-estrogens with Q1M Faslodex (500mg, self pay) and follow up CT.            
    • Present illness
      • The 66-year-old woman has had infiltrating ductal carcinoma of the left breast, ER(-), PR(60%), Her-2/Neu(1+), s/p partial mastectomy and axillary lymph nodes dissection, pT1N3(31/34)M0 in 2005/12. However, recurrence progression with bony mets s/p RT to right low lateral chest wall area (30Gy/15fx) on 2017, under hormonal therapy with Letrozole and Hormonal therapy with Famera and self-paid of Faslodex (500mg) QM was given from 2018/06/07. Then she started kisqali CDK4/6 inhibitor 2 tab QD from 2019/07/22 (3 weeks plus rest 1 week). Follow up chest CT on 2021/9/18 which revealed no evidence of recurrent/residual tumor in the current study.
      • The bone-densitometry showed normal also noted on 2021/12/6. RT OPD follow up and who assassment the area can’t RT again and suggest to orthopedics for vertebroplasty, but patient refused for probable side effect. Xgeva was given Q4W since 2021/12/9. Anti-estrogens with Q1M Faslodex (500mg, self pay) from 2021/12/19~.
      • Bone scan was arranged on 2022/11/24 showed in comparison with the previous study on 2021/11/18, the bone lesion in the L3 spine is less evident. Mildly increased activity in some middle and lower T-spines. Degenerative change may show this picture.
      • Follwed CT was perfromed on 2023/07/18 revealed mild fibrosis at lower lobes of lungs, stable. no locoregional recurrent breast tumor based this exam.
      • Due to low back pain in progress, she sent to NS OPD for help. Spinal-MRI showed recent compression fractur at L3 and L4 vertebral bodies. Lumbar spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp L3-4. Lumbar vertebra, L3 compression fracture status post L3 kyphoplasty on 2023/10/05.
      • This time, she denied vomit, bone pain or diarrhea, so she was admitted for follow up chest CT and Anti-estrogens with Q1M Faslodex (500mg, self pay) on 2023/12/29.
    • Course of inpatient treatment
      • After admission, she received Faslodex 500mg by self pay on 2023/12/30. Chest CT follow up on 2023/12/30 and report showed left adrenal nodule (1.0cm) and stable condition of bil. lung fibrosis. Under the stable condition, she can be discharged on 2024/01/01. OPD follow up is arranged.
    • Discharge prescription
      • Kisqali (ribociclib 200mg) 1# QD
      • BioThree (bacillus mesentericus, streptococcus faecalis, clostridium butyricum; 22mg) 1# TID
      • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
  • 2023-08-21 SOAP Hemato-Oncology Gao WeiYao
    • P: Refer to NS Lee for prior history of L compression fracture, but recent bone scan showed more prominent with back pain.
  • 2018-02-07 SOAP Psychosomatic Medicine Chen YiQian
    • Diagnosis
      • Panic disorder [episodic paroxysmal anxiety] without agoraphobia [F41.0]
    • Prescription x3
      • Zoloft (sertraline 50mg) 1# HS
  • 2018-01-15 SOAP Chest Medicine Su WenLin
    • Diagnosis
      • Asthma [J45.991]
      • Allergic rhinitis, unspecified [J30.9]
      • Malignant female breast neoplasm, NOS [C50.912]
      • Comnon migraine without mention of intractable migraine [G43.009]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Foster BID INHL
      • Xyzal (levocetirizine 5mg) 1# HS
  • 2017-01-23 SOAP Hemato-Oncology Gao WeiYao
    • S
      • For follow up
      • History of infiltratig ductal carcinoma of Lt breast, Lt, T1N3Mx post operation (2025-12-xx) at TSGH followed by taxotere and pharmorubicin
      • HEAVILY LN METASTASES - S-node (2/2), level I (14/14), level II (3/3), level III (3/3), unlabelled lymphoid tissue (9/12), ER (-), PR (+), Her-2 (-)
    • O
      • She had nolvadex for 5 years and femara for almost 5 yrx and she requested to discontinue the femara today (20161226)
      • She was informed to have autonomic dysfunction (20160905) She claimed it was relieved by Rivotril 0.5 tab 0.5 mg/tab plus lepax10 mg hs (ativan 0.5 mg/tab).
      • Radiologist Dr Kuo suggest to repeat mammo and breast sono 3 months later based on April 21 suspected mammo findings by Dr Kuo. (20140516)
      • Questionable nodule over LLL (20140516)
      • s/P mastectomy
      • migraine relieved by sibelium (suzin)
      • Under femara treatment
    • Diagnosis
      • Malignant female breast neoplasm, NOS [C50.912]
      • Comnon migraine without mention of intractable migraine [G43.009]
      • Mixed hyperlipidemia [E78.2]

==========

2024-01-25

[stable vitals amidst possible treatment-related hematologic effects]

The patient, currently treated with fulvestrant, letrozole, and ribociclib for her infiltrating ductal carcinoma, exhibited largely normal lab values on 2024-01-25, except for leukopenia (2.1K/uL) and anemia (HGB 10g/dL). These conditions might be associated with her treatment, particularly ribociclib (anemia: 17% to 19%; leukopenia: 27% to 33%) and/or fulvestrant (anemia: 4% to 40%; lymphocytopenia: 35%).

Throughout this hospitalization, the patient’s vital signs have remained stable, and no discrepancies in medication have been identified.

700349893

240125

[exam findings]

  • 2024-01-23 CXR erect
    • Increase bilateral lung markings.
    • Plerual calcification in right upper.
    • No cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis and compression fractures.

[MedRec]

  • 2024-01-25 Progress Note
    • Problem List
      • Problem #1: Thrombocythemia cause unknown
        • Assessment:
          • worsen for PLT higher
        • Plan:
          • bone marrow, BCRABL, Jak-c and chromosome is arranged
          • IVF hydration 1000ml qd
          • monitor PLT level
    • Problem #2: Urinary tract infection
      • Assessment:
        • no fever is stable condition
      • Plan:
        • antibiotic as Rocephine 2g qd
        • pending U/C
    • Attending physician ward round records and comments
      • Myeloproliferative disease should be ruled in.
  • 2024-01-24 Vs Note on Admission Day Gao WeiYao
    • A 90-yr-old man with stroke history with ECOG 4 was sent to ER on account of poor intake for 3 days and malaise for 1+ weeks. Care-giver denied he has fever, chills, choking, diarrhea or falls. At ED, his vital sign showed BP:89/60mmHg, HR:109/bpm, BT:35.5’C, RR 20/bpm, conscious E3V2M5. Lab data showed WBC 28470/uL, PL 1649000/uL (his platelet count was 900,000 in Mar 2023), Reticulocyte 2.810, Lactate 2.5, Na 154, BUN/Cr 86/1.88.
  • 2024-01-23 SOAP Medical Emergency Chen ZuYi
    • A/P
      • preliminary impression: other malaise
      • 2024/01/23 23:08 WBC = 28.47 x10^3/uL;
      • 2023/03/30 20:02 WBC = 14.50 x10^3/uL;
      • 2022/10/18 07:02 WBC = 17.70 x10^3/uL;
      • 2022/10/16 14:51 WBC = 17.47 x10^3/uL;
      • 2024/01/23 23:08 PLT = 1649 x10^3/uL;
      • 2023/03/30 20:02 PLT = 921 x10^3/uL;
      • 2022/10/18 07:02 PLT = 956 x10^3/uL;
      • 2022/10/16 14:51 PLT = 925 x10^3/uL;
  • 2023-12-07 SOAP Orthopedics Huang ZhenWen
    • O
      • bilateral knee OA, knee flexion contracture.
      • creatine: 1.24
    • Prescription x3
      • Celebrex (celecoxib 200mg) 1# QD
  • 2023-07-22 SOAP Orthopedics Zhu ChongHua
    • S
      • bilateral knee pain for days
      • surgical hx: left ITC fracture s/p ORIF
    • O
      • 2nd Prolia
    • A
      • left ITC fracture s/p ORIF
      • osteoporosis, T score: -4
      • bilateral OA knee
    • p:
      • prolia: 20221103, 20230722
      • Ca+ vit D supplemenet
    • Prescription x3
      • Mobic (meloxicam 15mg) ST IM
      • Celebrex (celecoxib 200mg) 1# QD
      • BioCal Chewable Tablets (tribasic calcium phosphate 1203mg, cholecalciferol 330IU) 1# TID
      • Prolia (denosumab 60mg) ST SC
  • 2017-03-22 SOAP Neurology Xiao ZhenLun
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.9]
      • Essential hypertention, unspecified [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.4]
      • Gout, unspecified [M10.9]
      • OA, localized, not specified whether primary or secondary, unspecified site [M19.90]
    • Prescription x3
      • Arcoxia (etoricoxib 60mg) 1# QD
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Syntam (piracetam 1200mg) 1# BID
      • Rivotril (clonazepam 0.5mg) 1# BID
      • Through (sennosides 12mg) 2# HS
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD

==========

700654288

240125

[lab data]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.44 S/CO
2024-01-25 Anti-HBc Nonreactive
2024-01-25 Anti-HBc-Value 0.17 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.09 S/CO

[exam findings]

  • 2024-01-25 Flow Volume Chart
    • Moderate restrictive ventilatory impairment
  • 2024-01-24 CXR erect
    • Chest PA view shows: Normal heart size.
      • Placement of right subclavian port-A catheter.
      • Medial mass with bulging contour.
      • Left pleural effusion.
  • 2024-01-24 Chest lateral Lt
    • Medial mass. Left pleural effusion, with blunted posterior costophrenic angle.

[MedRec]

  • 2024-01-24 SOAP Medical Emergency Chen ZuYi
    • S
      • Transferred from XinDian Cardinal Tien Hospital by Dr Ou WeiRen. The patient unexpectedly found that her white blood cells were too high after giving birth late last year, and she was suspected of having lymphoma after examination.
      • 2023/12/20 at Cardinal Tien Hospital: Vaginal delivery in normal pregnancy.
      • 2023/12/25 at Cardinal Tien Hospital: CT of the chest without/with intravenous contrast.
        • FINDINGS:
          • Pleura: small bilateral pleural effusion.
          • Mediastinum: a huge heterogeneous mass in superior mediastinum, with internal hemorrhagic part, about 183mm in greatest dimension.
          • Heart/great vessel: cardiomegaly.
          • Pericardial effusion.
          • Other: splenomegaly.
        • Impression:
          • Suspect thymic tumor, suggest further evaluation.
          • Splenomegaly.
      • 2024/01/10 at Cardinal Tien Hospital:
        • CHEST MRI
          • MRI of the chest without and with contrast enhancement shows:
            • A 18.5129cm lobular heterogeneously enhanced mass in the anterior upper mediastinum. Some cystic component in the mass.
            • No definite nodules at bilateral hilar, supraclavicular area and upper abdominal cavity.
            • Presence of small amount of pericardial effusion and bilateral pleural effusion.
            • Splenomegaly.
          • Imp:
            • Anterior upper mediastinal mass, suspect thymoma or lymphoma pericardial effusion and bilateral pleural effusion
            • Splenomegaly
        • BRAIN MRI
          • MRI of the brain without and with contrast enhancement shows:
            • No abnormal signal intensity lesion in the brain parenchyma.
            • Normal size of the ventricles and cerebral sulci.
            • No mass effect. No abnormal contrast enhancement.
          • Imp:
            • No abnormal findings
    • A/P
      • Preliminary impression: C81.99 Hodgkin lymphoma, unspecified, extranodal and solid organ sites
      • Susp lymphoma, Rt, susp mediastinitis, WBC 30K, Hb 9.9, CRP 5.2, Loforan, OA ONC

==========

2024-01-25

[vaccine recommendations for hepatitis B susceptible individuals with cancer]

Lab results on 2024-01-25 show both HBsAg and anti-HBc as nonreactive. This could indicate either susceptibility to future hepatitis B infection (if anti-HBs is nonreactive) or immunity from hepatitis B vaccination (if anti-HBs is also nonreactive).

For susceptible individuals, it is recommended all unvaccinated patients with cancer aged 19 or older should receive the hepatitis B vaccine. (Ref: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2024. MMWR Morb Mortal Wkly Rep. 2024 Jan 11;73(1):11-15. doi: 10.15585/mmwr.mm7301a3.) Additionally, coadministration of hepatitis B and hepatitis A vaccines is an option.

Inactivated vaccines are generally advised to be administered at least two weeks prior to starting chemotherapy or other immunosuppressive therapies to enhance the immune response. (Ref: Practical review of immunizations in adult patients with cancer. Hum Vaccin Immunother. 2015;11(11):2606-14. doi: 10.1080/21645515.2015.1062189.) A recombinant hepatitis B vaccine is available at this hospital.

700927977

240125

[MedRec]

  • 2023-10-13 SOAP Cardiology Huang XuanLi
    • Prescription x3
      • Coralan (ivabradine 5mg) 1# BID
      • Entresto (sacubitril 97mg, valsartan 103mg; 200mg) 0.25# QD skip once if SBP < 100mmHg
      • Feburic (febuxostat 80mg) 0.5# QOD
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
      • Pentop (pentoxifylline 400mg) 1# QD
      • Through (sennoside 12mg) 2# HS
      • Budema (bumetanide 1mg) 0.5# QD
  • 2017-01-04 SOAP Cardiology Huang XuanLi
    • Diagnosis
      • CHF; Congestive heart failure [I50.22]
      • Essential hypertention, unspecified [I10]
      • Femoral hernia unilateral or unspecified, recurrent without mention of obstruction or gangrene [K41.91]
      • Other insomnia [G47.09]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Neuralgia,neuritis, and radiculitis,unspecified [M79.2]
    • Prescription x3
      • Adalat Oros (nifedipine 30mg) 1# PRN
      • Urief (silodosin 4mg) 1# BID
      • Coxine (isosorbide-5-mononitrate 20mg) 0.5# HS
      • Busix (bumetanide 1mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
  • 2017-01-03 SOAP Neurosurgery Li DingZhou
    • Diagnosis
      • Spondylosis of unspecified site, with mention of myelopathy [M47.10]
      • Discitis, unspecified, lumbar region [M46.46]
      • Other spondylosis, cervical region [M47.892]
      • Unspecified systolic (congestive) heart failure [I50.20]
      • Spinal stenosis, site unspecified [M48.00]
      • Acute and subacute endocarditis, unspecified [I33.9]
      • Overflow incontinence [N39.490]
      • Cervical root disorders, not elsewhere classified [G54.2]
      • Close fracture of lumbar without mention of spinal cord injury [S32.000A]
      • Localized osteoporosis [Lequesne] [M81.6]
    • Prescription x3
      • Celebrex (celecoxib 200mg) 1# PRNQD
      • Neurontin (gabapentin 100mg) 1# QD
      • Aelocon (Vit B1 50mg, B2 5mg) 1# QD

[consultation]

==========

2024-01-25

[ongoing renal deterioration and bumetanide dosage considerations]

Recent test results indicate a mild increase in hs-Troponin I at 164.1 pg/mL, CKMB at 17.6 ng/mL, CK at 405 U/L, and ECG showing T wave depression in lateral leads, therefore a consultation with our cardiologist is just initialized.

This patient has experienced a gradual deterioration in kidney function in recent months. Consequently, all medication dosages on the active list have been adjusted to accommodate the patient’s current renal status.

  • 2024-01-25 Cre 4.24 mg/dL
  • 2024-01-25 BUN 57 mg/dL
  • 2024-01-25 eGFR 14.36 ml/min/1.73m^2
  • 2024-01-23 eGFR 16.14 ml/min/1.73m^2
  • 2024-01-05 eGFR 21.73 ml/min/1.73m^2
  • 2023-10-13 eGFR 27.16 ml/min/1.73m^2
  • 2023-09-15 eGFR 37.38 ml/min/1.73m^2

Additionally, for the patient’s eGFR <30, increased doses of bumetanide may be necessary for an effective diuretic response (2024-01-24 input 1710 output 230 + loss).

Given the absence of serological hepatitis virus data in the patient’s history in HIS5, the elevated liver enzyme levels (AST at 170 U/L and ALT at 95 U/L on 2024-01-25) might be further investigated once the patient’s cardiological conditions have stabilized.

701512638

240125

[exam findingns]

2024-01-25 HBsAg Nonreactive
2024-01-25 HBsAg (Value) 0.42 S/CO
2024-01-25 Anti-HCV Nonreactive
2024-01-25 Anti-HCV Value 0.14 S/CO
2024-01-25 Anti-HBc Reactive
2024-01-25 Anti-HBc-Value 3.19 S/CO
2024-01-25 Anti-HBc IgM Nonreactive
2024-01-25 Anti-HBc IgM Value 0.08 S/CO
2024-01-25 Anti-HBs 184.65 mIU/mL

[MedRec]

  • 2024-01-23 SOAP Hemato-Oncology Gao WeiYao
    • S
      • Hualian TzuChi Dr Hseu WL friend
      • Adenocarcinoma of stomach, diffuse type, Her-2 (-), pT4aN3aMb post total gastrectomy on 2024-01-02 (presenting with gastric outlet obstruction).
    • O
      • BP 125/76; BH 168 cm; BW 55 kg; BMI 19.5

==========

2024-01-25

[reactive anti-HBc and prophylactic antiviral strategy]

Lab results on 2024-01-25 indicated a reactive anti-HBc status. In light of this finding, it is advisable to consider prophylactic antiviral nucleoside analog therapy before commencing chemotherapy treatment.

700715400

240124

[lab data]

  • 2022-02-18
    • All-RAS mutation not detected (wild type)
    • BRAF mutation not detected (wild type)
    • EGFR G719X mutation not detected
    • EGFR Exon19 deletion not detected
    • EGFR S768I not detected
    • EGFR T790M not detected
    • EGFR Exon20 insertion not detected
    • EGFR L858R not detected
    • EGFR L861Q not detected

[exam findings]

  • 2023-11-24 CT - abdomen
    • History: S-colon cancer with liver metastasis S/P OP and C/T.
    • Findings: Comparison prior CT dated 2023/07/12 and MRI dated 2023/07/26.
      • Prior MRI identified seven metastases in left lobe liver are noted again, decreasing in size.
        • Liver metastases S/P C/T with partial response is highly suspected.
        • Follow up MRI 3 months later is indicated.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, decreasing in size to 1.7 cm.
      • S/P near total resection of S5/6/7.
        • S/P partial resection of S8 of the liver with biloma 4 cm.
        • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, decreasing in size.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • There is no focal lesion in both lung and mediastinum.
      • S/P right lobectomy of the thyroid?
        • please correlate with clinical history.
    • Impression:
      • Liver metastases S/P C/T with partial response is highly suspected.
      • Follow up MRI 3 months later is indicated.
  • 2023-08-07 PET
    • Increased FDG uptake in the S- and R-colon, probably feces accumulation.
    • At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases.
    • Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases.
    • Increased FDG uptake in the left rib cage, highly suspected bone metastases.
    • Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-07-26 MRI - liver, spleen
    • History: S-colon cancer with liver metastasis S/P OP and C/T.
    • Findings:
      • There are seven newly developed masses on S2-3-4 of the liver, showing hypointensity on T1WI, mild hyperintensity on both T2WI and DWI, and poor enhancement in dynamic study. The largest one 1.7 cm in S4.
        • Seven metastases are noted.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • A renal cyst 0.9 cm in left middle pole is noted.
    • Impression:
      • Seven metastases on S2-3-4 of the liver are noted.
  • 2023-07-12 CT - abdomen, pelvis
    • Findings:
      • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • S/P right lobectomy of the thyroid? please correlate with clinical history.
    • Impression:
      • There is an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. Please correlate with sonography and MRI.
  • 2023-04-19 CT - abdomen, pelvis
    • Findings:
      • S/P LAR with autosuture retention over the sigmoid colon.
        • In addition, Prior CT identified a cystic lesion 1.9 cm in the right lateral aspect of the anastomosis area is noted again, stationary.
      • S/P near total resection of S5/6/7.
      • S/P partial resection of S8 of the liver with biloma 4.6 cm.
      • S/P partial resection of left lateral aspect of S2-3 of the liver.
      • There is an ill-defined poor enhancing lesion 1.2 cm in the residual S2 of the liver. Follow up is indicated.
      • Prior CT identified some LNs at mediastinum, mesentery and retroperitoneum are noted again, stationary.
      • Hyperplasia of left adrenal gland.
      • A renal cyst 0.9 cm in left middle pole is noted.
      • S/P right lobectomy of the thyroid? please correlate with clinical history.
    • Impression:
      • S/P LAR with autosuture retention over the sigmoid colon. There is no evidence of tumor recurrence.
  • 2023-01-17 CT - abdomen, pelvis
    • History and indication: S-colon cancer s/p c/T OP for liver and primary lesion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 4.6cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
      • Minimal ascites. Hyperplasia of left adrenal gland.
      • Tiny renal cysts.
      • Absence of right thyroid gland.
      • Atherosclerosis of aorta, iliac arteries.
      • Right minimal pleural effusion.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 4.6cm).
      • Some LNs at mediastinum, mesentery and retroperitoneum.
  • 2022-10-20 CT - abdomen, pelvis
    • History and indication: Sigmoid colon cancer with liver mets, s/p neoadjuvant C/T with P-FOLFIRI, s/p over sigmoid and liver, s/p adjuvant C/T with P-FOLFIRI
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
      • Minimal ascites. Hyperplasia of left adrenal gland.
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
      • Right minimal pleural effusion.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation.
      • S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver.
      • Some LNs at mediastinum, mesentery and retroperitoneum.
  • 2022-08-16 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S2, S2 resection — Metastatic colonic adenocarcinoma
      • Liver, S8 and S3, partial hepatectomy — Metastatic colonic adenocarcinoma
      • Liver, S6-7, S6-7 resection — Metastatic colonic adenocarcinoma
      • Tumor regression grade: Grade 3 (fibrosis > cancer cells)
    • MACROSCOPIC EXAMINATION
      • Procedures: S2 and S6-7 resection, and S8 and S3 partial hepatectomy
      • Specimen Size: 16 x 10 x 5.0 cm & 190 gm (S2), 2.0 x 2.0 x 1.5 cm & 10 gm (S3), 9.0 x 7.0 x 5.0 cm & 110 gm S8), 20 x 11 x 6.0 cm and 420 gm (S6-7)
      • Tumor Focality: Multiple (number: 4)
      • Tumor Site: S2, S8, S3, and S6-7
      • Tumor Size: 6.0 x 5.0 x 5.0 cm (S2), 1.2 x 0.9 x 0.8 cm (S3), 6.5 x 5.5 x 5.0 cm (S8), and 11.5 x 7.9 x 6.5 cm (S6-7) respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= S2 tumor, B= S3 tumor, C1-C4= S8 tumor, D1-D4= S6-7 tumor
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Infiltrative
      • Tumor pseudocapsule: Absent
      • Percentage of necrosis:10%; Percentage of fibrosis: 50%
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.1 cm (S2, S8, S6-7)
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 3 (fibrosis > residual cancer cells)
      • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic portal inflammation, compatible with chemotherapy-associated liver injury
      • Fatty Change: Absent
  • 2022-08-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Sigmoid colon, sigmoid colectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, sigmoid colectomy – Free
      • Lymph nodes, mesocolic, sigmoid colectomy — Negative for malignancy (0/19)
      • Pathology stage: ypT3N0M1a; Stage IVA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Sigmoid colectomy
      • Specimen site: Sigmoid colon
      • Specimen size: 18.0 cm in length
      • Tumor size: 3.8 x 3.0 cm
      • Tumor location: 6.0 cm and 9.0 cm away from the two resection margins, respectively .
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1= tumor + pelvic wall, A2-A4= tumor, A5-A8= regional LNs, B= anastomosis site, proximal, C= anastomosis site, distal.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Pericolic soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Low
      • Margins
        • Proximal and distal anastomosis sites: Free
        • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
        • Pelvic wall: Fibrous adhesion without cancer cells
      • Lymph node metastasis, mesocolic: Negative for malignancy (0/19) (No. Positive / No. Total)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): ypT3 (Tumor invades pericolic tissue)
        • Regional Lymph Nodes (pN): ypN0 (No regional lymph node metastasis)
        • Distant Metastasis (pM): M1a (Metastasis to liver (see S2022-13475))
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • Treatment effect: Partial response; Residual cancer with evident tumor regression (partial response, score 2)
      • IHC(S2022-01236): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2022-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
  • 2022-07-29, -07-23 KUB
    • S/P sigmoid colon stenting.
  • 2022-07-23 KUB
    • S/P sigmoid colon stenting with marked distension of the proximal colon. stenting obstruction is highly suspected.
  • 2022-07-21 CT - abdomen, pelvis
    • Mild regression of S-colon cancer and liver metastases. S/P S-colon stenting. Dilatation of colon.
  • 2022-05-05 CT - abdomen, pelvis
    • Much regression of S-colon cancer and liver metastases.
  • 2022-01-22 CT
    • Findings
      • Huge heterogeneous soft tissue mass at both lobes of liver up to 12.5cm is found.
      • s/p sigmoid colon stent placement. The sigmoid colon wall is thick. Some lymph nodes (n = 4) is found.
    • Imp:
      • Sigmoid colon cancer s/p stent placement and liver mets.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T3N2M1
  • 2022-01-20 Patho - colon biopsy
    • Colon, sigmoid, biopsy - Adenocarcinoma, moderately differentiated
    • IHC: EGFR(+), PMS2(focal +), MLH1(+), MSH2(+), and MSH6(+).
    • Section shows pieces of colonic tissue with tumor necrosis, tubulovillous glands and scant invasive irregular neoplastic glands.
  • 2022-01-19 Colonoscopy
    • Colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy
    • Mixed hemorrhoid

[MedRec]

  • 2024-01-02 ~ 2024-01-05 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • S-colon cancer with liver metastases, T3N2M1a, stage IVA s/p S-colon stenting on 2022/01/19 and chemotherapy with FOLFIRI from 2022/01/24~2022/07/13 (for 12 cycles), Vectibix (panitumumab) from 2022/03/23~2022/07/13 (for 8 cycles) s/p Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15 s/p chemotherapy with FOLFIRI/Vectibix from 2022/09/13~2023/04/07, with liver metastasis, ypT3N2M1b, stabe IVB, s/p chemotherapy with FOLFIRI/Vectibix from 2023/08/29~
      • Chronic viral hepatitis B without delta-agent
      • Type 2 diabetes mellitus with hyperglycemia
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Dermatitis, due to Panitumumab related
    • CC
      • For palliative chemotherapy with FOLFIRI/Vectibix(self-paid)(C4D1).            
    • Present illness
      • This 60-year-old woman patient referred from Cardinal Tien Hospital due to abdominal discomfort 2022/01. According to patient and family statement, she had sufferred from of chronic constipation for 1 year and involuntary weight loss about 5kg in one month. She visited Cardinal Tien Hospital and low GI series was arranged. After examination, abdmonial fullness, watery diarrhea was noted, however laxatives had no effect. Due to persisted symptoms, she visited Cardinal Tien Hospital ER for help.
      • Abdominal CT on 2022/01/18 revealed dilated colon, a transition zone at sigmoid colon and multiple liver neoplasm, sigmoid cancer with multiple liver metastasis was highly suspected.
      • Sigmoidoscopy on 2022/01/19 showed colon cancer, sigmoid colon, with acute obstruction s/p self expandable metal stent placement and biopsy, mixed hemorrhoid. Sigmoid biopsy showed adenocarcinoma, moderately differentiated. Port-A catheter insertion on 2022/01/21. Chest CT on 2022/01/22 showed sigmoid colon cancer s/p stent placement and liver meta.
      • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) was given on 2022/01/24~2022/07/13 for 12 cycles. Target therapy with Panitumumab (Vectibix) (6mg/kg) 400mg on 2022/03/23~2022/07/13 for 8 cycles. Abdominal CT on 2022/05/05 showed much regression of S-colon cancer and liver metastases.
      • Lower abdominal fullness with severe pain on 2022/07. Abdominal CT on 2022/07/21 showed mild regression of S-colon cancer and liver metastases, S/P S-colon stenting and dilatation of colon. KUB on 2022/07/21 showed ileus. Sigmoidoscopy on 2022/07/21 showed sigmoid colon cancer post SEMS with stent dysfunction (obstruction), s/p placement of a new metal stent, proctocolitis distal to the tumor, anal prolapse and incomplete study of colon.
      • 2D echo on 2022/08/09 showed M-mode(Teichholz) = 74, 1.Normal LV filling pressure. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis.
      • Sigmoid colectomy and open S6-7, S2 and S8 partial and S3 partial hepatectomy on 2022/08/15.
      • Sigmoid colon pathology showed adenocarcinoma, moderately differentiated without lymph node metastasis(0/19), ypT3N0M1a; Stage IVA.
      • Liver pathology showed metastatic colonic adenocarcinoma.
      • Post-OP chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, given 400mg) was given on 2022/09/13(C1D1), 2022/09/27(C1D15), 2022/10/11(C2D1), 2022/10/28(C2D15), 2022/11/08(C3D1), 2022/11/22(C3D15), 2022/12/06(C4D1), 2022/12/20(C4D15), 2023/01/03(C5D1), 2023/01/17(C5D15), 2023/02/08(C6D1), 2023/02/27(C6D15), 2023/03/17(C7D1).
      • Abdominal CT on 2022/10/22 showed S/P colon operation, S/P liver operation with biloma formation (up to 6.1cm). Some hypodense lesions in liver and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/01/17 showed S/P colon operation, S/P liver operation with biloma formation (up to 4.6cm) and some lymph nodes at mediastinum, mesentery and retroperitoneum. Follow-up, Abdominal CT on 2023/04/22 showed S/P LAR with autosuture retention over the sigmoid colon, no evidence of tumor recurrence.
      • Follow-up, Abdominal CT on 2023/07/12 showed an ill-defined poor enhancing lesion 1.9 cm in S6 of the liver that may be metastasis and flow artifact. suggest correlate with sonography and MRI.
      • Abdominal MRI was done on 2023/07/26 showed seven metastases on S2-3-4 of the liver are noted.
      • Whole body PET scan on 2023/08/11 showed 1. Increased FDG uptake in the S- and R-colon, probably feces accumulation, 2. At least six nodular lesions of increased FDG uptake in the right lobe of the liver, highly suspected colon cancer with liver metastases, 3. Increased FDG uptake in several celiac lymph nodes, highly suspected colon cancer with distant lymph nodes metastases, 4. Increased FDG uptake in the left rib cage, highly suspected bone metastases, 5. Sigmoid colon cancer s/p treatment with celiac lymph nodes, liver and left ribs metastases, ycTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2023/08/29(C1D1), 2023/09/18(C1D15), 2023/10/09(C2D1), 2023/11/01(C2D15), 2023/11/21(C3D1), 2023/12/11(C3D15).
      • Follow up bdominal CT for survey on 2023/11/24 showed Liver metastases S/P C/T with partial response is highly suspected.
      • Now, she was admitted to ward for chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) on 2024/01/03(C4D1).
    • Course of inpatient treatment
      • After admitted, palliative chemotherapy with biweekly FOLFIRI (Campto 180mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) /Vectibx (6mg/kg, self pay, given 400mg) from 2024/01/03~2023/01/05(C4D1).
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting and Olanzpine 1# po HS for severe vomiting.
      • ULSTOP F.C 20mg/tab 1# PO BID for GERD.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti HBc(+).
      • Type 2 diabetes mellitus with Diet control and check finger sugar and Meftormin 500mg 2# po BID, Canaglu 100mg 1# PO QD and Glitis 30mg 1# PO QD.
      • Hypertension with Irbesartan 300mg 0.5# PO QD, Zanidip F.C 10mg 1# PO QD and Concor 5mg 1# PO QD.
      • Hyperlipidemia with Crestor 10mg 1# PO QN.
      • Dermatitis, due to Panitumumab related, Allegra 60mg/tab 1# PO BID and Topsym cream 0.05%, 10gm/tube 1qs for skin rash and itchy.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2024/01/05 and OPD followed up later.
    • Discharge diagnosis
      • Allegra (fexofenadine 60mg) 1# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Limeson (dexamethasone 4mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# QD
      • Zyprexa Zydis (olanzapine 5mg) 1# HS
      • Topsym Cream (fluocinonide 0.05%) QD EXT

[surgical operation]

  • 2022-08-15
    • Surgery: Sigmoid colectomy        
    • Finding: Sigmoid cancer with pelvic wall direct invasion
  • 2022-08-15
    • Surgery: open S6-7, S2 and S8 partial and S3 partial hepatectomy
    • Finding: multiple liver tumor 0.5 to 7 cm bilat lobe

[consultation]

  • 2022-07-21 colon and rectal surgery
    • Q
      • Lower abdomen pain VAS 10 for 2 days
      • Hx of sigmoid cancer with multiple liver metastasis
      • Deny abd op hx
    • A
      • S/O
        • S colon cancer with obstruction and multiple liver s/p stent by GI
        • low abdomen pain and no solid stool for 1~2 days
        • CT: favored solid stool stuck in stent
      • A/P:
        • suggested medical treatment + maybe st enema
        • T loop colostomy if no improving
  • 2022-01-21 hematology and oncology
    • please check AntiHbc for chemotherapy HBV evaluation
    • if proven colon cancer, for advanced metastasis colon cancer, systemic therapy is indicated. Ex: FOLFOX+/-avastin or FOLFIRI+/-avastin, +ceftuximab if KRAS wide type, consider IO if dMMR/MSI-H
    • pending pathology result and we wound like to follow up this case
  • 2022-01-19 colon and rectal surgery
    • This is a case of sigmoid cancer with obstruction, multiple liver metastasis. I’ve discussed with the patient and her families, palliative stent is indicated. After colonic stent, palliative chemotherapy and target therapy will be arranged.

[chemotherapy]

  • 2024-01-23 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
  • 2024-01-03 - panitumumab 6mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-11 - (FOLFIRI plus panitumumab)

  • 2023-11-21 - (FOLFIRI plus panitumumab)

  • 2023-10-31 - (FOLFIRI plus panitumumab)

  • 2023-10-09 - (FOLFIRI plus panitumumab)

  • 2023-09-18 - (FOLFIRI plus panitumumab)

  • 2023-08-29 - (FOLFIRI plus panitumumab)

  • 2023-04-07 - (FOLFIRI plus panitumumab)

  • 2023-03-17 - (FOLFIRI plus panitumumab)

  • 2023-02-27 - (FOLFIRI plus panitumumab)

  • 2023-02-08 - (FOLFIRI plus panitumumab)

  • 2023-01-17 - (FOLFIRI plus panitumumab)

  • 2023-01-03 - (FOLFIRI plus panitumumab)

  • 2022-12-20 - (FOLFIRI plus panitumumab)

  • 2022-12-06 - (FOLFIRI plus panitumumab)

  • 2022-11-22 - (FOLFIRI plus panitumumab)

  • 2022-11-08 - (FOLFIRI plus panitumumab)

  • 2022-10-25 - (FOLFIRI plus panitumumab)

  • 2022-10-11 - (FOLFIRI plus panitumumab)

  • 2022-09-27 - (FOLFIRI plus panitumumab)

  • 2022-09-13 - (FOLFIRI plus panitumumab)

  • 2022-07-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr (FOLFIRI plus panitumumab)

  • 2022-06-29 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-06-15 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-06-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-27 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-13 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 48hr

  • 2022-04-01 - panitumumab 6mg/kg 90min + irinotecan 180mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-03-23 - panitumumab 6mg/kg 90min

  • 2022-03-18 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-02-24 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-02-11 - irinotecan 150mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

  • 2022-01-24 - irinotecan 120mg/m2 90min + leucovorin 400mg/m2 2hr + 5-Fu 400mg/m2 10min + 5-Fu 2400mg/m2 46hr

==========

2024-01-24

[reconciliation]

The PharmaCloud database indicates that on 2024-01-22, the patient refilled prescriptions for Concor (bisoprolol), Zanidip (lercanidipine), Aprovel (irbesartan), and Xanax (alprazolam) at Cardinal Tien Hospital. These medications are currently being used, and no discrepancies in medication have been identified.

2023-11-01

[sharp rise and subsequent decline of CEA and CA199]

Both tumor markers, CEA and CA199, showed a sharp increase starting in 2023Q3 and have recently shown a decrease (although not yet in the normal range). Given that the primary treatment, P-FOLFIRI, has been used for over a year and a half without adjustments, the reasons for the decline in tumor markers may warrant further investigation.

  • 2023-10-25 CEA 55.55 ng/mL

  • 2023-09-06 CEA 484.09 ng/mL

  • 2023-08-29 CEA 581.20 ng/mL

  • 2023-07-17 CEA 172.08 ng/mL

  • 2023-06-17 CEA 30.15 ng/mL

  • 2023-05-25 CEA 7.86 ng/mL

  • 2023-03-30 CEA 2.33 ng/mL

  • 2023-03-09 CEA 2.64 ng/mL

  • 2023-01-31 CEA 2.44 ng/mL

  • 2023-01-17 CEA 2.46 ng/mL

  • 2023-01-03 CEA 2.54 ng/mL

  • 2023-10-25 CA199 52.99 U/mL

  • 2023-09-06 CA199 183.01 U/mL

  • 2023-08-29 CA199 268.44 U/mL

  • 2023-07-17 CA199 76.81 U/mL

  • 2023-06-17 CA199 16.80 U/mL

  • 2023-05-25 CA199 8.73 U/mL

  • 2023-03-30 CA199 5.91 U/mL

  • 2023-03-09 CA199 6.00 U/mL

  • 2023-01-31 CA199 6.64 U/mL

  • 2023-01-17 CA199 6.84 U/mL

  • 2023-01-03 CA199 7.19 U/mL

2023-08-30

The patient primarily receives medical care at Cardinal Tien Hospital. On 2023-08-28, refills were obtained for medications including metformin, pioglitazone, canagliflozin, bisoprolol, lercanidipine, irbesartan, rosuvastatin, and alprazolam. These drugs are mainly for the treatment of Type 2 Diabetes Mellitus and hypertension. As of now, these medications are accounted for in the active medication list and no discrepancies have been identified.

2022-07-22

  • Irinotecan has been titrated up from an initial 2/3 recommended dose to its current recommended dose with normal liver function lab results as of 2022-07-21.
  • It has been found that patients taking canagliflozin are more likely to develop genitourinary fungal infections (females: 11% to 12%; males: 4%), and those who do develop such infections are more likely to suffer recurrences. Additionally, pioglitazone has been associated with upper respiratory tract infections. Infection signs should be monitored as usual.

2022-04-01

  • a patient diagnosed with sigmoid colon cancer s/p stent placement and liver mets transferred from Cardinal Tien Hospital on 2022-01-19 and start receiving FOLFIRI since 2021-01-24 (plus panitumumab since 2022-03-23).
  • lab data reported on 2022-02-18 revealed that RAS and BRAF were both wild type and that no EGFR mutations were found. pathology results on 2022-01-20 indicated pMMR and EGFR(+). the patient is receiving appropriate treatment with no issues currently.

700852752

240124

[exam findings]

  • 2023-12-25 CXR
    • multifocal areas of consolidation and ground-glass opacities
    • in both lungs, upper lung predominance
  • 2023-11-28 SONO - abdomen
    • right neck tumor, r/o lymphadenitis
    • local cellulitis
  • 2023-10-02 Patho - esophageal biopsy
    • Labeled as “middle esophagus”, biopsy — benign squamous mucosa.
    • PAS stain highlights abundant colonies of candida species.
  • 2023-10-02 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • R/O Esophageal candidiasis, s/p biopsy
      • Superficial gastritis with erosions, s/p CLO
      • Gastric fundic gland polyps
      • Duodenitis
    • CLO test: Negative
    • Suggestion:
      • PPI therapy
      • Pursue CLO and pathology result
  • 2023-09-08 CXR erect
    • Faint aveolar opacity over RIGHT MIDDLE LOBE is found.
    • Aonther opacity over left central lung is found.
  • 2023-08-24 CT - chest
    • Impression
      • bilateral lung infection, most severe in RML with areas of necrosis and parapneumonic effusion.
      • extensive 3V-CAD. Calcified AV with stenosis and LVD.
  • 2023-08-24 SONO - chest
    • Echo diagnosis: pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located. Catheter was inserted with negative pressure smoothly. Right side pleural effusion was drawn smoothly. Watch out BP after tapping.
    • Suggestion:
      • check BP and taking rest after tapping.
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-08-18 SONO - chest
    • Echo diagnosis: right side minimal amount of pleural effusion, 450cc serosangious fluid was aspirated for analysis.
  • 2023-06-21 Nasopharyngoscopy
    • Findings: smooth np, larynx and hp
    • Diagnosis: lt deep neck infection s/p IV ABX
  • 2023-06-14 CT - neck
    • Indication: r/o deep neck infection
    • Without-contrast Ct scan of head and neck region with 3-mm axial, sagittal and coronal images reveals:
      • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall.
      • Multiple lymph nodes at both side of the neck, more prominent on left side with the largest one about 18 mm at left level II.
      • Extensive severe beam-hardening artifacts over oral cavity.
    • IMP:
      • Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck.
      • D/D: tonsilitis, malignancy.
  • 2023-06-12 Nasopharyngoscopy
    • Scope: smooth NPx, larynx, hypopharynx
    • adequate airway curently
    • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
  • 2023-05-09 CT - brain
    • No brain lesion.
    • Intracranial ICAs atherosclerosis.
    • Age-appropriate cerebral atrophy.
  • 2023-04-13 CT - abdomen
    • History and indication: Pancytopenia
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Bil. minimal pleural effusions.
      • Tiny liver and renal cysts.
      • Mild hyperplasia of left adrenal gland.
      • Wall edema of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P hysterectomy.
      • Bil. minimal pleural effusions.
  • 2023-04-12 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts-1
    • The sections show hypercellular marrow (70%). M/E ratio = 1:2 in CD71 and MPO stains. The erythoid precursors are marked increased, dispersed and scattered. The megakaryocytes are normal in number, and few micromegakaryocytes are present. Increased CD34+ and/or CD117+ immature cells, account for 5-10% of nucleated cells. No metastatic carcinoma can be identified in CK stain. The finding is compatible with myelodysplastic syndrome with excess blasts-1. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-04-11 EGD
    • Diagnosis:
      • Reflux esophagitis, Gr A
      • Superficial gastritis, antrum
    • CLO test: not done
    • Suggestion:
      • Medication and OPD f/u
      • Colon scope may be planned for GI bleeding and anemia survey
      • EGD was suggested annually for GERD f/u
  • 2023-01-02 SONO - abdomen
    • Impression:
      • Fatty liver.
      • Right renal stone.

[MedRec]

  • 2023-07-23 ~ 2023-08-02 POMR Hemato-Oncology Gao WeiYao
    • Present illness
      • This time, she has dizziness without SOB or dyspnea for 3 days. She was admitted for chemotherapy and blood transfusion on 2023/07/23.
    • Course of inpatient treatment
      • After admission, she received blood transfusion for anemia and thrombocytopenia correct. Chemo as C2 Dacogen since 7/24-7/28.
      • Fever was noted under neutropenic stage, antibiotic treatment for infection control, but no evidence of bacteremia. U/C mix growth without dysuria.
      • Under the stable condition, she can be discharged on 2023/08/02. OPD follow up is arranged.
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-06-24 ~ 2023-07-05 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Acute tonsillitis, unspecified
      • myelodysplastic syndrome with excess blasts-1
      • Oral mucositis (ulcerative), unspecified
      • Periapical abscess without sinus
    • CC
      • fever, sore throat and cough for 2~3 days
    • Present illness
      • She received target chemotherapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • Last hospitalization during 2023/06/11 to 2023/06/19 because of sore throat under the diagnosis of acute pharyngitis/tonsillitis, suspected deep neck infection, she received antibiotics treatment.
      • This time, she presented fever, sore throat and cough for 2~3 days. She visited to ENT for follow up with nasopharyngoscopy showed left deep neck infection.
      • Poor intake and generalized malaise developed, she visited to our ER. The laboratory disclosed pancytopenia and elevated CRP. CxR revealed clear bilateral costophrenic angles. Physical examination showed left tonsil, mild enlarged and redness and left upper neck swelling. Empirical antibiotics with Tapimycin was prescribed.
      • Under the tentative diagnosis of myelodysplastic syndrome with excess blasts-1 and left deep neck infection, she was admitted on 2023-06-24.
    • Course of inpatient treatment
      • After admission, tapimycin 4.5gm Q6H for tonsilitis.
      • Panadol was given for fever control.
      • On 2023/06/26, her fever subsided and sore throat was improved.
      • On 2023/06/27, we consult oral surgeon for further evaluation and 1. Oral ulcer of tooth 24 palatal side due to low immunity and 2. Apical abcess of tooth 26 noted.
      • Mycostatin 5cc QID + nincort were given.
      • Now, we keep complete IV tapimycin and will follow lab data later.
      • In addition, due to MDS with anemia and thrombocytopenia, we give blood transfusion for sdupportive care.
      • Under relative stable condition, she was discharge with OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
      • Through (sennoside 12mg) 2# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q12H
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT for constipation
      • Nincord Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-06-11 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
    • CC
      • for planned target therapy schedule.
    • Present illness
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20. After the last chemotherapy, she complained sore throat, poor appetite, weakness, and weigh two kilograms less, no fever or chills, no cough or sputum, no dyspnea, no nausea or vomit, no diarrhea.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.
    • Course of inpatient treatment
      • After admission, she complained sore throat. Comfflam was prescribed for her sore throat.
      • ENT was consulted. Acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out. Neck CT was arranged on 06/14.
      • Infx was also consulted. tapimycin 4.5g Q6H was used for her acute pharyngitis/tonsillitis.
      • She had no fever. Neck CT (2023/06/14): Enlargement of left palatine tonsil and thickening of left oropharyngeal and hypopharyngeal wall, associating with enlarged lymph nodes at left neck. D/D: tonsilitis, malignancy. Nasopharyngoscopy showed left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating.    
      • On 2023/06/15, her sore throat improved.
      • On 2023/06/19, skin rash on her left elbow improved.
      • Under stable condtion, she was discharged with Oncology and ENT OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Mycostatin oral suspension (nystatin 0.1MU/mL) 5mL QID
      • Through (sennoside 12mg) 2# HS
      • Bisadyl supp (bisacodyl 10mg/pill) 2# PRNHS RECT if no stool passage for 3 days
      • Ceficin (cefixime 100mg) 2# Q12H
      • Rivotril (clonazepam 0.5mg) 1# QD
      • Rivotril (clonazepam 0.5mg) 0.5# HS
      • Seroxat (paroxetine 20mg) 0.5# QD
      • Seroxat (paroxetine 20mg) 1# HS
  • 2023-05-12 ~ 2023-05-20 POMR Hemato-Oncology Gao WeiYao
    • discharge diagnosis
      • myelodysplastic syndrome with excess blasts-1
      • Abnormal weight loss
    • CC
      • for first decitabine
    • Present illness
      • Under the impression of Compatible with myelodysplastic syndrome with excess blasts-1, so she was admitted for first decitabine on 2023/05/12.
    • Course of inpatient treatment
      • After admission, she received Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20.
      • Promeran 3.84mg/tab 1# tidac and monitor GI tract problem.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
  • 2023-04-10 ~ 2023-04-13 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • myelodysplastic syndrome with excess blasts-1
    • CC
      • Tarry stool for 1 week
    • Present illness
      • This is a 73-year-old female with past history of
        • hyperlipidemia
        • gastric ulcer s/p treatment on 2018/12
        • right invasive ductal carcinoma, grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA, s/p partial mastectomy
        • uterine myoma s/p ATH.
      • This time, she suffered from tarry stool for 1 week.
      • She has suffered from chronic constipation for 6 months, 2-3 days of no stool passage would be followed by abdominal cramping pain and yellow-brownish diarrhea. The symptoms exacerabated since 2023/02, accompanied with decrease of appetite and general malaise. She went to Taipei city hospital HePing Branch for help on 2023/03 and colonoscopy was done and showed negative finding. According to the patient, diffuse abdominal pain especially at RLQ became more frequently since colonoscopy.
      • Last week she suffered from watery diarrhea for 3-6 times/day for 3 days. Thus, she went to a clinic for help. On 2023/04/09. she started to have watery tarry stool. There were 5 times of watery tarry stool passage in this 2 days. She also noticed body weight decrease for 4kg in 2 months. Thus, she went to the same clinic for help. Blood test was done and Hb 5.8mg/dL was found. Thus, she was refered to our hospital for help.
      • She went to Dr Gao’s OPD and was refered to ER for transfusion and arranged admission. At ER, vital signs was stable, with BP: 148/65mmHg, HR: 91bpm, BT: 36.6’C, RR:18bpm, Con’s:E4V5M6, SpO2:100%. Lab showed Hb 5.7mg/dL. 2 U of pRBC was tranfused and pantoprazole 40mg were first given. Afterwards, she was admitted to hemotology ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, 2U LPRBC was tranfused on 2023/04/11. EGD done on 2023/04/11 showed Reflux esophagitis, Gr A. Superficial gastritis, antrum. Therefore, we will try soft diet from 2023/04/12.
      • Due to CBC showed blast 13.9%., bone marrow biopsy (with chromosome) with peripheral smear was done on 2023/04/12. Peripheral smear showed hypercellular bone marrow with marked increase of erythroid lineage, and decreased M/E ratio. Furthermore, plasma cell markedly increased under microscopic high power field. Therefore, multiple myeloma lab profile was drawn, with results pending.
      • Due to blood-tinged stool noted on 2023/04/12 midnight, abdominal CT with contrast was done on 2023/04/13 which showed no structural lesion at small or large intestine.
      • Due to stable condition, the patient was discharged on 2023/04/13. Regular OPd f/u was arranged on 2023/04/18.
    • Discharge prescription
      • Nincort Oral Gel (triamcinolone 1mg/gm) BID TOPI
      • Through (sennoside 12mg) 1# PRNHS if no stool
      • Transamin (tranexamic acid 250mg) 1# PRNBID if bolldy stool

[consultation]

  • 2024-01-19 Chest Medicine
    • Q
      • The 73 y/o woman has myelodysplastic syndrome with excess blasts-1. Due to frequency pneumonia over upper both lung, so we need your help for management. Thanks!
    • A
      • HX, PE, CXR review, pt is a case of myelodprofierative disorder, preleukemia stage with excess blasts-1, with frequency pneumonia
      • Suggest
        • sputum TB work up
        • check cryptococcus and aspergillus ag when next blood test
        • RX underlying condtion myelodprofierative disorder, preleukemia stage
        • best supportive carenutrtion, nutrition, I/O, electrolyte balance
        • add on amikin inhale
        • follow up lab, image and bacteria days later after work up and adjust antibiotics regimen
  • 2023-11-09 Dermatology
    • Q
      • The 73 y/o woman has MDS under chemotherapy and blood transfusion. Her general skin rashes and itchy, so we need your help for management. Thanks!
    • A
      • Under the impression of blood tranfusion-related gernalized allergy reaciton. notice antibiotics ie Tapimycin association.
      • The following sugestion:
        • consider Vena 1 Amp and Deca 1 Amp Ivdrip before the following blood transfusion (prevention)
          • shift another type of antibiotic use as your experists.
        • adequent systemic medication use now.
        • If lesions progressive, consider elevate Vena dosage to 1 Amp Q8H use and regular sytemic steroid ie compresolone 2# QD to Bid po use.
        • Topysm cream (fluocinonide) 2 tube topical bid use over reddish lesions.
  • 2023-09-01 Dermatology
    • Q
      • The 73 y/o woman has MDS with pancytopenia. This time, she has pneumonia over right lower lung. Due to oral candiads, we gave Flu-D for treatment, but skin rash is noted since 8/31 night. We hold it and gave antihistamin since 8/31 night, but in vain. We need your help for management. Thanks!
    • A
      • This patient suffered from generalized erytehamtous papules-plaques on trunk for days.
      • Imp: Subacute dermatitis
      • Suggestion:
        • dexamethasone *1 / Qd
        • Zaditen (ketotifen) 1 /Bid
        • Mycomb (nystatin, triamcinolone, neomycin, gramicidin) *10 tubes/bid
  • 2023-08-24 Chest Medicine
    • Q
      • The 73 y/o woman has MDS under aggessive care. Due to fever and right lung pneumonia, so she was admitted. Her fever without control, chest CT was done this morning. We need your help for bilateral pneumonia management.
    • A
      • O
        • 20230823 CT of chest
          • RML lobar consolidation with air-bronchograms with areas of poor enhancement. dependent band subsegmental atelectasis at both lower lobe.
          • extensive consolidation with surrounding ground glass opacity over superior lingular and apicoposterior segment of LUL.
          • patchy consolidation and ground glass opacities at RUL.
          • airspace nodular opacities in LLL and LUL too.
        • Lab
          • 2023-08-22 WBC 1.28 x10^3/uL
          • 2023-08-22 HGB 9.3 g/dL
          • 2023-08-22 PLT 77 *10^3/uL
          • 2023-08-22 Neutrophil 1.3 %
          • 2023-08-22 Lymphocyte 80.3 %
          • 2023-08-22 Monocyte 0.6 %
        • 20230820 sputum culture: MNF.
      • Impression:
        • Lobar Pneumonia, RML.
        • Pneumonia, LUL (apicopost. segment), left lingula. RUL.
      • Suggestion:
        • AFB and TB/C of sputum: 3 sets in the morning (risk of pulmonary tuberculosis), possible TB PCR of sputum if positive
          • Suggest chest tapping again for culture, right side pleural effusion. (20230824 afternoon: safty completed)
        • Sputum culture, mycoplasma and chlamydia IgM of blood, Streptococcus pneumonia and legionella Ag in urine.
        • PJP PCR of sputum, CMV DNA (NHI)and IgM in blood, Cryptococcus Ag in blood, Aspergillus Ag in blood.
        • Empiric antibiotics first and guided by subsequent culture results.
  • 2023-08-15 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • 73-year-old MDS with leukemic transformation female patient suffers from neutropenic fever and right lung pneumonia.
        • White count only 1020, with ANC only 35.
        • Tapimycin is replaced by Mepem this afternoon.
      • Suggestion:
        • Continue Mepem for one week first
        • Add Targocid for possible MRSA coverage, Targocid 600mg iv q12h for 3 doses till 9AM, 2023/08/16, then 500mg iv qd since 2023/08/17.
        • Check blood and sputum culture report.
  • 2023-06-27 Oral and Maxillofacial Surgery
    • Q
      • For gum pain
      • This 73 years old woman is a patient of myelodysplastic syndrome with excess blasts-1 s/p Target therapy as Decitibine 20mg/m2 IVD 1hr since 5/16-5/20, past history of
        • ptosis of eyelid,
        • hyperlipidemia,
        • gastric ulcer,
        • right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA)
        • uterine myoma s/p abdominal total hysterectom
      • this time was admitted to our ward for acute-tonsilitis.
      • Now her tonsilitis improved with no fever.
      • She complainted about pain in the upper left gums for about 6 days.
      • We need your expertise for evaluation of gum pain, thank you!
    • A
      • This is a 73-year-old woman with pain over her upper left gingiva for 6 days.
      • O:
        • A white patch with ulcerative surface over upper right gingiva near the palatal side of tooth 24, palpation pain was noted.
        • Mild swelling over her upper left posterior gingiva near the buccal side of tooth 26, percussion pain of tooth 26 was noted.
      • A:
        • Oral ulcer of tooth 24 palatal side due to low immunity
        • Apical abcess of tooth 26
      • P:
        • Physical exam
        • Keep observation of the oral ulcer, please contact us after her ANC raise to normal level.
  • 2023-06-13 Infectious Disease
    • Q
      • For antiobiotics of acute pharyngitis/tonsillitis, ENT suggested consulting for ABX
      • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
      • sore throat with dysphagia for since 5/16 after target therapy, left more severe
      • odynophagia+, fever-, WBC:2l, CRP:2.1
      • We consulted ENT for acute pharyngitis/tonsillitis, Abx was suggested.
      • We need your expertise for antiobiotics of acute pharyngitis/tonsillitis, thank you!
    • A
      • The patient’s conditin as your description.
      • Tapimycin 4.5g iv q8h is suggested for the acute pharyngitis/tonsillitis.
      • Please arrange neck CT to exclude deep neck infection.
      • Please collect adequte culture.
  • 2023-06-12 Ear Nose Throat
    • Q
      • For evaluation of dysphagia after first dose of target therapy, cycle 1 Decitabine since 2023/05/16 to 05/20
      • This 73 years old woman is a patient of compatible with myelodysplastic syndrome with excess blasts-1, and past history of ptosis of eyelid, hyperlipidemia, gastric ulcer, right invasive ductal carcinoma s/p right partial mastectomy (grade I, ER+, PR-, Her2-, p53-, Ki67 5%, pT1bN0M0; pStage: IA), and uterine myoma s/p abdominal total hysterectomy.
      • She received target therapy with cycle 1 Decitabine since 2023/05/16 to 05/20.
      • After last chemotherapy, she complained dysphagia, sore throat and cough. No fever.
      • This time, she is admiited to our Hematology Oncology ward for planned target therapy schedule.  
      • We need your expertise for evaluation of dysphagia before second target therapy, thank you!
    • A
      • S:
        • sore throat with dysphagia for since 5/16 after target therapy, left more severe
        • odynophagia+, fever-, dyspnea-
        • Allergy: denied
      • O:
        • Oral cavity and oropharynx: left post. pharyngeal wall bulging
        • no uvula deviation
        • Scope: smooth NPx, larynx, hypopharynx
          • adequate airway curently
          • left tongue base, lateral pharyngeal wall, post. pharyngeal wall bulging with pus coating
        • left upper neck tenderness
      • A: acute pharyngitis/tonsillitis, deep neck infection can’t be ruled out
      • Plan:
        • After discussing with Dr. Lan
          • Consult infection for IV antibiotic suggestion (stronger is favored)
          • suggest hold target/chemo therapy, infection control first
          • Pain control
          • self-paid Difflam spray and parmason for oral hygiene if the patient agreed
          • Instruct the patient to rinse her mouth after meals and avoid eating hot and spicy foods.
          • Monitor airway, well educated about airway issue
          • check infection profile
          • if s/s still progressed after antibiotic Tx, consider CT with/without contrast exam if no contraindication to rule out deep neck infection/mediastinitis
          • ENT OPD f/u
        • neck CT (without contrast CT): no obvious abscess formation, left pharyngeal wall swelling with enlarged LNs
        • leading Dx: infection with reactive LN
        • DDx: malignancy can’t be ruled out, lymphoma……..
        • please keep IV anti for 2 weeks
        • if s/s no improvement, suggest left tonsillectomy to rule out malignancy

[chemotherapy]

  • 2023-11-02 - decitabine 20mg/m2 21mg NS 100mL 1hr D1-5
  • 2023-07-24 - decitabine 20mg/m2 31mg NS 100mL 1hr D1-5
  • 2023-05-16 - decitabine 20mg/m2 32mg NS 100mL 1hr D1-5

==========

2024-01-24

[addressing hemoptysis with inhaled tranexamic acid]

Today’s progress note indicated that the patient experienced a mild episode of coughing up blood last night. Should the hemoptysis persist, the use of inhaled tranexamic acid (500mg/5mL, up to five days) has been reported to effectively reduce the volume of hemoptysis, expedite its resolution, and potentially shorten the duration of hospitalization.

Ref: - Inhaled Tranexamic Acid for Hemoptysis Treatment: A Randomized Controlled Trial. Chest. 2018;154(6):1379. - Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020;13(1):45.

2023-07-05

  • I visited the patient around 11:15 on 2023-07-05 carrying the decitabine medication usage information. The patient was lying in bed and her awake husband was sitting in the bench by the window.

  • I first asked the patient’s husband how the patient’s recent condition was and whether the discomfort in the mouth had worsened or improved? The husband said that the patient is currently using the oral paste prescribed by the doctor, and the condition is manageable. He also asked if the infection was caused by the use of decitabine. I responded that since April, the patient’s white blood cell count has consistently remained around 2000 +- 500, and there was no significant fluctuation due to the administration of decitabine in mid-May. Although the effect of decitabine on white blood cells can’t be entirely ruled out, it does not seem to be the primary cause based on the observations.

701007202

240124

[exam findings]

2024-01-23 lab data showed both DGH and Toxin A/B positive.

==========

2024-01-24

[TDM scheduling for optimized vancomycin treatment in CDI]

Lab data from 2024-01-23 confirmed positivity for both DGH and Toxin A/B.

For patients with severe or fulminant C. difficile infection, an initial oral dose of vancomycin can be 10 mg/kg, administered four times daily for 10 days, with a maximum dose of 500 mg per administration. In critically ill patients, the addition of intravenous metronidazole may be considered.

This patient exhibits impaired renal function as evidenced with an eGFR of 21 mL/min/1.73m², an elevated serum creatinine (2.94 mg/dL) and blood urea nitrogen (BUN) (31 mg/dL) on 2024-01-24. While the vancomycin manufacturer’s labeling lacks specific dosage adjustments for this degree of renal impairment, the low systemic absorption of vancomycin suggests dose modification may not be necessary.

Oral vancomycin 500mg QID has just been prescribed from 2024-01-23 for a duration of seven days, adhering to standard usage. Therapeutic drug monitoring (TDM) is recommended to be scheduled on day 3, specifically on 2024-01-26, with a blood sample to be drawn within 30 min before the next dose.

Ref: Does oral vancomycin use necessitate therapeutic drug monitoring? Infection. 2020 Apr;48(2):173-182. doi: 10.1007/s15010-019-01374-7.

700752671

240123

[lab data]

2022-10-24 Anti-HBc Reactive
2022-10-24 Anti-HBc-Value 6.32 S/CO
2022-10-24 HBsAg Nonreactive
2022-10-24 HBsAg (Value) 0.35 S/CO
2022-10-24 Anti-HCV Nonreactive
2022-10-24 Anti-HCV Value 0.13 S/CO

[exam findings]

  • 2023-10-24, -10-02 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Borderline cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-10-23 CT - abdomen
    • History and indication: duodenum cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites.
      • Splenomegaly.
      • Tiny renal cysts.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with ascites c/w tumor seeding. Splenomegaly.
  • 2023-08-30 Joint soft tissue sonography
    • Findings: Hypoechoic disruption of the right supraspinatus tendon fibers extending from the bursal surface to the articular surface
    • Impression: Right supraspinatus tendon full-thickness tear
  • 2023-08-02 Antegrade Venography
    • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion. Patency of SVC.
  • 2023-07-31 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the L-spine with convex to left side.
    • Ileus projecting at LMQ abdomen is suspected.
    • Pneumobilia on both hepatic lobes are noted.
  • 2023-07-18 CT - abdomen
    • Clinical history: 81 y/o female patient with abdominal pain, suspect IAI.
    • With and without contrast enhancement CT of abdomen - whole:
      • Infiltrative soft tissue tumors in the GB, IHDs and along CHD region, hepatic hilar regions and around duodenum.
      • Dilatation of IHDs with pneumobilia, dilatation of P-duct.
      • Soft tissue tumors in the peritoneum and subphrenic region, could be due to carcinomatosis.
      • Mucosal enhancement at ascending colon.
      • Portal venous thrombosis.
      • Presence of ascites.
    • Impression:
      • Malignancy in GB, IHDs and CHD regions, hepatic hilar and around duodenum. Stationary.
      • Peritoneal tumors with ascites, r/o carcinomatosis.
      • More prominent mucosal enhancement at ascending colon. Suggest clinical correlation.
  • 2023-07-16 KUB
    • Presence of scoliosis of the lumbar spine.
    • Presence of ileus.
  • 2023-07-16 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • Left axis deviation
    • Abnormal ECG
  • 2023-06-27 ECG
    • Sinus bradycardia
    • Left axis deviation
  • 2023-05-19 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the basal inferolateral wall.
    • Reverse redistribution of radioactivity to the apical lateral wall, either normal variant or myocardial ischemia may show this picture.
  • 2023-05-02 Angegrade venography
    • Venography via left port-A catheter administration revealed some blood clot around distal end of the catheter without occlusion.
  • 2023-04-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 21.0) / 72.1 = 70.87%
      • M-mode (Teichholz) = 70.6
    • Conclusion:
      • Dilated LA
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, TR
  • 2023-04-19 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-04-17 CT - abdomen
    • History and indication: duodenum with S4 liver invasion, multiple metastatic nodes
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Malignancy in GB and duodenum with adjacent structures invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
      • Splenomegaly.
      • Enlargement of left thyroid gland.
      • Tiny renal cysts.
      • Partial atelectasis at LLL.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Malignancy in GB and duodenum with adjacent structures invasion (stable). Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites. Splenomegaly.
  • 2023-03-02 SONO - abdomen
    • Liver tumor, S4, suspect metastasis
    • GB lesion, suspicious tumor, and cholecystopathy
    • Intra-IHD lesion, B8, unknown etology and IHD dilatation
    • CBD wall asymmetric thickness, suspicous infiltrative cause
    • Marked MPD dilatation
    • Splenomegaly
  • 2023-01-12 CT - abdomen
    • History and indication: Adenocarcinoma of gallbladder cancer with S4 liver invasion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites.
      • Splenomegaly.
      • Enlargement of left thyroid gland.
      • Tiny renal cysts.
      • S/P Port-A infusion catheter insertion. Degeneration and spondylosis of L-S spine.
    • IMP:
      • GB cancer (2.7cm) with liver invasion. Thrombosis of left portal vein. Dilatation of biliary tree and p-duct with pneumobilia. Multiple enlarged LNs in peritoneal cavity and retroperitoneum. Some soft tissues in peritoneal cavity with small amount ascites r/o tumor seeding.
  • 2022-11-09 Patho - liver biopsy needle/wedge
    • Liver, EUS-FNB — Adenocarcinoma, moderately differentiated
    • The sections show a picture of adenocarcinoma, composed of nests of columnar neoplastic cells with glandular formation and mucin secretion, embedded in fibrous stroma.
    • IHC shows: CK7(+), CK20(-), and CDX2(+).
    • Comment: The histological pattern and immunophenotype are similar to duodenal biopsy specimen (S2022-9593). Adenocarcinoma of duodenum origin can not be completely excluded. Suggest clinic correlation.
  • 2022-11-09 Patho - duodenum biopsy
    • Duodenum, 2nd portion PW, biopsy — Adenocarcinoma, moderately differentiated, upper GI type
    • The secvtions show a picture of adenocarcinoma, upper gastrointestinal type, composed of columnar neoplastic cells, arranged in glandular and papillary patterns with desmoplastic stromal reaction.
    • IHC, tumor cells reveal: CK7(+), CK20(-), and CDX2(+).
  • 2022-11-08 EUS
    • Diagnosis:
      • GB tumor prob. cancer s/p EUSFNB (A)
      • Hepatic tumor Prob. GB cancer with liver involvement s/p FNB (B)
      • duodenal tumor s/p Bx (C)
      • Ascites, moderate
      • MPD dilatation
      • Lymphadenopathy
    • Suggestion:
      • pursue pathological result
  • 2022-11-04 MRI - MR Chloangiography, MRCP
    • Findings:
      • There is an ill-defined, mild heterogeneous mass measuring 7.3 x 4 cm in the gallbladder fossa and S4 of the liver, showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement in arterial phase, portal-venous phase and delayed phase images.
        • Gallbladder cancer is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC.
      • There are enlarged nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space that are c/w metastatic nodes.
      • There is ascites and soft tissue lesions in the parietal peritoneum in right perihepatic space and omentum that may be carcinomatosis? Please correlate with ascites cytology.
      • There is marked dilatation and pneumobilia on both lobes IHDS. please correlate with clinical history.
      • There is irregular liver contour, hypertrophy of S1, atrophy of S2-3, non-visualization of left portal vein.
        • Chronic cholangitis induce biliary cirrhosis is highly suspected.
      • There is spleen size prominence (long axis: 11 cm) and ascites that may be portal hypertension.
      • The pancreatic duct shows dilatation the may be IPMN, main duct type.
      • There are several renal cysts on both kidney and the largest one measuring 0.5 cm in size at left upper pole.
    • IMP:
      • Gallbladder cancer with S4 liver invasion is highly suspected.
        • The differential diagnosis include cholangiocarcinoma and poorly differentiated HCC at S4 liver with gallbladder invasion.
      • Multiple Metastatic nodes in gastrohepatic ligament, celiac trunk, hepatoduodenal ligament, aortocaval space, and para-aortic space.
      • Carcinomatosis is suspected. Please correlate with ascites cytology.
      • IHDs dilatation and pneumobilia.
      • Chronic cholangitis induce biliary cirrhosis is suspected.
      • IPMN of the pancreas is highly suspected.
  • 2022-10-25 Patho - gall bladder (malignancy)
    • Labeled as “gallbladder”, core needle biopsy — high grade dysplasia. See description.
    • Section shows high grade dysplasia lined tissue with focal inner muscular layer and outer muscular layer.
    • IHC stains: CK 19 (+), Ki-67: 5%. Also present is one piece of benign liver tissue and benign bile canaliculi tissue.
  • 2022-10-24 SONO - abdomen
    • Diagnosis:
      • Liver parenchymal disease
      • liver tumors: cause to be determined
      • dilatation of bilateral IHD, pneumobilia
      • GB sac could not be identified
      • dilatation of main pancreatic duct: body portion(some parts of pancreas obscured)
      • ascites: small amount
    • Suggestion:
      • 4 phase CT or dynamic MRI study

[MedRec]

  • 2022-10-23 ~ 2022-10-26 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Upper abdominal pain, unspecified
      • Malignant neoplasm of gallbladder suspected S/P CT guide biopsy on 2022-10-25 and pathology report was pending .
    • CC
      • upper abdominal pain since Sep 2022
    • Present illness
      • This 81-year-old woman, a patient suspected gallbladder cancer by whole abdominal CT exam at CGMH hospital. She suffered form upper abdominal pain, distension, poor appetite and body weight loss (2-3kg) since Sep 2022 and she visited to CGMH for medical attention where abdominal CT showed decreased and heterogenous enhancement at biliary tract and mild dilated pancreatic duct, mild ascites noted, no GB stone nor CBD stone was found. She was referred to oncologist Dr. Kao’s OPD for second opinion.
      • Upon admission, she noted persisted intermittent epigastralgia and mild panic, no fever, no chillness, no bowel habit change, no jaundice. the laboratory data showed no significance, no abnormal liver chemistry, pending for tumor biomarker. Owing to above, she was aditted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, image study with abdominal sono (2022/10/24) showed Liver parenchymal disease, liver tumors: cause to be determined, dilatation of bilateral IHD, pneumobilia, (GB sac could not be identified), dilatation of main pancreatic duct: body portion(some parts of pancreas obscured), ascites: small amount. Radiologist was consulted for CT guide biopsy evaluation.
      • CT guide biopsy was performed on 2022/10/25, smoothly without active bleeding or abdominal pain. The pathology report was pending. She was discharged on 2022/10/26 under stable condition and will follow-up at OPD.
  • 2022-10-20 SOAP Hemato-Oncology Gao WeiYao
    • S
      • for 2nd opinion, referred by sister Lin
      • Being informed to have hepatobiliary tract neoplasm
      • Epigastric pain for one month but it resolved by itself and CT done at Linkou CGMH
      • History of biliary tract infection before
    • O
      • BP 145/85; HR 78
    • A
      • BH 152, BW 66.7

[consultation]

[chemotherapy]

  • 2024-01-22 - oxaliplatin 85mg/m2 127mg D5W 250mL 6hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-27 - (FOLFOX)
  • 2023-11-14 - (FOLFOX)
  • 2023-10-02 - (FOLFOX)
  • 2023-09-13 - (FOLFOX)
  • 2023-08-30 - (FOLFOX)
  • 2023-08-14 - (FOLFOX)
  • 2023-06-27 - (FOLFOX)
  • 2023-06-02 - (FOLFOX)
  • 2023-05-02 - (FOLFOX)
  • 2023-04-18 - (FOLFOX)
  • 2023-03-29 - (FOLFOX)
  • 2023-02-13 - (FOLFOX)
  • 2023-01-30 - (FOLFOX)
  • 2023-01-09 - (FOLFOX)
  • 2022-12-26 - (FOLFOX)
  • 2022-12-13 - (FOLFOX)
  • 2022-12-01 - oxaliplatin 85mg/m2 137mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-17 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 500mL 48hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2024-01-23

[CEA marker trends and imaging updates]

The patient has been undergoing FOLFOX treatment since Dec 2022, for over a year, and has generally tolerated it well.

She is also receiving Baraclude (entecavir) for reactive Anti-HBc and Megejohn (megestrol acetate) for cachexia, with no discrepancies in medication identified.

The CEA marker showed a recent high in November 2023. There has been no updated imaging study since Oct 2023, which may warrant renewal.

701227488

240123

[MedRec]

  • 2024-01-21 ~ 2024-01-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Other pancytopenia
      • Thrombocytopenia, unspecified
      • Anemia, unspecified
    • CC
      • shortness of breath for months
    • Present illness
      • This is a 89-year-old female with anemia for over ten years. She had family history of thalassemia. This time, she came to our HEMA OPD due to severe anemia, shortness of breath noted for months. She also complaint about low back pain for years. At OPD, blood test revealed pancytopenia, blood transfusion with LPRBC 2u was arranged. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. The patient was admitted for clarifying the nature of severe anemia and pancytopenia.
    • Course of inpatient treatment
      • After admission, blood test was arranged which showed Hb 4.9 g/dL, blood transfusion with LPRBC 2u was ordered. She underwent bone marrow puncture and biopsy on 2024/01/22. Under stable condition, she discharged on 2024/01/22 and OPD follow up was arranged.
  • 2024-01-18 SOAP Hemato-Oncology Gao WeiYao
    • S
      • Gyn Prof. Dr Hwang’s relative
      • History of anemia post transfusion 7 yrs ago
      • History of severe anemia as low as 3.9.
      • back pain, lower back nature?
      • family history of thalassemia
    • O
      • WBC = 1.94 x10^3/uL;
      • HGB = 4.2 g/dL;
      • MCV = 92.6 fL;
      • PLT = 47 x10^3/uL;
      • BP:116/47; HR:78/min;
    • A
      • BW 40
      • pancytopenia nature to be determined

701484337

240123

[exam findings]

  • 2024-01-20 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Clinical sigmoid ccancer s/p treatment.
      • Small left renal stone without obstruction.
      • Right renal cyst, 1.1cm.
      • Stationary paraaortic lymph nodes.
      • Soft tissue tumor, 2cm in right pelvic cavity (lymph node or ovary?) stationary.
      • There are multiple liver tumors, up to 6.1cm in S4-8 liver, with peripheral nodular enhancement, r/o liver hemangiomas.
      • Dilatation of CBD.
      • Outpouching lesions in ascending colon, suggesting colon diverticula.
    • Impression:
      • Clinical sigmoid ccancer s/p treatment.
      • Stationary paraaortic lymph nodes.
      • Right pelvic cavity soft tissue, lymph node or ovary? stationary.
      • Multiple liver tumors, r/o hemangiomas.
      • Dilatation of CBD.
      • Ascending colon diverticula.
  • 2023-12-19 CXR erect
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Borderline cardiomegaly
  • 2023-11-28 Gynecologic Ultrasonography
    • R/O Endometrial polyp
    • Uterine myoma
  • 2023-10-27 CT - abdomen
    • Findings: Comparison: prior CT from NTUCC dated 2023/05/11.
      • There is no focal wall thickening at the rectum.
        • Please correlate with colonoscopy.
      • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
        • Please correlate with PET scan.
      • Prior CT identified ten hemangiomas on both hepatic lobes (the largest one 6 cm in S6/7) are noted again, stationary.
        • In addition, few cysts on both hepatic lobes are also noted.
      • S/P cholecystectomy.
        • There is mild dilatation of IHDs and CHD.
        • Please correlate with serum alk-p and bilirubin level.
      • A renal cyst 1.2 cm in right middle pole is noted.
    • Impression:
      • There is no focal wall thickening the rectum.
        • Please correlate with colonoscopy.
      • Prior CT identified one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space are noted again, stationary.
        • Please correlate with PET scan.
  • 2023-07-10 All-RAS + BRAF mutation
    • Cellblock No. F2023-00289 A2
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-06-23 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
      • Resection margins, ditto — Free of tumor invasion
      • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
      • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 8.5 x 6 x 2.2 cm
      • Skin: 3.5 x 0.7 cm
      • Nipple: Not received
      • Tumor: 1.1 x 1.1 cm
      • Resection margins: Free, 0.2 cm away from closest 3 o’clock margin, 0.9 cm from base and at least 1.3 cm away from peripheral margins
      • Lymph node: left axillary sentinel LNs, sent for frozen section (F2023-00289)
      • Representative sections as F2023-00289 FSA: L’t axillary sentinel LNs, FSB: 3 o’clock margin and base, A1-A3: tumor and A4: skin
    • MICROSCOPIC EXAMINATION
      • Histologic type: solid papillary carcinoma with invasion
      • Size of invasive carcinoma: 1.1 x 1.1 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free of tumor invasion
      • Nodal status: Free of tumor metastasis (0/4)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: Not identified
      • Perienural invasion: Not identified
    • IMMUNOHISTOCHEMISTRY
      • F2023-00289A2: synaptophysin(+, diffuse), chromogranin-A(+, scatter) for tumor, CK5/6(-) and P63(-) for myoepithelial cell
      • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
  • 2023-06-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 34) / 84 = 59.52%
      • M-mode (Teichholz) = 59
    • Conclusion:
      • Mild septal hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; severely dilated LA.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
      • Mild aortic root calcification; mildly dilated proximal ascending aorta (32 mm).
  • 2023-06-13 Patho - breast biopsy (no need margin)
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
  • 2023-06-13 SONO - breast
    • Imp
      • Left breast tumor, r/o malignancy, suggest biopsy.
      • Left breast cyst.
    • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2023-06-13 Mammography
    • Impression: Hyperdense tumor, 1.47cm in UOQ of left breast (posterior third portion), suggest sonographic correlation.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2023-06-07 MRI - pelvis
    • Findings:
      • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
        • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
      • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
        • Please correlate with PET scan.
      • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
        • In addition, few cysts on both hepatic lobes are also noted.
      • S/P cholecystectomy.
      • A renal cyst measuring 1.2 cm in right middle pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N1b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-06-05 PET
    • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
    • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
    • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
    • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.

[MedRec]

  • 2023-12-07 SOAP Urology Wu ShuYu
    • S: frequency for long, urgency, improving on Oxbu
    • O: ask for refill only
    • A: OAB (overactive bladder)
    • Prescription x3
      • Oxbu (oxybutynin 5mg) 1# QD
  • 2023-10-19 Hemato-Oncology Xia HeXiong
    • S: Celebrex (celecoxib) and Solaxin (chlorzoxazone) prescribed on 2023-10-02 in NTUH BeiHu Branch, for soreness over body
  • 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2023/06/23 PATHO - breast mastectomy with regionl lymph nodes
        • Breast tumor, left, BCT + frozen —- Solid papillary carcinoma with invasion
        • Resection margins, ditto — Free of tumor invasion
        • Lymph node, left axillary sentinel area, frozen (F2023-00289) — Free of tumor metastasis (0/4)
        • AJCC Pathologic Anatomic Stage — pT1cN0, if cM0, stage IA; Prognostic Stage — Stage IA
        • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
        • Margins: Free of tumor invasion
        • F2023-00289A2: synaptophysin (+, diffuse), chromogranin-A (+, scatter) for tumor, CK5/6 (-) and P63 (-) for myoepithelial cell
        • Please refer to S2023-11754 for ER, PR, Her2/neu and Ki67 status
    • A/P
      • bevcizumab (bevacizumab will be given)
      • Admission for 1st cycle of FOLFOX
  • 2023-06-19 ~ 2023-06-24 POMR General and Gastrointestinal Surgery Chen YenZhi
    • Discharge diagnosis
      • Invasive carcinoma of left of breast, no special type, cT1bN0M0, stage IA, status post left partial mastectomy and sentinel lymph node biopsy and right port-A implantation on 2023/03/21, ECOG:0, ER (+), PR(+), Her2(-), Ki-67(10 %)
      • Malignant neoplasm of sigmoid colon
      • Essential (primary) hypertension
    • CC
      • Left breast tumor was incidentally noted during sigmoid cnacer survey.
    • Present illness
      • This 74 years old female has history of 1) Hypertension under medicaiton control, 2) Sigmoid cancer cT2N1bM1a, stage IV.
      • According to her statement, sigmoid cancer was diagnosis on April, 2023 at NTUH. She went to our hospital for second opinion. However, left breast tumor was incidentally noted during sigmoid cnacer survey.
      • On 06/05 PET was performed which revealed primary rectal-sigmoid cancer with lymph node metastasis and suspecious primary breast cancer. She was referred to GS OPD for breast tumor survey.
      • On 06/13 mammography showed a hyperdense tumor, 1.47cm in UOQ of left breast. Breast sono revealed left 3o’clock/2.23cm, size 0.8x0.48cm irregular shape hypoechoic tumor, suspect malignancy, BI-RADS: Category 4c.
      • Therefore, arrange left breast sono-guide biopsy was done, pethology revealed invasive carcinoma, no special type, IHC stains: ER (+, 100%, strong intensity), PR(+, 75%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p63 (-), CK5/6 (-), Ecadherin (+). Physical examination showed no palpable mass at bilateral breast without tenderness, no nipple retraction and without disacharge nor bleeding, no palpable axillary lymph node.
      • Under impression of left breast cancer, she admitted for surgery management.
    • Course of inpatient treatment
      • After admitted, we arrange cardiopulmonary function test for preoperation survey. She received left breast partial mastectomy, sentinel lymph node biopsy and right port-A implantation was performed on 2023/06/21.
      • The post-operative course was relatively smooth without complication. During the hospitalization analgesic agent were administered and the wound management was performed. There were no nosocomial infection and other complications. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable. The wound is clean and without hematoma. Under improved general condition, she was allowed to discharge today, take one JP drain to home and OPD follow up was arranged. 
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
  • 2023-06-15 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S
      • left breast tumor was incidently noted
    • O
      • 2023/06/13 PATHO - breast biopsy (no need margin)
        • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 100%, strong intensity), PR (+, 75%, strong intensity), Her2/neu: negative (score=0), Ki-67 (10 %), p63 (-), CK5/6 (-), E-cadherin (+).
    • A/P
      • left breast BCT and right chest port-A implantation
  • 2023-06-13 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Newly diagnosed sigmoid cancer
      • PH: HTN, lipoma, LC, ERCP
      • For further management of the disease
    • O
      • 2023/06/05 Whole body PET scan:
        • A glucose hypermetabolic lesion at the R-S junction, compatible with the primary rectal cancer.
        • Increased FDG uptake in the left para-aortic lymph nodes, at the L2-3 spine level, metastatic lymph nodes should be considered.
        • Increased FDG uptake in the left breast, the other primary breast cancer should be considered, suggesting biopsy for investigation.
        • Increased FDG uptake at the upper pole of the right kidney, the nature is to be determined also (urine retention, tumor, or other nature ?). Please correlate with other clinical findings for further evaluation.
        • Low-dose CT showed focal or nodular lesions of faint FDG uptake in the liver and in the left upper lung, suggesting follow-up.
      • 2023/05/11 CT (at NTUH) 0401180014
        • History of S-colon cancer – CEA = 1.73 ng/ml; CA19-9 = 16.8 U/ml (2023/05/8).
        • CT without and with contrast enhancement Indication: for evaluation Findings:
          • colon – the S-colon cancer should be correlated with clinical findings. – no regional LNs; – there is no evidence of paraaortic LAPs in abdomen; there is no evidence of LAPs in pelvic cavity and bilateral inguinal areas. – there is no ascites
          • liver – a large hemangioma 65.0mm at the S4a/8 area; – a large hemangioma 60.7mm at the S6 of right lobe of liver; – other multiple smaller hemangiomas are noted in both lobes of liver (arrow key images) – several small cysts in both lobes of liver; – hepatic veins and portal veins are patent
          • operative change of the GB; slightly dilated common bile duct
          • a duodenal diverticulum is noted at the second portion of duodenum
          • tiny cysts in the right kidney; there are no focal lesions in the spleen pancreas both adrenal and kidneys
          • no definite focal lesions in the pelvic cavity
          • atherosclerosis of the aorta;
          • spondylosis of the lumbar spine is noted; The alignment is intact.
          • A vertebral body hemangioma at the L2;
      • Impression
        • S-colon cancer cTxN0M0
        • multiple liver hemangiomas
      • 2023/06/07 MRI Pelvis
        • Findings
          • There is soft tissue lesion in the left lateral wall of the upper rectum, measuring 1.2 cm in size, with submucosa involvement that is c/w adenocarcinoma (T2).
            • In addition, there are three enlarged node 0.4 cm in left perirectal space, 1.6 cm in right internal iliac chain, and 0.6 cm in left sigmoid mesocolon that are c/w regional metastatic node (N1b).
        • There is one enlarged node 1.3 cm in right external iliac chain and three enlarged nodes in left para-aortic space and aortocaval space. Non-regional metastatic node (M1a) is highly suspected.
          • Please correlate with PET scan.
        • There are ten hemangiomas on both hepatic lobes and the largest one measuring 6 cm in S6/7.
          • In addition, few cysts on both hepatic lobes are also noted.
        • S/P cholecystectomy.
        • A renal cyst measuring 1.2 cm in right middle pole is noted.
        • T2N1bM1a, STAGE: IVA
    • P
      • Suggest admission for C/T with FOLFIRI with or without bevcizumab

[surgical operation]

  • 2023-06-21
    • Surgery
      • left partial mastectomy and SLNB
      • port-A implantation
    • Finding
      • left 3/3 tumor
      • SLNB: negative of malignancy, 0/4
      • right chest port-A implantation via right cephalic vein with cut-down method and 7fr Kabi set fixed at 14cm

[chemotherapy]

  • 2024-01-22 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-12-29 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-11-28 - bevacizumab 5mg/kg 260mg NS 100mL 90min + oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-10-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-09-27 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-09-08 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-08-23 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-08-04 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-07-21 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-07-07 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2024-01-23

[Vit B and CIPN: no clear recommendation, potential benefits remain]

B-Red (hydroxocobalamin) 1mg IM was administered on 2024-01-23 after chemotherapy to prevent oxaliplatin-induced neurotoxicity.

The year 2020 ASCO and joint ESMO/EONS/EANO guidelines concluded that clinicians should not offer vitamin B as a neuroprotectant agent to individuals receiving potentially neurotoxic chemotherapy.

Schloss et al. reported that vitamin B complex supplementation was statistically ineffective at preventing CIPN as compared to the placebo, although as indicated by the results of the Patient Neurotoxicity Questionnaire (PNQ), patients taking the vitamin B complex perceived a reduction in sensory peripheral neuropathy. Importantly, in cases of CIPN coexisting with vitamin B12 deficiency, patients did benefit from the oral supplementation of this medication. Lastly, Abe et al. reported that oral vitamin B12 supplementation did not help in the prevention of the CIPN onset. Their study did not include the control group and they compared the efficacy of B12 supplementation versus goshajinkigan—observed incidence of neuropathy was 88.9% and 39.3%, respectively.

Vitamin B complex supplementation cannot be recommended as the main way of CIPN prevention. Nevertheless, since such therapy does not impact the effectiveness of chemotherapy (with the exception of high doses of pyridoxine), and in some particular cases could potentially have an ameliorative effect, treatment with the vitamin B complex could be a safe and cheap solution.

Ref: Nutrients 2022, 14(3), 625; https://doi.org/10.3390/nu14030625

700857014

240122

[exam findings]

  • 2024-01-17 SONO - abdomen
    • Mild GB wall thickening, possibly secondary to acute hepatitis
    • Minimal right perirenal fluid, focal
  • 2024-01-15 Peripherally Inserted Central Catheter
    • Indication of PICC: plastic anemia with severe thrombocytopenia and anemia, for further chemotherapy
    • We perform PICC at cath room. Under the peripheral echo guiding, We successful pucnture left basilic vein. Under the fluroscopy revealed the wire in true lumin. Micro-sheath was advanced. PICC catheter tip advanced in high right atrial under the fluroscopy smoothly.
    • SvO2 was also check, it revealed 68 %.
      • Estimated Fick Cardiac index 2.28 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
      • Estimated Fick cardiac output 3.58 L/min. (nomral cardiac output range 5~6 L/min)
  • 2024-01-02 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — marked hypocellularity.
    • Section shows piece(s) of bone marrow with 1% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are markedly reduced in number. There is no malignancy present.
    • IHC stains: CD117: <1%; CD34: <1 %; MPO: 50%, CD61: <1 %; CD71: 50 % (of the nucleated cells). Feature suggestive of severe aplastic anemia. Please correlate with clinical, hemogram, and other laboratoy findings.

[MedRec]

  • 2024-01-12 SOAP Hemato-Oncology Gao WeiYao
    • A: Aplastic anemia with severe thrombocytopenia and anemia
  • 2023-12-29 ~ 2024-01-02 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe Thrombocytopenia, unspecified
      • Severe anemia, unspecified
      • Other pancytopenia
    • CC
      • gum bleeding for three months
    • Present illness
      • This is a 58-year-old female with the past history of brain surgery 40 years ago due to intracranial hemorrhage caused by traffic accident.
      • This time, she visited our hema OPD due to purpura over extremiteis for years and gum bleeding for three months. Accompanied with mild dyspnea. There was no fever, no chills, no chest pain, no nausea or vomiting, no tarry stool. Blood test was arranged which revealed pancytopenia. She was then referred to ER for emergent blood transfusion and admission for further studies.
      • At our ER, her vital signs were BP 150/64; HR 114; BT 37’C; RR 18; Con’s:E4V5M6, SpO2 100%. Blood transfusion with LPRBC 4u was arranged. Chest x-ray revealed negative findings.
      • Under the impression of pancytopenia, she was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, blood transfusion with LPRBC 4u on 12/29, 2u on 12/30, LRP 2u on 12/29 were ordered. We followed up blood test which revealed Hb 4.3 -> 6.5 -> 8.5 g/dL, WBC 2920->1590->1670 uL, PLT 9000->106000->74000 uL. Bone marrow puncture and biopsy was arranged on 2024/01/02 which showed relative dry tapping, yellowish bone marrow biopst, suspect myelofibrosis.
      • She had no significant discomfort during her stay. Under under stable condition, she discharged on 2024-01-02 and OPD follow up was arranged.

[chemotherapy]

  • 2024-01-16 Thymoglobuline (rabbit anti-human thymocyte immunoglobulin) 3.5mg/kg 194mg NS 500mL 12hr D1-5
    • [methylprednisolone 40mg + diphenhydramine 30mg + acetaminophen 1000mg PO + NS 250mL] D1-5

Triple IST (hATG, CsA, EPAG) — Triple immunosuppressive therapy (IST) for severe AA (SAA) comprises eltrombopag (EPAG; a bone marrow stimulating agent) plus two immunosuppressive agents (horse antithymocyte globulin [hATG] and cyclosporine [CsA]). As discussed above, triple IST is generally preferred over treatment with hATG plus CsA alone (no eltrombopag). Ref: 2024-01-22 https://www.uptodate.com/contents/treatment-of-aplastic-anemia-in-adults

==========

2024-01-22

[managing leukopenia and thrombocytopenia in aplastic anemia]

A 58-year-old female, newly diagnosed with aplastic anemia, began treatment with antithymocyte globulin at a dosage of 3.5mg/kg daily for five days starting on 2024-01-16. Additionally, ciclosporin at 300mg daily, divided into two doses (approximately 6mg/kg), was initiated on 2024-01-22. To manage severe leukopenia, G-CSF (filgrastim) has been administered since 2024-01-20. Due to observed thrombocytopenia episodes with platelet counts below 20K/uL, the concurrent initiation of eltrombopag with standard immunosuppressive therapy (antithymocyte globulin and cyclosporine) can also be considered.

Given the patient’s relatively young age, it might be advisable to assess eligibility and seek a match for allogeneic hematopoietic cell transplantation in advance.

700887256

240122

[MedRec]

  • 2023-10-18 ~ 2023-10-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Pancreatic cancer under chemotherapy in VGHTPE, last chemotherapy with FOLFIRINOX on 2023/10/04
      • Agranulocytosis secondary to cancer chemotherapy
      • Fever, culture pending
      • Chronic ischemic heart disease, unspecified
      • Paroxysmal atrial fibrillation
      • Other hyperlipidemia
      • Hypomagnesemia
      • Hypokalemia
    • CC
      • He was found lying on the ground by his family members.
    • Present illness
      • The 77 year-old male with history of
        • Pancreatic cancer under chemotherapy in TPEVGH, last chemotherapy with FOLFIRINOX on 2023/10/04,
        • heart disease for least 10 years, CAD s/p stents,
        • spondylolisthesis s/p,
        • Retinal vascular occlusion left eye,
        • Prostatectomy for 10 years.
      • According to the statement of the family, he was found lying on the ground by his family members, so he was brought to our ER for help. Associated symptoms included poor appetite, weakness, fatigue and fever.
      • At ER he conscious level is E4V4M6, vital sign: BT: 38.5’C; PR: 61 time/min; RR: 18 time/min; BP: 124/59mmHg, physical examination showed not under distress, conjunctiva: pale, bilateral clear breathing sounds, no tenderness, no muscle guarding, no rebounding pain, no knocking pain. Denied TOCC history in recent three months.
      • Lab data showed leuokopenia, neutropenia, anemia were noted. CXR was showed no active lung lesion.
      • Follow Brain CT(-C) showed Brain atrophy. Under the tentative diagnosis of neutropenia fever due to cancer chemotherapy. So, he was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, last time chemotherapy with FOLFIRINOX on 2023/10/04 to 2023/10/06, neutropenia fever was noted, Granocyte 250mcg/vial 1vial SC QD from 2023/10/18~2023/10/20.
      • Empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/10/17~2023/10/22.
      • Electrolyte imbalance and anemia were noted, after correction, get improved.
      • With the stable condition, he was discharged on 2023/10/22 and went to TPEVGH OPD followed up later.    

700972958

240122

[lab data]

2024-01-20 Anti-HCV Nonreactive
2024-01-20 Anti-HCV Value 0.16 S/CO
2024-01-20 HBsAg Nonreactive
2024-01-20 HBsAg (Value) 0.35 S/CO
2024-01-20 Anti-HBc Reactive
2024-01-20 Anti-HBc-Value 3.34 S/CO

==========

2024-01-22

[acute pancreatitis: supportive care on track, hepatic markers soar (ABD SONO reveals gallbladder sludge)]

This patient’s current primary medical concern is acute pancreatitis. Supportive therapy with fluid replacement and pain control (using normal saline and tramadol) is being effectively implemented.

Although vital signs, urine output, electrolytes, and serum glucose grossly remain within acceptable ranges, significant elevations were observed in hepatobiliary-related markers (AST, ALT, alkaline phosphatase, gamma-GT, and bilirubin) on 2024-01-20.

Abdominal sonography performed on 2024-01-22 revealed the presence of gallbladder sludge, which may represent a potential contributing factor requiring further management. Is this patient a candidate for cholecystectomy?

701157014

240122

[MedRec]

  • 2023-10-14, -07-22, -04-29, -03-04, 2022-11-12 SOAP Orthopedics Liu JiYuan
    • Prescription x3 (2023-03-04 x2)
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Celebrex (celecoxib 200mg) 1# QD
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# BID
  • 2022-06-19 ~ 2022-06-24 POMR Orthopedics Liu JiYuan
    • Discharge diagnosis
      • Left femoral head avascular necrosis post Bipolar hemiarthroplasty on 2022/06/20
    • CC
      • Left hip pain for three months
    • Present illness
      • The 54 y/o male has hypertension under medication control. He has smoking and alcohol history. He received right bipolar hemiarthroplasty 3-4 ago. This time, he noticed left hip pain while climbing stairs and came to local clinic for treatment.
      • Due to failure to conservative treatment, he was referred to our OPD for evaluation. The PE showed limping gait and painful ROM. The xray showed left femoral AVN r/o septic arthritis. The bipolar hemiarthroplasty was suggested.
      • He was admitted for preoperative survey and further management.
    • Course of inpatient treatment
      • After admission, preoperative survey revealed no contraindication. The left bipolar arthroplasty was done on 2022/06/20 smoothly. The patient tolerated the procedure well. The postoperative care initiated and the Hb was rechecked on the second days which showed acceptable level. The wound showed mild oozing without loose stitch. The hemovac showed serous discharge and it was removed under low drain amount. The Foley was removed after the patient could walk with assistance to toilet. The patient was taught to place pillow between legs after operation. The rehabilitation started with stable clinical condition. Initially, The strengthening exercise of lower limb was taught and the patient could walk with walker for short distance. The general condition was improved after postoperative care and the wound was kept dry and clean. Due to stable condition, the patient was discharged on 2022/06/24 with some painkiller and the OPD follow-up was arranged one week later.   
    • Discharge prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
      • Sindine (povidone iodine aq soln) ASORDER EXT

[surgical operation]

  • 2022-06-20 - Op Method: Left hip bipolar hemiarthroplasty         
    • Finding:
      • Left femoral head avascular necrosis
      • Prosthesis :
      • Brand : Stryker
      • Cup : 48mm
      • Head : 28mm, metal
      • Stem : #7         
    • Procedure:
      • Under spinal anesthesia, the patient was placed in right decubitus position with side post support in the back and the lower abdomen. Left hip and the whole left leg was disinfected and draped as usual.
      • Posterolateral approach with a curvilinear incision 12 cm in length centered over the greater trochanter was made. The wound was deepened. the fascia lata was split in the same direction along the wound. The short external rotators of the hip and the upper half of the gluteus maximus tendon were detached from their insertion to expose the joint capsule. One T capsulotomy was made and the hip was dislocated with internal rotation. The fractured femoral head was removed with a cork screw driver and the diameter of the head was measured. The remnant of the ligamentum teres was excised. The surface of the acetabulum was checked for smoothness.
      • The hip was flexed, adducted, and internally rotated again. The length of the neck was trimmed with one finger breath left. The femoral canal was prepared with reamer and rasp till appropriate size.
      • Then the femoral stem of desired size was inserted into the femoral canal. the femoral head and cup components of the prostheses were assembled and reduced into the joint cavity after profuse irrigation. The stability of the prostheses was checked.
      • Then the capsule was repaired. One #1/8 hemovac drain was placed. The gluteus maximus and the short external rotators were reattached. The fascia lata was repaired and the wound was closed in layers with compressive dressing to finish the procedure.         

701481589

240122

[lab data]

2023-05-30 Anti-HBc Reactive
2023-05-30 Anti-HBc-Value 3.37 S/CO
2023-05-30 Anti-HBs 80.54 mIU/mL

[exam findings]

  • 2024-01-18 Nasopharyngoscopy
    • Scope: much crust at bi nasopharynx, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
    • Conclusion
      • NPC s/p CCRT
      • Post-irradiation nasopharyngeal necrosis
  • 2023-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 21) / 88 = 76.14%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Trivial MR, TR
  • 2023-12-04 MRI - nasopharynx
    • Findings comparison 2023/05/30 MRI
      • Remarkable tumor regression in the nasopharynx, skull base and intracranial parts. Still abnormal signal intensity of the skull base bones.
      • Total regression, No neck LAP.
      • Decreased pneumontization of the bilateral mastoid air cells indicating chronic mastoiditis.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • IMP:
      • Remarkable tumor regression. Total regression, No neck LAP. Bilateral mastoiditis. Bil. CPS.
  • 2023-11-16 Nasopharyngoscopy
    • Findings
      • much crust at bi nasopharynx (R>L) and right choana, removed; bi nasopharynx posterior wall and roof soft tissue necrosis and whitish change
    • Conclusion
      • NPC s/p CCRT
      • Post-irradiation nasopharyngeal necrosis
  • 2023-10-19 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; residual crust at right nasopharynx
    • Conclusion
      • NPC s/p CCRT
      • suspect post-irradiation nasopharyngeal necrosis
  • 2023-09-21 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen
    • Conclusion
      • NPC s/p CCRT
      • bi sinusitis, suggest nasal douch
  • 2023-09-11 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 48 dB HL; LE 31 dB HL.
    • RE mild to severe mixed type HL.
    • LE normal to moderately severe HL.(0.5k,1k Hz masking dilemma)
  • 2023-08-24 Nasopharyngoscopy
    • Findings
      • much crust at bi posterior nasal cavity and bi nasopharynx (R>L), removed partially; mucosa detail of the nasohparynx not clearly seen ; hypopharynx and larynx np; suspected right posterior nasal cavity synechiae
    • Conclusion
      • NPC s/p CCRT
  • 2023-07-27 Nasopharyngoscopy
    • Findings
      • bi anterior nasal cavity erosions, crust/mucus coating on bi nasohparynx (right>left) and right middle meatus and bi choana, no gross tumor found
    • Conclusion
      • NPC with right nasal cavity invasion under CCRT
  • 2023-06-29 Nasopharyngoscopy
    • Findings
      • mucus coating on bi nasohparynx and right middle meatus, pulsatile at right sphenoid ostium; tumor size decreased significantly
    • Conclusion
      • NPC with right nasal cavity invasion under CCRT
  • 2023-06-01 PET
    • A large glucose hypermetabolic lesion involving the right posterior nasal cavity, right maxillary sinus, nasopharynx, skull base, sphenoid sinus and right medial temporal fossa of the brain, compatible with a primary malignant tumor.
    • Glucose hypermetabolism in some bilateral retropharyngeal lymph nodes and in some bilateral neck level II lymph nodes. Metastatic lymph nodes may show this picture.
  • 2023-05-30 MRI - nasopharynx
    • Findings
      • Bilateral nasopharynx tumor, with nasal cavity invasion, invsion to the skull base bones and medial right temporal fossa and cavernous sinus.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Enlarged bilateral neck LNs, all above the level of cricoid cartilage.
    • IMP:
      • NPC with skull base and right intracranial extension T4N2M0 stage IVA
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:4(T_value) N:2(N_value) M:0(M_value) STAGE:IVA (Stage_value)
  • 2023-05-24 Patho - nasopharyngeal/oropharyngeal biopsy (Y2)
    • Nasopharynx, right, biopsy — Squamous cell carcinoma, non-keratinizing and undifferentiated
    • The specimen submitted consists of 3 tissue fragments measuring up to 1 x 0.5 x 0.5 cm in size, fixed in formalin. Grossly, they are grayish and solid. All for section.
    • Microscopically, section shows undifferentiated, non-keratinizing squamous cell carcinoma composed of syncytial growth with oval or round vesicular nuclei and prominent nucleoli. There is inflammatory response with necrosis in the adjacent stroma.
    • IHC stain — EBER (+), CK (+), p16 (-)
  • 2023-05-23 Nasopharyngoscopy
    • Findings
      • granular tumor with touch bleeding at bi nasopharynx posterior wall, right NP roof, right choana, bi septum posterior part, right inferior T posterior part and right middle meatus
      • biopsy from right nasopharynx done
    • Conclusion
      • right nasopharyngeal and right nasal tumor
  • 2023-05-23 ENT Hearing Test
    • Tymp type C
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 60 dB HL; LE 25 dB HL
      • RE mild to profound MHL
      • LE normal to moderate SNHL
  • 2023-05-19 CT - sinuses for navigator
    • Indication: right sinonasal tumor s/p biopsy. nasopharyngeal tumor
    • CT of sinus without/with contrast enhancement shows:
      • lobulated enhancing tumor centered at nasopharynx and posterior nasal cavity, maximal diameter about 4.5cm, with involvement of posterior ethmoid sinus, posterior and medial right maxillary sinus, right pterygopalatine fossa, sphenoid sinus, paired longus colli muscles, and possible also skull base bone involvement. Suspect nasopharyngeal carcinoma (NPC) or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
      • enlarged lymph nodes at bilateral level II, probably lymphadenopathy.
      • right maxillary sinusitis change with increased effusion.
    • Impression:
      • Suspect NPC or nasal cancer. Suggest tissue proof, and MRI evaluation for more accurate and complete staging.
  • 2023-05-19 Patho - paranasal biopsy
    • Nasal cavity, right, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated
    • Microscopically, section shows poorly differentiated squamous cell carcinoma characterized by diffuse sheets of non-keratinizing tumor with invsive growth pattern. The tumor shows nuclar hyperchromasia, pleomorphism, prominent nculeoli, high N/C ratio and mitotic activity.

[MedRec]

  • 2023-07-27 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange weekly CDDP for CCRT “then followed by PF x 3”
  • 2023-06-08 SOAP Hemato-Oncology Xia HeXiong
    • A: NPC with right nasal cavity invasion; cT4N2M0; stage:IVA
    • P:
      • prepare for CCRT
      • Port-A on 2023-06-13
      • Simulation on 2023-06-05
      • Arrange weekly CDDP for CCRT
  • 2023-06-05 SOAP Radiation Oncology Chang YouKang
    • Diagnosis: Nasopharyngeal cancer, NK & undiffentiated carcinoma, cT4N2M0; stage IVA; ECOG = 1.
    • Plan: CCRT followed by adjuvant C/T or induction C/T followed by CCRT may be considered.
      • RT to NPX tumor and LAPs for 7140cGy/34 fx is suggested for locoregional control. Possible radiation toxicity (radiation mucositis, pharyngitis, esophagitis, dermatitis) is told to her.
      • CT simulation will be arranged on 2023-06-05, 09:30. Diet education & psychological support is given.
  • 2023-05-29 POMR Ear Nose Throat Huang TongCun
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, T4N2M0; stage:IVA
    • CC
      • Tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year
    • Present illness
      • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated and body weight loss 3kg for half year. Epistaxis off and on and intermittent nasal rhinorrhea for years was noted. Denied smoking, drinking and betel nut. She visited local clinic, but the symptom didn’t subside despite medical treatment. Therefore, the patient came to our ENT OPD for help. Physical exam showed polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Bilateral nasopharynx posterior wall mass with smooth surface and mucus coating was also noted.
      • Biopsy of right nasal tumor was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated.
      • Biopsy of right nasopharynx on 2023/5/23 also revealed Squamous cell carcinoma, non-keratinizing and undifferentiated.
      • Under the impression of nasopharyngenl carcinoma with nasal cavity involvement, admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, the patient was admitted for cancer work-up.           - Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. Nasopharynx MRI showed nasopharynx carcinoma T4N2M0, stage:IVA. Abdominal sonography showed negative. PET was done on 2023/06/01 and the result was pending.
      • OS was consulted for pre-RT tooth evaluation. Radio-oncologist was consulted for radiation therapy. Under relative stable condition, the patient was dishcarged with OPD follow up
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID

[consultation]

  • 2023-05-30 Oral and Maxillofacial Surgery
    • Q
      • For tooth evaluation
      • This 62 year-old female patient denied any underlying disease. She suffered from tinnitus and aural stuffiness (R>L) since 3 years ago, aggravated for half year and epistaxis off and on. She went to our ENT OPD for help. In OPD, polypoid mass at right nasal cavity upper part and right middle meatus with involvement of bilateral posterior septum and right choana. Biopsy was done on 2023/05/18 and pathology revealed squamous cell carcinoma, non-keratinizing and poorly differentiated. Under the impression of nasopharyngenl Carcinoma. The patient was admitted for cancer work-up on 2023/05/29. After admitted, arragne MRI on 5/30; Abd sonography on 5/31; PET on 6/1. We will arrange CCRT for this patient. We need your help for tooth evaluation. Thank`s a lot
    • A
      • We are consulted for dental evaluation prior to CCRT.
      • panoramic film:
        • Prosthodontics: 27,36
        • no large decayed tooth or severe periodontitis of teeth
      • Plan:
        • intraoral physical eaxmination
        • take a panoramic film
        • teach her how to do home care (The patient’s current dental condition does not require extraction treatment.)
        • full mouth scaling and oral hygiene instruction

[radiotherapy]

  • 2023-06-14 ~ 2023-08-01 - 7140cGy/34 fractions (6 MV photon) to NPX tumor and LAPs.

[chemotherapy]

  • 2024-01-19 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-12-18 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-11 - cisplatin 60mg/m2 90mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL (Y-sited cisplatin D1) D1-4 (PF Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-28 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-14 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-07 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-30 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-16 - cisplatin 40mg/m2 60mg NS 500mL (Y-sited NS 1000mL) (CDDP QW CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-22

[reconciliation]

Lab data from 2024-01-19 indicated generally normal levels across blood cell counts, electrolytes, and liver and kidney functions. Additionally, a review of the medication records revealed no discrepancies.

2023-10-30

[Achrimobacter xylosoxidans bacteremia]

For treating Achromobacter xylosoxidans infections in patients without cystic fibrosis:

  • Ceftazidime 1-2 gm IV q8-12 h
  • Imipenem-cilastatin 500 mg IV q6h or Meropenem 1-2 gm IV q8h or Doripenem 500 mg IV q8h (not for pneumonia)
  • Ciprofloxacin 400 mg IV q12h

700206320

240119

[exam findings] (not completed)

  • 2023-12-19 Patho - ureter biopsy
    • Labeled as “right renal pelvis tumor”, URS biopsy — carcinoma, high grade.
    • Specimen submitted in formalin consists of 3 piece(s) of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm. All tissue for section(s) in one cassette(s).
    • Section shows pieces of high grade carcinoma.
    • IHC stains: CK7 (+), GATA-3 (equivocal), CD10 (-), CAIX (-), vientin (-), RCC (-). The tumor location and the IHC pattern are in favor of urothelial carcinoma.

[MedRec]

  • 2023-12-19 ~ 2024-01-04 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Right renal pelvis urothelial carcinoma, cT3N2M0, stage IV status post 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion on 2023-12-25; 3) Immunotherapy with Nivolumab (#1) on 12/27, Chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27, Chemotherapy with Gemcitabine (D8) on 2024-01-03
      • Benign neoplasm of right kidney
      • Right hydronephrosis
    • CC
      • Presented with hematuria and right flank soreness for the past two weeks
    • Present illness
      • This 47-year-old female with no surgical or chronic medical history. Previously sought emergency care for urinary tract infection and migraines. On 2016-11-05, elevated Cr of 1.3 mg/dL was detected. Regular follow-ups have been conducted since then. Presented with hematuria and right flank soreness for the past two weeks. Sought consultation at the Nephrology Department, where lab data revealed elevated Cr of 2.9 mg/dL. Renal ultrasound showed right renal pelvic mass lesion and hydronephrosis, r/o urothelial carcinoma. Subsequently, referred to the Urology Department for further investigation.
      • Under the impression of right renal tumor, we advised the patient to receive right fURS exam biopsy. After well explaining, the patient agreed. This time, she was admitted for further evaluation and manageme.
    • Course of inpatient treatment
      • After admission, the surgery of 1) Rightr ureterorenoscopic exam & double-J stenting on 2023-12-19; 2) Port-A insertion was performed on 2023-12-25. Post operation, MRI revealed right renal pelvis urothelial carcinoma, cT3N2M0, stage IV. Pathrology showed carcinoma, high grade.
      • PET showed metastatic lymph node. She received Immunotherapy with Nivolumab (#1) on 12/27 and chemotherapy with Carboplatin + Gemcitabine (#1 D1) on 12/27.
      • After treatment, severe nausea and poor oral intake was noted. IVF support and symptom treatment. Stable condition she receive chemotherapy with Gemcitabine (D8) on 2024-01-03.
      • With fair urination, he was discharged today and would be followed up at urologic clinic for further treatment.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Roumin (prochlorperazine maleate 5mg) 1# PRNQ12H
  • 2021-02-26, 2020-11-20, -08-14, -05-22, -02-04, 2019-11-12, -08-13 SOAP Nephrology Hong SiQun
    • Prescription x3
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QD
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2019-05-21 SOAP Nephrology Hong SiQun
    • S
      • AIMHI study V1
    • O
      • Cr 1.6 -> 1.8 -> 1.8 -> 1.8 -> Cr 1.9, LDL 136
    • Diagnosis
      • Abnormal renal function test [R94.4]
      • Dyslipidemia [E78.4]
    • Prescription x3
      • Vytorin (ezetimibe 10mg, simvastatin 20mg) 1# HS
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2019-01-11 SOAP Nephrology Hong SiQun
    • S
      • elevated CRE and came for F/U
      • add prednislone 2# qod and follow up
    • Diagnosis
      • Abnormal renal function test [R94.4]
    • Prescription x3
      • Compesolon (prednisolone 5mg) 2# QOD
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2018-09-21 SOAP Nephrology Hong SiQun
    • S
      • CKD for follow up
      • add trental and follow up
      • elevated CRE and came for F/U
      • acute on chronic CKD, cause?
    • O
      • arrange further study
      • consider renal biopsy if progression
    • Diagnosis
      • Abnormal renal function test [R94.4]
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2018-08-23 SOAP Metabolism and Endocrinology Zen YiQian
    • S
      • PH: migraine, CKD
      • CC: frequently attacked recently, painkiller can’t improve, photophobia
    • O
      • E4V5M6
      • CNs: intact
      • MP: full
      • sensaiton: intact
      • FNF: no dysmetria
      • gait: steady
      • impression: migraine
      • plan: imigran and try suzin
      • 2017/12/26 BUN 26 mg/dL, CRE 1.6 mg/dL
      • 2018/05/04 BUN 25 mg/dL, CRE 1.6 mg/dL
      • 2018/05/04 CA 125 53.7 IU/mL
    • Diagnosis
      • Comnon migraine with intractable migraine, so stated [G43.019]
      • Chronic renal insufficiency [N18.9]
    • Prescription x3
      • Imigran (sumatriptan 50mg) 3# QW
  • 2017-07-13 SOAP Metabolism and Endocrinology Zen YiQian
    • S
      • migrane attacked and lasted over 24 hrs
      • not subsided after panadol and NSAID tx
      • PH: eczema
    • O
      • palpule with severe itching and excoriation over back
      • 2016/11/23 GLU 136 mg/dL, CRE 1.3 mg/dL
    • Diagnosis
      • Eczema [L30.8]
      • Renal function impairment [N18.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Allegra (fexofenadine 60mg) 1# BID

[consultation]

[immunochemotherapy]

  • 2024-01-19 - carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
  • 2024-01-03 - gemcitabine 1000mg/m2 1400mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-12-27 - nivolumab 300mg NS 100mL 1hr + carboplatin 260mg NS 100mL 1hr + gemcitabine 1000mg/m2 1400mg NS 100mL 1hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 500mL
  • 2023-12-20 mitomycin-C 30mg/m2 30mg BI 1hr

==========

2024-01-19

[transfusion in chemotherapy-induced anemia]

Given the patient’s renal impairment, a modified treatment regimen of nivolumab combined with gemcitabine and carboplatin was administered instead of the standard nivolumab, gemcitabine, and cisplatin therapy.

The patient’s hemoglobin levels have shown a consistent decline, indicating anemia:

  • 2024-01-19 HGB 6.9 g/dL
  • 2024-01-03 HGB 8.1 g/dL
  • 2023-12-19 HGB 9.5 g/dL
  • 2023-12-12 HGB 10.2 g/dL

Anemia is associated with gemcitabine (68%; grade 3: 7%; grade 4: 1%), carboplatin (21% to 90%), and nivolumab (26% to 41%; grades 3/4: <=3%). The downward trend in HGB might suggest insufficient red blood cell production to match the treatment schedule. A transfusion was performed on 2024-01-19, which is considered an appropriate action. If adverse reactions increase, modifying the administration interval or dose reduction could be further decided.

700959021

240119

{Triple cancer - endometrium ca, rectal ca, RCC}

[exam findings]

  • 2024-01-18 SONO - chest
    • Symptom: dyspnea
    • Indication: r/o pleural effusion
    • Clinical diagnosis:
      • Triple cancer (endometrium, rectal ca, kidney RCC )
      • ESRD under maintenance H/D TIW
    • The patient was in sitting upright posture while th chest echography was performed using: 3.75-mHz convex probe.
    • Findings
      • Left-side of thorax:
        • moderate loculated effusion, septum and fibrin
      • Pleural thickening
        • LLL atelectasis
      • Right-side of thorax:
        • no effusion
        • no active lung lesion
      • Special Procedure
        • A 16# long catheter was inserted into left 5th ICS along mid-posterior scapular line. 750ml yellow fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block, TB-PCR.
    • Echo diagnosis
      • Pleural effusion, moderate, left, complicated
      • Atelectasis, LLL
  • 2024-01-17 CT - neck
    • Indication: Left clavicle region swelling for 3 days, pain(+). History of endometrial cancer, colon cancer
    • Neck CT without/with contrast enhancement shows:
      • bilateral symmetric pharyngeal mucosa.
      • no definite enlarged cervical lymphadenopathy.
      • suspect left proximal humerus greater tubercle fracture.
      • no definite destructive bone lesion at bilateral clavicle or other visible bones.
      • left pleural effusion, status post pigtail insertion.
      • left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
    • Impression:
      • Suspect left proximal humerus greater tubercle fracture.
      • No destructive bone lesion.
      • Left pleural effusion.
      • Left perihilar lung collapse with calcification, occult lung lesion cannot be excluded. Suggest further evaluation.
  • 2024-01-17 Clavicle LT
    • Left clavicle X-rays show: Left proximal humerus fracture, greater tubercle. Calcification near greater humeral tubercle, calcified tendinosis of distal supraspinatus tendon is suspected.
  • 2024-01-10 Peropheral Vascular Test - AV fistula
    • Clinical diagnosis: AVF dysfunction
    • Report:
      • Access type: graft
      • Site: left upper arm
      • Clinical problem: left arm swelling
      • Age of vascular access:
      • Result:
        • Left brachio-graft axillary shunt, feeding volume 1489 ml/min, graft degeneration improved after POBA
        • There is no obvious hematoma over elbow area.
      • Suggestion: Clinical follow up
  • 2024-01-09 Cardiac Catheterization
    • Past Medical History
      • The patient has a history of ESRD under H/D.
    • Indication
      • The patient was referred with left arm swelling. The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the graft graft where a 6F sheath was inserted. Percutaneous access was performed through the graft graft where a 6F sheath was inserted.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 50cc. The patient was treated with Dormicum (dosage 2.5mg).
    • Finding Summary
      • Left Brachio graft axillary shunt, A to V puncture site with 50% stenosis(graft degeneratoin) GV junction with 55% stenosis with colalterals and left central vein with 90% stenosis.
    • Recommendation
      • PTA
    • Intervention Summary
      • Left Brachio graft axillary shunt, A and V puncture site degeneration, Pre-DS = 50%
        • MLD/RVD=3.5/7 mm → 5.6/7 mm, Post-DS = 20%.
        • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 10 atmospheres.
      • Left Brachio graft axillary shunt, GV junction, Pre-DS = 55%
        • MLD/RVD=3.36/7.45 mm → 5.52/6.83 mm, Post-DS = 19%.
        • Balloon: Bard Conquest. 7.0 X 40 mm. Pressure: 20 atmospheres.
      • Left Brachio graft axillary shunt, left central vein, Pre-DS = 90%
        • MLD/RVD=1.2/12 mm → 4.48/10.22 mm, Post-DS = 62%.
        • Balloon: Boston Mustang. 10.0 X 40 mm. Pressure: 14 atmospheres.
        • Balloon2: Abbott Armada 35. 12.0 X 40 mm. Pressure: 10 atmospheres. but still suboptimal result,
    • In conclusion:
      • Left brachio graft-axillary shunt, A and V puncture site (graft) degeneration, GV junction and left central vein stenosis s/p POBA successful bur left central vein suboptimal result.
    • Recommendation:
      • close monitor venous pressure
  • 2024-01-09 Peripheral Vascular Test - AV fistula
    • Clinical diagnosis: AVF dysfunction
    • Report:
      • Access type: graft
      • Site: left upper arm
      • Clinical problem: arm swelling
      • Age of vascular access:
      • Result: Left brachio-graft-axillary shunt, feeding volume 413 ml/min, AV junction 0.38 cm, near AV junction graft degeneration 0.15 cm, A puncture site 0.64 cm, V puncture site 0.42 cm, GV junction no obvious stenosis
    • Suggestion:
      • Because of arm swelling, and prior PTA history, arrange IVDSA and PTA PRN.
      • Suggestion: PTA
  • 2024-01-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (174 - 128) / 174 = 26.44%
      • M-mode (Teichholz) = 26.4
      • 2D (M-Simpson) = 31.8
    • Conclusion:
      • Sclerosis of AV with severe AS, mild AR (AVA 0.86, Vmax 3.64)
      • Thickened and calcified MV, mild MR
      • Concentric LVH, dilated LV
      • Poor LV systolic function, global hypokinesia and apical akinesia
      • Mild PR, mild TR, normal IVC size
      • Dilated LA, pleural effusion noted
  • 2024-01-07 CT - chest
    • Left pleural effusion with left lung collapse and clacifications.
    • Nodules (up to 5.6mm) at right lung.
    • Liver cirrhosis with a cyst (1.6cm).
    • Cardiomegaly.
  • 2024-01-07 ECG
    • Sinus tachycardia with frequent Premature ventricular complexes in a pattern of bigeminy
    • Left ventricular hypertrophy with repolarization abnormality
  • 2023-12-12 Parathyoid scan with SPECT
    • Two focal areas of mildly increased radiotracer uptake in the middle portion of the right thyroid bed and lower portion of the left thyroid bed respectively. The nature is to be determined (hyperplastic parathyroid glands or parathyroid adenomas? some kind of thyroid lesions?). Please correlate with clinical findings for further evaluation.
  • 2023-09-05 CT - abdomen
    • S/P left nephrectomy.
    • Liver cirrhosis.
    • Left pleural effusion.
    • GB stones.
    • R/O liver cyst, 1.5cm in right lobe liver.
    • Coronary artery calcifications.
  • 2023-07-06 CXR erect
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • A nodular opacity projecting in the right lower medial lung, retrocardiac area, is suspected. Please correlate with CT.
  • 2022-12-08 ENT Hearing Test
    • Tymp RE type As, LE type A
    • ART bil absent
    • PTA:
      • Reliability FAIR
      • Average RE 18 dB HL, LE 23 dB HL
      • bil normal to mild SNHL
  • 2022-11-11 CT - chest
    • Calcified coronary arteries is found.
    • Faint aveolar opacity over Right upper lobe, right lower lobe and left lower lobe
    • Bilateral pleural effusion.
    • Liver cirrhosis with splenomegaly
  • 2022-10-20 EEG
    • Conclusion: Abnormal EEG.
    • The background activities were composed by alpha rhythm at 8-9 Hz, 20-60 uV in bilateral posterior head areas and beta rhythm at 13-15 Hz, 10-20 uV in bilateral anterior head areas. There were occasional diffuse slow waves at 4-6 Hz, 20-50 uV in bilateral hemispheres. No obvious photic driving response was noted. This EEG suggests mild diffuse cortical dysfunction. Advise clinical correlation.
  • 2022-09-09 Patho - kidney partial/total resection
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left kidney, laparoscopic radical nephrectomy — Clear cell renal cell carcinoma
      • Resection margin, ditto — Free of tumor invasion
      • Ureter, ditto — Free of tumor invasion
      • Perirenal fat, ditto — Free from tumor invasion
      • AJCC Pathologic staging — pT1a, if cN0 and cM0, stage I
    • Gross Description:
      • Procedure: laparoscopic radical nephrectomy
      • Laterality: Left
      • Specimen size: 19.2 x 12.3 x 3.8 cm, 468 gm in weight
        • kidney: 6.7 x 3.3 cm
        • ureter: 7.1 cm in length, 0.3 cm in diameter
      • Tumor size: 2.3 x 1.8 cm
      • Tumor site: hilar region
      • Tumor focalty: solitary
      • Tumor extent: The tumor is grossly confined in the kidney
      • Representatively embedded for sections as A1-A2: renal pelvis, A3-A7: tumor, A8: renal hilum, A9: perirenal fat and A10: ureter
    • Microscopic Description
      • Histological type: clear cell renal cell carcinoma
      • Histological grade: grade 2
      • Pathological staging: pT1a, if cN0 and cM0, stage I
      • Resection margins: Free
      • Lymphovascular invasion: Not identified
      • Tumor necrosis: absent
      • Additional pathologic findings: cystic change
      • Immunohistochemistry: CK7(-), vimentin(+), PAX8(+, focal), CD10(+, focal) and CA IX(+) for tumor
      • Non-tumor kidney: chronic pyelonephritis with thyroidization, diffuse global glomerulosclerosis, microcalcification and subintimal hyperplasia of arteries with microcalcification of arterial wall
  • 2022-02-11 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 6.5 x 6.0 x 2.5 cm
      • Tumor Site: Periphery
      • Tumor Size: 2.8 x 2.6 x 1.8 cm
      • Gross tumor patterns: poorly defined,
      • Tissue for sections: A1: resection margin; A2: lung, non-tumor; A3-5: tumor.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are consistent with metastatic colonic tumor.
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS):Present
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): present
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 0.3 cm;
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
  • 2019-03-20 SONO - nephrology
    • Interpretation:
      • Bilateral parenchymal renal disease with samll-sized kidney.
      • Right renal cyst.
      • Right moderate hydronephrosis.
      • Right peri-renal fluid acculumation.
  • 2018-01-22 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS:
      • Lung, LLL, lobectomy —– Adenocarcinoma, moderately differentiated, consistent with metastatic colonic origin
      • Lymph node, lobar, lymphadenectomy —– Negative for malignancy (0/5)
      • Lymph node, area 5, lymphadenectomy —– Negative for malignancy (0/2)
      • Soft tissue, area 7, lymphadenectomy —– Negative for malignancy (0/0)
      • Lymph node, area 10, lymphadenectomy —– Negative for malignancy (0/1)
    • MACROSCOPIC EXAMINATION:
      • Topography: LLL
      • Procedure: lobectomy
      • Size of lung received: 14.8 x 8.0 x 4.5 cm
      • Weight of lung received: 120 gm
      • Tumor location: peripheral
      • Tumor size: 2.5 x 2.0 x 1.5 cm
      • Tumor description: gray, solid, and necrosis
      • Satellite tumor nodules: absent
      • Mainstem bronchus: not involved
      • Bronchial margin: free, 1.2 cm from margin
      • Visceral pleural margin: free, 0.9 cm
      • Pleura: smooth
      • Non-neoplastic lung: congestion
      • Lymph node: area 5, 7, and 10
      • Representative sections are taken and labeled as: A1: resection margin; A2: lymph node, lobar; A3: lung, non-tumor; A4-8: tumor; B: lymph node, area 5; C: lymph node, area 7; D: lymph node, area 10.
    • MICROSCOPIC EXAMINATION:
      • Histology type: adenocarcinoma; The immunohistochemical stains reveal CDX2(+) and TTF-1(-). The results are in favor of metastatic colonic adenocarcinoma.
      • Histology grade: moderately differentiated (G2).
      • Tumor necrosis: moderate (40%)
      • mitotic activity: marked (> 20/10hpf)
      • peritumor infiltrates: mild
      • in situ carcinoma: absent
      • angiolymphatic invasion: present
      • perineural invasion: absent
      • mainstem bronchus: no involvement
      • bronchial margin: free
      • visceral pleural involvement: The tumor does not invade the visceral pleura (P0).
      • Tumor cells in the subpleural lymphatics: no
      • non-neoplastic lung: congestion
      • Lymph node metastasis
        • group as specified
        • lobar: 0/5
        • area 5: 0/2
        • area 7: 0/0
        • area 10: 0/1
        • over all: 0/8
      • perinodal (extracapsular) tumor extension: absent

[MedRec]

  • 2022-08-04 ~ 2022-08-06 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Malignant neoplasm of rectum
      • K-ras wild type, recurrent adenocarcinoma of rectum with lung metastasis, pT3N1bM1 pStage: IV
      • pathology (S2013-17848, 2013-11-19): Uterus, corpus, laparoscopic assisted vaginal hysterectomy (s/p RT) — endometrioid adenocarcinoma, Grade 2 — TNM: ypT1a, FIGO stage: ypIA.
      • Chronic kidney disease, unspecified
      • Type 2 diabetes mellitus without complications
    • CC
      • arrange chest CT exam for survey
    • Present illness
      • The 56-year-old woman has past history of old right brainstem hemorhagic stroke was noted on 2009, and then could not walk independently since 2016, hypertension for over 20 years, COPD for over 20 years without regular medications control currently, type II DM for around 10 years, and end-staged renal disease status post regular H/D since 2019/03 (QW135 currently).
      • She also had previous histories of endometrial cancer, adeno of rectal cancer stage IIIB on 2015/6, and left lower lung metastatic cancer (colonic related) status post surgical treatment (Please see the details at the past histories).
      • Left arteriovenous graft occlusion post Percutaneous Transluminal Angioplasty + thrombectomy on 2021/06/22. She was then referred back to our Chest surgery Dr. Xie’s OPD back for the further survey.
      • Further chest CT showed lobulated mass at left lower lobe, favored metastatic lesion related. After fully explanation and discussion to the patient and her families, she received video-assisted thoracic surgery (Left upper lobe tumor wedge resection) on 2022/02/10. Pathology showed Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor, CDX2(+) and TTF-1(-).
      • The chemotherapy regimen started as C1D1 HDFL on 2022/03/03 was complicated of related hepatic encephalopathy treated.
      • Under the impression of lung metastasis from colonic cancer, so she was admitted for reduced dose chemotherapy for recent history of HDFL related hepatic encephalopathy on 2022/03/29.
      • FOLFIRI was discontinued on 2022/03/31, because of the patient had improvement of numbness and weakness after the chemotherapy injection.
      • Sigmoidscopy was done, report showed internal hemorrhoid and no bleeding later.
      • The EEG on 2022/03/15 showed No obvious photic driving response was noted.
      • The tumor marker showed CEA:<0.3, CA-199:9.271.
      • She started took Xeloda 1# po bid since 2022-04-28 then shifted to 2# po bid since 2022-05-05.
      • Today, she was admitted arrange chest CT exam for Xeloda treatment response evaluation on 2022/08/04.
    • Course of inpatient treatment
      • After admission, Xleoda 2# po bid was given. The chest CT (2022-08-05) showed chest:s/p op. over left lower lobe with regional soft tissue is found. Suggest closely follow up. Small lymph nodes are found in the mediastinum. There is no evidence of mediastinal LAP. Patent airway is found. Left pleural effusion is found. Abdomen: Soft tissue mass with strong enhancement at left kidney up to 2.6cm is found. There is stone at dependent portion of GB. GB stone(s) are noted. Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis. The renal vein and INFERIOR VENA CAVA are patent.
      • QW 1.3.5 H/D was given. She was discharged on 2022-08-06 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • none
  • 2017-06-13 SOAP Metabolism Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Kludone (gliclazide 60mg) 1# QDAC
      • Victoza (liraglutide) 1.2mg QDAC SC
      • Blopress (candesartan 8mg) 1# QD
      • Glucobay (acarbose 100mg) 1# TIDAC
  • 2017-02-07 SOAP Hemato-Oncology Gao WeiYao
    • Diagnosis
      • Malignant rectum neoplasm [C20]
      • Maliganat uterus neoplasm, corpus uteri, except isthmus [C54.1]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
  • 2017-01-10 SOAP Neurology Su YuQin
    • Diagnosis
      • Unspecified late effect of cerebrovascular disease [I69.80]
      • Malignant rectum neoplasm [C20]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Urinol (allopurinol 100mg) 1# QD
      • NovoNorm (repaglinide 1mg) 2# BID
      • Imolex (loperamide 2mg) 1# PRN
      • Grumed (glimepiride 2mg) 1.5# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
      • Lipanthyl Supra (fenofibrate 160mg) 0.5# QD

==========

2024-01-19

[myocardial injury indicators: rising hs-Troponin I]

Lab results indicate low CK levels, normal CK-MB, and a consistent increase in hs-Troponin I, suggesting myocardial injury.

  • 2024-01-17 CKMB 4.4 ng/mL
  • 2024-01-17 CK 26 U/L
  • 2024-01-17 hs-Troponin I 1095.8 pg/mL
  • 2024-01-17 hs-Troponin I 983.3 pg/mL
  • 2024-01-07 hs-Troponin I 589.8 pg/mL
  • 2020-09-15 hs-Troponin I 69.6 pg/mL

The pattern of these biomarkers might point to several potential causes:

  • Microinfarctions: These could occur without significant CK elevation due to their small scale.
  • Unstable Angina: Persistent reduced blood flow may not trigger a pronounced CK rise but can still cause elevated hs-Troponin I levels.
  • Myocarditis: This condition, marked by inflammation of the heart muscle, could elevate hs-Troponin I without substantially increasing CK.

Given these findings, consulting a cardiologist may be beneficial for further evaluation and management.

[optimizing midodrine dosage for this hemodialysis patient]

Midodrine, dosed at 7.5mg, commenced pre-hemodialysis treatment QW135 from 2024-01-18, aiming to prevent post-dialysis hypotension, with current blood pressure around 90/50 mmHg. The dosage, confirmed via telephone with the nurse practitioner, aligns with the patient’s customary regimen.

(the following text is wrong and not posted)

Midodrine, at a dose of 7.5mg, has been initiated for post-hemodialysis treatment as of 2024-01-18, with current blood pressure readings around 90/50 mmHg.

Midodrine’s effectiveness is attributed to its major metabolite, desglymidodrine, generated through the deglycination process. The peak plasma concentration of midodrine occurs about 30 minutes post-administration, with a half-life of approximately 25 minutes. Desglymidodrine reaches peak levels in the blood between 1 to 2 hours after midodrine administration and has a half-life of 3 to 4 hours.

For patients undergoing thrice-weekly intermittent hemodialysis, initiating midodrine at a low dose, such as 2.5 mg once or twice daily, is advisable. Dosage can be adjusted based on individual response and tolerability, with careful monitoring.

701505232

240119

[MedRec]

  • 2024-01-10 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 30 days.
    • O: Chronic ulcer with necrotizing fasciitis is found over the left medial ankle s/p Dermacell implantation about 3 * 5 cm in size –> superficial debridement –> wound CD with Allevyn Ag q2d
  • 2024-01-03 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation for 23 days.
    • O: Chronic ulcer with necrotizing fasciitis is found about 4 * 6 cm in size over the left medial ankle s/p Dermacell implantation –> removal of skin staples –> wound CD with Allevyn Ag q3d
  • 2023-11-23 ~ 2023-12-27 POMR Rheumatology and Immunology Chen ZhengHong
    • Discharge diagnosis
      • Systemic lupus erythematosus
      • Chronic ulcer with necrotizing fasciitis over the left medial ankle; statsus post deep debridement + fasciectomy + negative pressure wound therapy on 2023/11/27, deep debridement + negative pressure wound therapy on 2023/12/04, deep debridement + Dermacell artificial dermis implantation + negative pressure wound therapy on 2023/12/11
      • Glomerular disease in systemic lupus erythematosus
      • Acute kidney failure
      • Antiphospholipid syndrome
      • Tiny duodenal ulcer, superior duodenal angle
      • Hypomagnesemia
      • Hemolytic anemia post spleenectomy
      • Hyperkalemia
      • Abnormality of albumin
      • Reflux esophagitis, grade A(minimal)
    • CC
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks
    • Present illness
      • This 41-year-old famale had histories of
        • Sytemic lupus erythematous with diffuse proliferatine lupus nephritis and membranous nephritis, ISN/RPS class IV+V,modified NIH AI:19& CI:4;2;with autoimmune hemolytic anema (post spleenectomy in 2018), with aPL psitive, seizure with lupus PRES,with lupus angitis, with suspect lupus pneumonitis, and plerual efffusion/ ascities status post.
        • Lupus nephritis,
        • Left medial ankle bulla, suspect lupus related —> calciphylaxis ulcer
        • Gall bladder stone with acute on chronic cholecystitis, refused surgery
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
      • She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle,mild redness around wound, local heat, no discharge, VAS 5.
      • Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
    • Course of inpatient treatment
      • Belimumab (self-paid) course (Belimumab is an IgG1-lambda monoclonal antibody that prevents the survival of B lymphocytes by blocking the binding of soluble human B lymphocyte stimulator protein (BLyS) to receptors on B lymphocytes. This reduces the activity of B-cell mediated immunity and the autoimmune response.)
        • 1st Belimumab 640mg on 2023/09/13
        • 2nd Belimumab 640mg on 2023/09/27
        • 3rd Belimumab 640mg on 2023/10/13
        • 4th Belimumab 400mg on 2023/10/24
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks. She visited our OPD of plastic surgery. Physical examination showed chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle, mild redness around wound, local heat, no discharge, VAS#5. Surgical tangenital debridement were recommended. Then, she was admitted for surgical intervention.
      • After admission, hyperkalemia (6.6) with metabolic acidosis, bicarbonate = 15 and hemolytic anemia were noted, We consulted Nephrology and DC Exforge, add Sodium bicarbonate 2# TID, NESP 20 ug IV st and QW3 for anemia, add Lasix, Kalimate, RI + Vitagen 50% for potassium control, follow up K showed improved potassium level: (5.8 -> 6.0 -> 5.1 -> 5.4 -> 4.7 -> 4.9 -> 4.8).
      • CVC was inserted on 2023/11/24 because of difficulty in placing peripheral intravenous catheters. We consulted Rheuma under the impression of SLE, lupus nephritis with uncontrolled lupus disease activiety and autoimmune hemolytic anemia.
      • Debridement for chronic ulcer with necrosis over the left medial ankle was performed on 2023/11/27. Due to uncontrolled lupus disease activity, she was transfered to Rheuma ward on 2023/11/27.
      • After transferral to rheumatology ward, we checked APS profile, SSA/SSB, anti-ICS, anti-BMZ, ESR, CRP, thyroid function & electrolytes which disclosed APS with Anti-Cardiolopin IgG 2023-11-28 51 GPL-U/mL, Anti-ENA SS-A(Ro) 224 EliA U/ml, and Anti-ENA SS-B(La) 24 EliA U/ml. We kept DMARDs treatment (CellCept250 mg/cap 4 cap BID, Plaquenil 200mg/tab 1 tab BID) and Prednisolone 1 tab BID for SLE with lupus nephritis control, Warfarin 1mg/tab 1 tab BID for APS control, Revatio 20mg/tab (Sildenafil) 1 tab TID for pulmonary hypertension control according to discharge summary of TMUH. We rechecked risk management plan before Belimumab infusion which disclosed Anti-HBc Reactive, Anti-HCV and HBsAg nonreactive.
      • Immunotherapy of Belimumab (self-paid) was administered on 2023/11/30. The 2023/11/28 cardiac echo revealed EF 75% with concentric LV hypertrophy with indeterminated LV filling pressure; mildly dilated LA, marked calcification of mitral papillary muscles with trivial MR; mild aortic valve with trivial AR, minimal amount pericardial effusion ( < 50ml), and sinus tachycardia.
      • Albumin 1 bot IVD x 3 days (11/28~30) was administered for hypoalbuminemia (Albumin 2.4 g/dL). The following thyroid function revealed Free-T4 1.10 ng/dL, TSH 1.754 uIU/mL.
      • For persistent nausea and intermittent vomiting since 2023/10, we arranged gastroscopy on 2023/11/29 - Reflux esophagitis LA Classification grade A (minimal), superficial gastritis, antrum, tiny duodenal ulcers, superior duodenal angle and PPI with Nexium was added for duodenal ulcers and GERD grade A.
      • We taper off Kalimate for hyperkalemia resolved and MgSO4 IVD stat + MgO 1# TID was added for hypomagnesemia (Mg 2023-11-29 1.1 mg/dL).
      • Deep debridement + negative pressure wound therapy (small size) was performed on 2023/12/04 and we kept wound care by negative pressure wound therapy.
      • We rechecked D-dimer, PT/APTT, lipid profile, Albumin which disclosed HGB 8.7 g/dL, D-dimer 4181.00 ng/mL, Albumin 2.7 g/dL, Cr 1.25 mg/dL, eGFR 50.20 ml/min. DVT of left foot was suspected and Clexane 60mg/0.6mL/syringe 60 mg SC QD was prescribed since 2023/12/09 and the follolwing D-dimer: 2284 ng/mL on 2023/12/11, D-dimer 1701.00 ng/mL on 2023/12/14. We consulted CV for pulmonary hypertension evaluation and recommendation for Revatio indication and suspect DVT who suggest to arrange venous duplex evaluation, check NTproBNP level, according to pulmonary hypertension history at TMUH, may keep revatio use, if still renal function and potassium, consider Angiotensin receptor blockade QD and carvedilol bid and spironolactone 1#QD for better BP control, and then discontinue clonidine under the impression of hypertensive heart disease, pulmonary hypertension? (may trace right heart catheterization and echocardiogram report at TMUH).
      • She received deep debridement + Dermacell artificial dermis implantation (4*4 cm) + negative pressure wound therapy (small size) on 2023/12/11 smoothly.
      • The following laboratory data revealed Cr 1.31 mg/dL, NT-proBNP 7291.8 pg/mL. We changed anti-hypertensive agents and monitored BP variation to protect renal function and adjusted to Carvedilol 25mg QD. 2023/12/15 Vein sonography showed no evidence of deep vein thrombosis at bilateral lower limbs, bilateral long saphneous vein engorgement at thigh level, left side more severe; with soft tissue edema at medial side of bilateral thighs. For foaming urine sometimes, we rechecked C3, C4, ESR, CRP, D-dimer, NT-proBNP and 24 hrs urine protein which disclosed low C3, mild improved creatinine, D-dimer and NT-proBNP.
      • She received immunotherapy of Belimumab (self-paid) 400 mg on 2023/12/26 smoothly. We tried to off VAC negative pressure and her Dermacell artificial dermis implantation attachment well, then was shiftted to self-paid Allevyn Ag covered. The whole therapeutic process was smooth & patient tolerated it well without severe side effect or complaints. With relatively stable condition, she was discharged on 2023/12/27 and AIR + PS OPD follow-up was arranged on 2024/01/03.
    • Discharge prescription
      • Atotin (atorvastatin 20mg) 1# QOD
      • Blopress (candesartan 8mg) 1# BID
      • CellCept (mycophenolate mofetil 250mg) 4# BID
      • Cofarin (warfarin 1mg) 1# BID
      • Compesolon (prednisolone 5mg) 1# BID
      • Eltroxin (levothyroxine 50ug) 1# QDAC
      • hydralazine 50mg 1# TID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • MgO 250mg 1# TID
      • Nexium (esomeprazole 40mg) 1# QDAC 2023/11/29 gastroscopy: GERD grade A
      • Plaquenil (Hydroxychloroquine 200mg) 1# BID
      • Revatio (sildenafil 20mg) 1# TID if SBP <90/50 mmHg hold
      • Rivotril (clonazepam 0.5mg) 1# BID
      • Spiron (spironolactone 25mg) 1# QD
      • Strocain (oxethazaine polymigel 5mg) 1# TIDAC for stomach ache
      • Syntrend (carvedilol 25mg) 1# BID
      • Zinga (zinc gluconatte 78mg) 1# QD
  • 2023-11-17 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • P
      • Admission for debridement + NPWT (small), HBOT, IV antibiotic, Dopplar sonography
      • Consult Rheu, Nephro
  • 2023-11-14 SOAP Plastic and Reconstructive Surgery Zhang MengZong
    • S
      • Chronic ulcer with necrosis is found over the left medial ankle for about 6 weeks.
      • Hx. of SLE, Lupus nephritis, seizure attack
    • O
      • Height 160, Weight 47, BMI 18.4
      • Chronic ulcer with necrosis is found about 4 * 6 cm in size over the left medial ankle. –> superficial debridement (wound culture) –> wound CD with prontosan gel bid
    • P
      • education
      • HBOT is suggested.

==========

2024-01-19

[SLE management]

Based on the PharmaCloud database, this patient had multiple admissions to TMUH before seeking treatment at our hospital around late 2023. Given that immunosuppressive agents were used prior to her current treatment, vigilant monitoring for signs of infection is recommended. Typically, immunizations should precede immunosuppressive therapy.

Exposure to UV light can trigger or worsen systemic lupus erythematosus (SLE) symptoms, though this varies among patients. About one-third may react to sun exposure, another third with prolonged exposure, and the rest may not react at all. Most SLE patients are advised to avoid direct or reflected sunlight and UV light sources, using sunscreens with a minimum SPF of 55 that block both UV-A and UV-B rays.

A recent study in the Annals of the Rheumatic Diseases has confirmed the renal protective effects of sodium glucose cotransporter 2 (SGLT2) inhibitors in lupus nephritis, both in mouse models and patients, suggesting significant clinical benefits of this treatment approach. (Reference: Onuora S., “SGLT2 inhibitors protect podocytes in lupus nephritis”, Nat Rev Rheumatol, 2023 Oct, 19(10): 605, DOI: 10.1038/s41584-023-01024-1, PMID: 37666997).

701511827

240119

[lab data]

2024-01-18 Anti-HBc Nonreactive
2024-01-18 Anti-HBc-Value 0.42 S/CO
2024-01-18 HBsAg Nonreactive
2024-01-18 HBsAg (Value) 0.40 S/CO
2024-01-18 Anti-HCV Nonreactive
2024-01-18 Anti-HCV Value 0.15 S/CO

[MedRec]

  • 2024-01-17 SOAP Medical Emergency Lin QinXiang
    • Preliminary Impression: N39.0 Urinary tract infection, site not specified
    • 20231222 33072AB_Abdomen C-/C+ N Imaging findings:
      • CT scan of the abdomen and pelvis without/with IV contrast enhancement shows:
      • suboptimal study due to some respiratory motion artifacts.
      • pericardial effusion(s) with calcifications of the tortuous aorta; bronchiectasis and bronchial wall thickening with ill-defined consolidation and air bronchogram at the left lingular, right middle and bil. lower lobes; moderate pleural effusion(s) on both sides; r/o funnel chest (pectus excavatum); presence of the interventricular septum sign, r/o anemia.
      • r/o parenchymal liver disease with hepatic cysts, both lobes.
      • gallbladder sludge, r/o cholecystitis, with pericholecystic fluid collection(s).
      • left renal cyst.
      • no evidence of focal lesion at the spleen, pancreas, bil. adrenals, and right kidney.
      • reflexed and enlarged uterus, r/o uterine fibroid(s), with simple fluid in the uterine cavity, and pelvic edema; enlargement and edema of the uterine cervi x with endocervical enhancement; s/p urinary catheterization in position with chronic cystitis.
      • s/p nasogastric (NG) intubation in position, r/o reflux esophagitis; r/o antral gastritis.
      • mild ascites with dirty mesenteric and omental fat; no evidence of enlarged lymphadenopathy.
      • mild degenerative scoliosis of the lumbar spine; chronic to old benign compression fracture(s) and wedge deformity or decrease in height of the T12 and L5 vertebrae with intravertebral vacuum phenomenon(a), suggestive of osteonecrosis, at the L5 level; varying-sized osteolytic lesions scattered at the bil. iliac bones.
      • extensive subcutaneous edema at the trunk.
      • Impression:
        • pericardial effusion(s);
        • bronchiectasis with secondary infections, left lingular, right middle and bil. lower lobes; bil. pleural effusion(s);
        • r/o funnel chest (pectus excavatum);
        • r/o anemia.
        • r/o parenchymal liver disease with hepatic cysts, both lobes.
        • GB sludge, r/o cholecystitis.
        • left ren al cyst.
        • reflexed and enlarged uterus, r/o uterine fibroid(s);
        • r/o pelvic inflammatory disease (PID) with possible cervicitis; chronic cystitis.
        • r/o reflux esophagitis;
        • r/o antral gastritis.
        • mild ascites, r/o peritonitis.
        • mild degenerative scoliosis, lumbar spine;
        • chronic to old benign compression fracture(s), T12 and L5 vertebrae, with osteonecrosis, L5 level;
        • r/o multiple bony metastases?, bil. iliac bones.
        • extensive subcutaneous edema, trunk.
  • 2024-01-12 SOAP Psychosomatic Medicine Zen YuLun
    • S
      • C.C. & P.I.: The first time visit, the patient is abscent, her daughter come.
      • Background and current position: .
      • Hx of Suicide/Self-injury/Violence: .
      • Hx of Substance abuse: .
      • Hx of psychi/medical disease and treatment: .
      • Current medications: .
      • Family Hx: .
      • Premorbid personality: .
      • Key person and social support: .
    • O
      • Height:150 cm; Weight:38 kg; BMI: 16.9
      • [PPFE] Mental status examination:
        • Consciousness: clear
        • Appearance:
        • Attitude:
        • Affect:
        • Speech:
        • Behavior:
        • Thought:
        • Perception:
        • JOMAC:
    • A/P
        • Establish therapeutic alliance
        • Confirm a diagnosis:
        • Psychoeducation on the disease course
        • Examinations
        • Pharmacotherapy
        • instill hope.

[consultation]

  • 2024-01-17 Urology
    • Q
      • C.C. suspect papillary urothelial malignancy, poor intake since 2023 September, BW loss 59 -> 38 kg, dysuria and hypogastric pain for 2 months
      • Allergy: NKDA
      • PHx: major depression disorder
        • no cough, no dyspnea, no cold sweating
        • no fever, no chills
        • (+) hypogastric pain, no chest/back pain
        • no nausea, no vomiting, no diarrhea
        • no tarry stool
        • (+) dysuria
    • A
      • This 69-year-old female patient was transferred from the oncology ward at other hospital. We were consulted for suspected GU tract cancer.
      • PH:
        • Major depression
        • Chronic bed ridden status due to anorexia
      • Lab:
        • Urine
          • 2024-01-17 Color Yellow
          • 2024-01-17 App Turbid
          • 2024-01-17 SG 1.010
          • 2024-01-17 PH 5.5
          • 2024-01-17 Leucocyte Ester 3+
          • 2024-01-17 NIT 1+
          • 2024-01-17 Sediment-RBC 10-19 /HPF
          • 2024-01-17 Sediment-WBC >=100 /HPF
          • 2024-01-17 Bacteria 1+ /HPF
        • Blood
          • 2024-01-17 Creatinine 0.35 mg/dL
      • Image:
        • No image was available
        • The report of prior CT exam showed no evidence of bladder tumor, hydronephrosis or upper GU tract tumor
      • Impression:
        • Unknown cause of body weight loss
      • Suggestion:
        • There is no evidence of GU tract tumor currently.
        • Further examination can be arranged at OPD.
        • Suggest OPD follow up.

701343853

240118

[MedRec]

  • 2024-01-17 DutyNote Li YuZhong
    • Problem List
      • Problem 1: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy
    • Course of disease or treatment
      • This is a 72 year old female with underlying of HTN, CAD s/p PCI under bokey, uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
      • She complaint of general weakness, dizziness, nausea, vomiting and epigastric dullness on 2024/01/15 night. Tarry stool passage was seen on 2024/01/16 for 3 times. She was brought to our ER on 2024/01/16 morning. Vital sign was as following: BP:112/67; HR:109; BT:36.4’C; RR:18; Con’s:E4V5M6. Serum data reported normocytic anemia (Hb8.7 g/dL), mild leukocytosis and high BUN (55mg/dL). Blood transfusion 3 unit and PPI were given.
      • Under the impression of upper GI tract bleeding, EGD was done and reported: gastric ulcer, Forrest classification III, prepyloric antrum, AW/LC, s/p CLO test and biopsy.
      • Follow up serum data showed some recovery of anemia (9.4 g/dL). After her condition was relative stable, she was admitted to ward for further evaluation and management.
    • Treatment recommendations
      • Monitor vital sign
      • Recheck CBC, DC, renal function and electrolyte tomorrow
      • NPO with glucose one touch monitoring
      • Taita no5 500ml BID
      • Pantoprazole 40mg Q12H
      • Transamine 500mg Q12H
      • Hold bokey and xanthium
      • Keep other OPD medications
      • May try soft diet if serum data no abnormal tomorrow
  • 2024-01-17 VsNoteOnAdmissionDay Li ZhongXian
    • Attending progress Note on admission
    • A:
      • Response to treatment: pending
      • GU with recent bleeding
    • P:
      • Diagnostic plan:
        • Check B/R, BUN/Cr, Na, K, ALP, GGT, GOT, GPT, TB, Amylase, lipase, CRP, Alb, LDH, UA, Free T4, TSH, HbA1c, HBsAg, Anti-HCV, IgM anti-HAV, AFP, Lactate, BNP, CRP, PCT, Urine/R, Stool/R, Stool/C, Blood/C, Urine/C, Sputum/C, iFOBT, EKG, CxR, KUB
        • Sono abdomen, colon scope and EGD may be planned
        • CT of abdomen/ liver, biliary tract and pancreas may be planned
      • Treatment plan:
        • NPO/Try water/diet
        • Empiric antibiotics with
        • PPI Tx + GI medication + Symptomatic treatment
        • Adequate volume resuscitation and Keep I/O & E balance
        • Keep Pt’s OPD medication
        • Consult GS/RAD specialist for
      • Education plan:
        • Explained the patient’s serious condition and all plans,infection related complications to the family and the patient
        • Avoid alcohol drinking, hepatoxicity agent, Nsaids, anticoagulants, spicy and fatty foods
  • 2022-07-18 ~ 2022-07-23 POMR Urology Luo QiWen
    • Discharge diagnosis
      • Uterine prolapse status post Robotic assisted sacrocolpopexy 2022/07/20
      • Urge incontinence
      • Nocturia
    • CC
      • Urinary frequency (Q1H) for over six months
    • Present illness
      • This is a 71 year-old female with systemic underlying disease of Hypertension and history of angina s/p catheterization but without stenting, and were all under medications control with Norvasc, bokey, and theophylline. Her ADL is totally independent.
      • According to her statement and medical records, she suffered from severe urinary frequency (Q1H) and nocturia (4 times) for over six months. Besides, a protruding mass was also noted at her vigina, but spontaneously subscided. No pain, no abnormal discharge, no operation history, no incarceration nor other remarkable discomfort was told. She was referred from GI Dr. Chao to GU Dr. Yang’s OPD due to the clinical problem mentioned above. Urinalysis found no sign of urinary tract infection. However, uroflometry found urinary frequency. Thus, symptomatic treatment with detrusitol was prescibed and she can hold urine than before. Due to her clinical problem still persisted, surgical intervention was then suggested.
      • Under the impression of over active bladder with pelvic organ prolapse, she was admitted to our ward for robotic assisted uterine suspension and further care.
    • Course of inpatient treatment
      • After admission, she recieved Robotic assisted sacrocolpopexy on 2022/07/20. The operation went smooth without immediate complications. She had keep bed rest for two days. No fever, no wound oozing nor pus discharge, but gastric discomfort was noted. We had removed foley on 2022/07/22 and no urine retension was found. Now, her clinical condition is relatively stable and may discharge and follow up at OPD.
    • Discharge prescription
      • Through (sennoside 12mg) 2# HS
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Cardizem Retard (diltiazem 90mg) 1# QD
      • Sindine (povidone iodine aq soln 10%) ASORDER EXT

[surgical operation]

  • 2022-07-20 - Op Method: Robotic assisted sacrocolpopexy         
    • Finding:
      • pevic organ prolapse, stage III; cervix 2 cm outside of introitus
      • console time 3 hr 35 cm

==========

2024-01-18

Pre-meal blood glucose levels were recorded at 132, 157, and 108 mg/dL on 2024-01-16, 2024-01-17, and 2024-01-18, respectively, indicating consistently elevated values. It is recommended that the patient continues with follow-up monitoring.

Upon review of the HIS5 records, no discrepancies in medication were identified.

701358512

240117

[MedRec]

  • 2023-12-22 ~ 2023-12-25 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Left renal cell carcinoma, T3aN1M1, Stage IV
      • Anemia (Hb:6.6g/dl)
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • Weakness, dizziness, poor appetite, and persistent nausea for several days.
    • Present illness
      • This is a 53-year-old woman with history of:
        • Hypertension
        • Type II DM
        • Left renal cell carcinoma, T3aN1M1, Stage IV
          • Axitinib + Pembrolizumab for 4 times, shift to Atezolizumab on 2021/07/15-2023/01/06 (19th) due to heart failure  
          • target tx with cabozantinib approved (2022/03/07-2023/11/26) and Afinitor (2023/10/23-11/21).
          • Immunotherapy with Nivolumab on 2023/02/10-2023/10/17, due to regioal lymphadenopathy and bilateral lung meta.
        • Sepsis, heart failure, left distal common femoral artery pseudoaneurysm in 2023/07.
      • She had been under the Cabozantinib and Nivolumab treatment.
        • CT on 2023/05/31 showed partial response to Nivo + cabo.
        • CT on 2023/10/18 revealed mild increased tumor size, disease progression.
      • Thus, shift to afinitor and cabozantinib had been made. After starting Afinitor treatment on 10/23, she experienced severe diarrhea and feelings of nausea and vomiting. Additionally, she had a noticeable weight loss. She was hospitalized twice to manage these symptoms and stopped taking Afinitor on 2023/11/21.
      • This time, She has suffered from weakness, dizziness, poor appetite, and persistent nausea for several days. Thus, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, she accepted blood transfusion therapy, due to anemia. During treatment, she still has weakness, dizziness, poor appetite, and mild nausea. After the blood transfusion, the hemoglobin level increased from 6.6 g/dL to 9.8 g/dL.
      • Because symptoms relieved after treatment, she was discharged today and would be followed up at urologic clinic.
  • 2022-02-15 ~ 2022-02-19 POMR Urology Cai YaoZhou
    • Discharge diagnosis
      • Left renal cell carcinoma, cT3aN1M1, stage 4 status post immunotherapy with Atezozulimab (#8)
    • CC
      • Admission for immunotherapy with Atezozulimab (#8)
    • Present illness
      • This 51-year-old women had histories of
        • Hypertension and DM under medication control;
        • Left RCC, cT3aN1M1, stage 4 start Axitinib + Pembrolizumab for 4 times, shift Atezozumab since 2021/07/15 due to heart failure.
      • This time, she admission for immunotherapy with Atezozulimab (#8).
    • Course of inpatient treatment
      • At admission, 8th immonotherapy with Atezozulimab was gave. She was discharged with stable condition on 2022/02/19 and would be followed up at urologic clinic.

[immunochemotherapy]

  • 2023-10-17 - nivolumab 200mg NS 100mL 1hr
    • diphenhydramine 30mg + NS 250mL
  • 2023-09-28
  • ……….
  • 2022-02-15 - atezolizumab 1200mg NS 250mL 1hr
    • diphenhydramine 30mg + NS 250mL

  • 2023-11-21 ~ 2024-01-17 going - sunitinib
  • 2023-02-09 ~ 2023-11-26 - cabozantinib

==========

2024-01-17

[stage IV RCC on sunitinib: historical anemia, emergency event & HGB low]

This 53-year-old female patient with stage IV renal cell carcinoma (RCC) was started on sunitinib in late Nov 2023 after progression on cabozantinib. The patient had a history of anemia prior to starting sunitinib, with no hemoglobin (HGB) values within the normal range in 2023.

On 2024-01-16, the patient presented to the emergency department with suspected coffee-ground emesis. This was likely the primary cause of the recent anemia episode. However, sunitinib is known to be associated with an incidence of decreased HGB (26% to 79%; grades 3/4: 3% to 8%; grade 4: 2%) and hemorrhage (22% to 37%; grades 3/4: <=4%). Therefore, the historic low HGB value on 2024-01-16 cannot be definitively excluded as a side effect of sunitinib. The patient underwent a blood transfusion on the same day, which was a reasonable course of action. In addition, this patient also underwent multiple blood transfusions in 2023.

  • 2024-01-16 HGB 6.3 g/dL
  • 2023-12-25 HGB 9.8 g/dL
  • 2023-12-22 HGB 6.6 g/dL
  • 2023-11-23 HGB 8.9 g/dL
  • 2023-11-21 HGB 9.7 g/dL
  • 2023-11-03 HGB 9.1 g/dL
  • 2023-10-16 HGB 8.7 g/dL
  • 2023-09-28 HGB 8.1 g/dL
  • 2023-09-05 HGB 9.5 g/dL
  • 2023-08-18 HGB 9.9 g/dL
  • 2023-07-25 HGB 10.7 g/dL
  • 2023-07-24 HGB 10.5 g/dL
  • 2023-07-21 HGB 9.8 g/dL
  • 2023-07-20 HGB 7.9 g/dL
  • 2023-07-18 HGB 9.2 g/dL
  • 2023-06-25 HGB 10.0 g/dL
  • 2023-06-07 HGB 10.3 g/dL
  • 2023-05-21 HGB 10.6 g/dL
  • 2023-05-02 HGB 11.0 g/dL
  • 2023-04-14 HGB 10.4 g/dL
  • 2023-03-29 HGB 11.2 g/dL
  • 2023-03-10 HGB 10.4 g/dL
  • 2023-02-23 HGB 9.8 g/dL
  • 2023-02-10 HGB 8.5 g/dL
  • 2023-01-05 HGB 10.1 g/dL

In the event of grade 3 or 4 hemorrhage, it is recommended to withhold sunitinib until resolution to <= grade 1 or baseline, then resume at a reduced dose or discontinue (depending on severity and persistence). Discontinue sunitinib if grade 3 or 4 hemorrhagic events do not resolve.

The standard dosage of sunitinib for advanced RCC is 50mg daily, but the patient is currently taking 12.5mg daily. This is a significant underdose, and there seems no room to further reduce the dose.

701393041

240116

[lab data]

2023-12-20 CMV viral load assay 1040 IU/mL

2023-12-19 STR DNA fingerprint FINISH %

2023-12-18 CMV viral load assay 396 IU/mL

2023-12-12 CMV IgM Nonreactive
2023-12-12 CMV IgM Value 0.10 Index

2023-12-11 CMV viral load assay 74 IU/mL

2023-12-08 Anti-HBc Reactive
2023-12-08 Anti-HBc-Value 3.10 S/CO

2023-12-06 CMV viral load assay <35 IU/mL

2023-11-18 STR DNA fingerprint FINISH %

2023-11-13 EB VCA IgG Positive Ratio
2023-11-13 EB VCA IgG Value 3.6 Ratio

2023-11-10 HBsAg (NM) Negative
2023-11-10 HBsAg Value (NM) 0.539
2023-11-10 Anti-HBs (NM) Positive
2023-11-10 Anti-HBs value (NM) 59.1 mIU/mL
2023-11-10 Anti-HCV (NM) Negative
2023-11-10 Anti-HCV Value (NM) 0.047
2023-11-10 Anti-HBc (NM) Positive
2023-11-10 Anti-HBc Value (NM) 0.008

2023-11-09 VZV IgG Positive Index
2023-11-09 VZV-G Value 5.9 Index

2023-11-09 Mycoplasma IgM Negative Index
2023-11-09 Mycoplasma IgM Value 0.1 Index

2023-11-08 RPR Nonreactive

2023-11-08 EB VCA IgM Negative Index
2023-11-08 EB VCA IgM Value 0.1 Index

2023-11-08 CMV IgG Reactive
2023-11-08 CMV IgG Value 92.1 AU/mL
2023-11-08 CMV IgM Nonreactive
2023-11-08 CMV IgM Value 0.27 Index

2023-11-08 HIV Ab-EIA Nonreactive
2023-11-08 Anti-HIV Value 0.05 S/CO

2023-11-08 Anti HTLV I/II Nonreactive
2023-11-08 Anti HTLV I/II Value 0.08 S/CO

2023-10-20 IgE 14.5 IU/mL
2023-10-19 IgG 1831 mg/dL
2023-10-19 IgM 51.0 mg/dL
2023-10-19 IgA 421 mg/dL

2023-07-20 Ferritin (NM) 1548.71 ng/ml
2023-06-23 Ferritin (NM) 1258.84 ng/ml

2023-06-23 HLA DQ-high 02:01
2023-06-23 HLA DQ-high 04:02

2023-04-10 HLA A-high 24:02
2023-04-10 HLA A-high 33:03
2023-04-10 HLA B-high 40:01
2023-04-10 HLA B-high 58:01
2023-04-10 HLA C-high 03:02
2023-04-10 HLA C-high 07:02

2023-04-10 HLA DR-high 03:01
2023-04-10 HLA DR-high 08:09

[exam findings]

  • 2023-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 38) / 106 = 64.15%
      • M-mode (Teichholz) = 63
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LVH, grade 1 LV diastolic dysfunction
      • Mild AS, AR, and PR
  • 2023-12-16, -12-14 Abdomen - Standing (Diaphragm)
    • Spondylosis of the L-spine is noted.
  • 2023-12-14 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-07-14 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myelodysplastic syndrome
    • The specimen submitted consists of two cores of gray-brown and hard bony tissue, measuring up to 2.7 x 0.3 x 0.3 cm. All for section after decalcification.
    • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 and MPO stains. The erythoid precursors are dispersed and scattered. The CD61+ megakaryocytes are moderately increased, and occasional micromegakaryocytes are present. Mild perivascular and paratrabecular fibrosis can be found. Slightly increased increased CD34+ and/or CD117+ immature cells, account for 3% of nucleated cells. The finding is compatible with myelodysplastic syndrome. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-01-04 SONO - Spleen
    • Homogeneous echogenicity of the spleen.
    • Soft tissue nodule, 2.06 in the lower pole of the spleen, accessary spleen? Suggest follow up study.
  • 2022-06-20 SONO - Spleen
    • Homogeneous echogenicity of the spleen.
    • Mild splenomegaly (12.73 x 5.32 cm).
    • Soft tissue nodule, 1.7 x 1.51 cm in splenic hilar region, accessary spleen? Suggest follow up study.

[MedRec]

  • 2023-11-05 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

    • Discharge diagnosis
      • Acute myeloblastic leukemia, post allo-PBSCT on 2023/11/17
      • Refractory anemia with excess of blasts
      • GVHD with mucositis and liver function
      • Anemia
      • Electrolyte imbalance
      • Hickman insertion
    • CC
      • for allo-PBSCT
    • Present illness
      • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp. According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
      • He came to our hemato-oncologic clinic (Dr Zhang ShouYi) on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
      • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
      • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic. Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04-2023/9/18.
      • Family conference was done for allo-PBSCT on 2023/09/25.
      • This time, he sufferes from dry cough also noted at night. He denied fever, oral ulcer, sore-throat or anal pain. He was admitted for allo-PBSCT on 2023/11/05.
    • Course of inpatient treatment
      • After admission, he received hickmen insertion from CVS on 2023/11/09. During hospitalization, he received GCSF 150mcg qd for neutropenia.
      • ID/NST/OS were consulted for assessment.
      • Chemo are arranged as FluMel140-ATG since 2023/11/11-11/15 and ATG since 11/15-11/16.
      • Ciclosporin 1.5mg/kg q12h since 11/16.
      • Hydration and sent to BMT room on 11/16 night.
      • Allo-PBSCT on 11/17.
      • Chemo as MTX 15mg/m2 on 11/18 and 11/22.
      • GCSF 300mcg since 11/18.
      • Lasix 20mg bid for keep I/O balance.
      • MUD allogeneic PBSCT with donor blood type O and recepitent blood type A.
      • Day 0 in 2023/11/17 (CD34+/kg x 10^6 = 11.6/kg x 10^6).
      • Fortunately, his WBC up 960 in Day 10 on 11/27.
      • Blood transfusion during hospitalization.
      • Antibiotics as Cefepime and Targocid for fever control and add steroid for suspect engraftment symdrom.
      • Spiking fever was noted, so we shift Cefepime to Mepem treatment.
      • Follow up Cyslosporin level and adjust dose to 275mg daily.
      • GVHD with liver function impairement and lip mucositis grade II.
      • Hickman catheter was removed on 12/04 and wound healing well.
      • Under the stable condition, he can be discharged and take oral prednisolon 2# bid going back home. MBD on 2023/12/08. OPD follow up is arranged.       
    • Discharge prescription
      • MgO 250mg 1# TID
      • Rivotril (clonazepam 0.5mg) 1# PRNHS
      • Sandimmun Neoral (ciclosporin 100mg) 1# Q12H
      • Sandimmun Neoral (ciclosporin 25mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Compesolon (prednisolone 5mg) 2# BID
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-08-19 ~ 2023-09-04 POMR Hemato-Oncology Gao WeiYao

  • 2023-07-26 ~ 2023-08-01 POMR Hemato-Oncology Gao WeiYao

    • Discharge diagnosis
      • Refractory anemia with excess of blasts, unspecified
      • Acute myeloblastic leukemia, not having achieved remission
      • Anemia, unspecified
    • CC
      • mild gum bleeding
    • Present illness
      • The 59 years old male was diagnosed of myelodysplastic syndrome (MDS) with Refractory Anemia with excess of blast (RAEB) since April 2022 at FuRen Univ Hosp.
      • According to the patient, the initial presentation was dizziness. After diagnosing, he was then regularly taking Hydroxyurea 1# QOD since April 2022 at FuRen Univ Hosp.
      • He came to our hemato-oncologic clinic on 2022/06/18 and we have arranged JAK2 mutation test (2022/06/20) which was revealed undetectable.
      • We applied Azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/06/27. We suggest to check HLA high resolution for stem cell collection.
      • He was then started Azacitidine at our OPD since 2022/07/04 and regular follow up at our clinic.
      • According to the OPD medical record, therapy with Azacitidine was launched on C1 azacitidine 75mg/m2 SC D1~D7 Q4W x 4 on 2022/07/04. C1b azacitidine x 2 on 2022/07/11, C2 azacitidine on 2022/08/01. C2b on 2022/08/08. C3 on 2022/08/29. C4 on 2022/09/05, C4b on 2022/09/26, C5 azacitidine 75mg/m2 SC D1~D7 Q4W x 7 on 2022/11/08, C6 on 2022/12/05, C7 on 2023/01/23, C8 on 2023/02/13, C9 2023/03/15, C10 2023/04/12, C11 2023/05/24 at our OPD.
      • He could tolerate with the therapy as well. This time, he has suffered from mild gum bleeding for days since 2023/07/23 as experienced before. Thus, he visited our OPD and revelaed leukopenia (WBC:1870, PLT:32K, MCV:95.2, Hb:6.8) was noted, then he was refered to ER for advanced evaluation. Under the impression of MDS with RAEB, he was admitted for further care.
    • Course of inpatient treatment
      • After admission, we have applied azacitidine 146mg SC D1~D7 x 7 since 2023/07/26 for him and explained about the stem cell collection for him. Family meeting was suggested in future. Patient could understand it as well. Under the stable condition, he was arranged discharge on 2023/08/01 and OPD follow up as planned.
  • 2022-10-04 SOAP Dermatology Zhou WeiTing

    • S: dry skin over expose area.
    • O: xerotic dermaitits due to target therapy.
    • Prescription
      • Topsym Cream (fluocinonide 0.05%) QN EXT
      • Xyzal (levocetirizine 5mg) 1# QN
      • Sinpharderm Cream (urea) BID TOPI
      • Asthan (ketofifen 1mg) 1# QD
  • 2022-09-01 SOAP Dermatology Zhou WeiTing

    • S: severe itchy papules and plaques erupition over trunk after medication
    • Prescription
      • Topsym Cream (fluocinonide 0.05%) BID EXT
      • Compesolon (prednisolone 5mg) 1# QD
      • Xyzal (levocetirizine 5mg) 1# QN
      • Orolisin (chlorpheniramine maleate 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNTID
      • C.B. Ointment (chlorpheniramine, lidocaine, methyl salicylate, menthol, camphor) PRNBID TOPI
  • 2022-06-20 SOAP Hemato-Oncology Zhang ShouYi

    • Order
      • LRP 1U
      • LPRBC 2U
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Benamine (diphenhydramine 30mg) ST IVD
      • Decan (dexamethasone 4mg) ST IVD
      • NS 500mL ST IVD
  • 2022-06-18 SOAP Hemato-Oncology Zhang ShouYi

    • S
      • 58 y/o male, a pt of myelofibrosis (?) or MDS wt RAEB (?), Dx in April 2022 at FuRen Univ Hosp, suffered from dizziness in April 2022.
      • Bone marrow biospy (4/29 22): Blast: 5.6%.
      • MDS wt excess blast & fibrosis.
      • Hb (3/29 22):7.1, MCV:89.4, MCHC:36.4, plt:61K, WBC:2610, blast:5%.
      • under Hydroxyurea 1# QOD since April 2022 by at FuRen Univ Hosp.
      • no exertional dyspnea, no easy fatigue, no easy dizziness, no lethargy, no palpitation
      • no tarry nor bloody stool passage
      • gum bleeding (+) epistaxis, no easy bruising.
      • no particular drugs in use (eg Aspirin or NASID or anonymous drugs)
      • came to our hemato-oncologic clinic on 6/18 22
      • R/I myelofibrosis
      • R/I MDS wt RAEB (?),
      • will do JAK2 mutation test (6/18 22).
      • will do abd sono (6/18 22).
      • will do CBC & DC, reticulocyte,
      • will do PT, APTT, fibrinogen.
      • s/p educate pt about preventing from trauma & avoiding NSAID (6/18 22).
      • RTC 1 wk later on 6/28 22 for JAK2 report.
    • Diagnosis
      • Anemia, unspecified [D64.9]
      • IDA, unspecified [D50.8]

[chemotherapy]

  • 2023-11-28 - methotrexate 10mg/m2 19mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-23 - methotrexate 10mg/m2 18mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-20 - methotrexate 10mg/m2 19mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-18 - methotrexate 15mg/m2 28mg NS 50mL
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-11-11 - fludarabine 30mg/m2 50mg NS 250mL 1hr D1-5 + melphalan 70mg/m2 120mg NS 500mL 1hr D4-5
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-09-18 - azacitidine 75mg/m2 143mg SC D1-7
  • 2023-07-26 - azacitidine 75mg/m2 146mg SC D1-7
  • 2023-05-24 - azacitidine 75mg/m2 142mg SC D1-7
  • 2023-04-12 - azacitidine 75mg/m2 145mg SC D1-7
  • 2023-03-15 - azacitidine 75mg/m2 145mg SC D1-7
  • 2023-02-13 - azacitidine 75mg/m2 130mg SC D1-7
  • 2023-01-03 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-12-05 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-11-08 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-09-26 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-09-29 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-08-01 - azacitidine 75mg/m2 130mg SC D1-7
  • 2022-07-04 - azacitidine 75mg/m2 130mg SC D1-7

==========

2024-01-16

[Ciclosporin dose optimization]

Following the adjustment of the daily dose to 220mg, observed serum trough levels have shown a gradual decline. To maintain the desired concentration range of 200-300 ng/mL, an increase in the daily dose to 240mg is recommended.

  • 2024-01-15 Cyclosporine-A 242.5 ng/mL
  • 2024-01-12 Cyclosporine-A 295.5 ng/mL
  • 2024-01-08 Cyclosporine-A 344.1 ng/mL

The administration of Grancicure (ganciclovir) 500mg Q12H IVD has effectively reduced the CMV viral load. Starting from 2024-01-17, Grancicure will be replaced with Valcyte (valganciclovir) 900mg QD PO.

  • 2024-01-15 CMV viral load assay 786 IU/mL
  • 2024-01-08 CMV viral load assay 64300 IU/mL
  • 2023-12-30 CMV viral load assay 12200 IU/mL
  • 2023-12-20 CMV viral load assay 1040 IU/mL
  • 2023-12-18 CMV viral load assay 396 IU/mL
  • 2023-12-11 CMV viral load assay 74 IU/mL
  • 2023-12-06 CMV viral load assay <35 IU/mL

Also note that the patient’s WBC count and HGB level are gradually decreasing.

  • 2024-01-15 WBC 2.30 x10^3/uL

  • 2024-01-12 WBC 2.24 x10^3/uL

  • 2024-01-08 WBC 3.89 x10^3/uL

  • 2024-01-06 WBC 3.59 x10^3/uL

  • 2024-01-04 WBC 4.30 x10^3/uL

  • 2024-01-02 WBC 4.96 x10^3/uL

  • 2024-01-15 HGB 7.3 g/dL

  • 2024-01-12 HGB 8.6 g/dL

  • 2024-01-08 HGB 9.3 g/dL

  • 2024-01-06 HGB 9.3 g/dL

  • 2024-01-04 HGB 7.4 g/dL

  • 2024-01-02 HGB 10.2 g/dL

2024-01-03

[Sandimmun injection (Ciclosporin) TDM]

Following the recent ciclosporin trough level of 416.5 ng/mL on 2024-01-02, the Sandimmun injection dosage has been adjusted from 250mg to 220mg daily. To monitor the effectiveness of this adjustment, it is kindly requested a new blood sample four days after the adjustment, to be drawn prior to the scheduled administration, for another trough level test.

2023-12-26

[steady rise, time to tune down: ciclosporin level management - Sandimmun injection (Ciclosporin) TDM]

This patient has been taking ciclosporin 275mg QD since 2023-12-12. Lab results for ciclosporin trough levels on 2023-12-15, 2023-12-18, 2023-12-21, and 2023-12-25 showed values of 152, 222, 292, and 318 ng/mL, respectively. Based on this monotonic trend, if the current dose is continued, the trough level could exceed the recommended upper limit of 400 ng/mL by the end of 2023 or early 2024. Therefore, it is recommended to reduce the dose to 250mg QD and recheck the trough concentration 4 days after the change.

2023-09-25

The attending physician Dr. Gao held an interprofessional practice and patient family meeting in the ward conference room at 15:00 on 2023-09-25, to introduce the patient to the importance, possible risks, and prognosis of allogeneic peripheral blood stem cell transplantation in the treatment plan, and to answer questions from patients and their families. The patient did not ask the pharmacist any specific questions during the meeting. In a chat with the patient after the meeting, I emphasized the importance of controlling potential post-transplant infections.

700570266

240115

  • diagnosis
    • 2022-08-15 discharge
      • Malignant neoplasm of cervix uteri, unspecified
      • cervical cancer (adenocarcinoma), stage IVa post CCRT, suspected cancer recurrence (C53.9)
      • urinary tract infection, urine culture: mixed growth 7000
      • constipation
  • past history
    • Septoplasty, 20 years ago
    • Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion, start radiotherapy and chemotherpy since 2021/04
    • Large gallstone 2021/03
    • Left side moderate hydronephrosis and hydroureter 2021/03
    • C/S surgery (Cesarean Section), by patient personal choose  

[family history]

  • Mother: Colon cancer
  • Father: HCC
  • Sister: Breast cancer   

[exam findings]

  • 2023-12-07 CT - abdomen
    • History and indication: Cervical cancer s/p OP and C/T
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3.
      • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
      • Swelling of left lower extremity.
      • S/P Port-A infusion catheter insertion. S/P foley catheter indwelling.
      • A nodule (4.5mm) at RLL.
    • IMP:
      • S/P hysterectomy. A nodule (4.5mm) at RLL r/o metastases. Some small LNs at mediastinum, retroperitoneum and bil. inguinal regions. Focal sclerotic change of L3 r/o metastases.
  • 2023-11-03 SONO - nephrology
    • Interpretation:
      • Bilateral chronic change with right small sized kidney.
      • Left mild hydronephrosis with D-J.
      • Bladder hyperechoic lesion, cause?
  • 2023-09-22 All-RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene
  • 2023-09-07 MRI - pelvis
    • Clinical history: 61 y/o female patient with Cervical cancer s/p OP and CCRT and C/T
    • Findings:
      • S/P hysterectomy. Irregular soft tissue tumor (2cm) between urinary bladder and vaginal stump, right, r/o recurrent tumor.
      • Enlarged lymph nodes in left inguinal region.
      • Diffuse swelling of left lower extremity.
      • S/P double J catheter insertion.
      • Non-enhancing nodule, 0.4cm in right lobe liver, r/o liver cyst.
      • There are lymph nodes in paraaortic and aortocaval regions.
    • Impression:
      • S/P hysterectomy. S/P double J catheter insertion, bilateral.
      • R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
      • Left inguinal lymph nodes, paraaortic and aortocaval lymph nodes, r/o metastasis.
      • Diffuse swelling of left lower extremity.
  • 2023-06-29 CT - abdomen
    • History and indication: Cervical cancer s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some small LNs at retroperitoneum and bil. inguinal regions.
      • S/P bilateral double J catheters insertion. Bil. renal cysts (up to 1.2cm). Tiny liver cysts.
    • IMP:
      • S/P hysterectomy. No evidence of tumor recurrence.
      • S/P bilateral double J catheters insertion.
  • 2023-04-07 CT - abdomen
    • Findings
      • S/P hysterectomy
      • S/P double J catheter insertion, bilateral.
      • Prior CT identified a hepatic cyst 5 mm at S5/8 of the liver is noted again, stationary.
        • In addition, Left renal cyst, 1.2cm, also shows stationary.
    • Impression:
      • S/P hysterectomy.
      • There is no evidence of tumor recurrence.
  • 2023-01-06 MRI - pelvis
    • Findings
      • S/P hysterectomy.
      • Segmental wall edema/thickening at rectosigmoid colon.
      • S/P double J catheter insertion, bilateral.
      • Non-enhancing nodule in left kidney, r/o left renal cyst (1.4cm).
    • Impression:
      • Clinical cervical cancer s/p hysterectomy.
      • Segmental wall edema/thickening at rectosigmoid colon. Suggest clinical correlation.
      • R/O left renal cyst.
  • 2022-11-10 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
    • S/P bilateral double J catheters insertion.
  • 2022-10-12 CXR
    • S/P Port-A infusion catheter insertion.
    • S/P bilateral double J catheters insertion.
    • Solitary pulmonary nodule at RLL.
    • Normal appearance of trachea and bil. main bronchus.
  • 2022-10-04 SONO - breast
    • Diagnosis
      • Benign neoplasm of breast, infavor of benign fibrocystic disease (FCD), Uncertain breast tumor, in favor of benign fibroadenoma (FA)
    • Treatment
      • biopsy is not necessary
    • Suggestion and Plan
      • Regular OPD follow-up, Follow up breast sonography in next OPD visit
      • BI-RADS 3 - Probably Benign Finding (<2% malignant) Initial Short-Interval Follow-Up Suggested
  • 2022-08-11 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • PTA
      • R’t : 30 dB HL, normal to mild SNHL
      • L’t : 33 dB HL, normal to severe SNHL.
  • 2022-07-13 Patho - uterus with or without SO non-neoplastic/prolapse
    • Cervix uteri cancer checklist:
    • pathologic diagnosis
      • Tumor, uterine cervix, laparoscopic total hysterectomy — Adenocarcinoma
      • Endometrium, uterus, ditto — Free of tumor
      • Myometrium, uterus, ditto — Tumor invasion, leiomyoma
      • Lymph nodes, dissection — Not received
      • AJCC pathological stage (post CCRT) — ypT2a1, if cN0 and cM0, stage IIA1 / FIGO stage IIA1
    • microscopic examination
      • Tumor location:
        • Cervix
        • Vagina involvement: N/A
        • Corpus involvement: involved and one leiomyoma measured 3 cm
      • Tumor size: 2.5 x 2.0 cm
      • Tumor type: Adenocarcinoma
      • Histologic grade: moderately differentiated
      • Depth of invasion: about 0.6 cm, >1/2 cervical wall
      • Parametrial involvement: N/A
      • Parametrial cut end: N/A
      • Vaginal cut end: N/A
      • Lymphovascular invasion: NOT identified
      • Perineural invasion: Present
      • Lymph nodes: NOT received
    • IHC
      • P16(-), CEA(+), ER(-), PR(-), vimentin(-), P53(focal +, wild type), compatible with endocervical origin
  • 2022-05-31 Patho - cervix biopsy, endocervix curretage/biopsy
    • Uterus, cervix, biopsy (S2022-8981) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (+).
    • Uterus, endocervix, ECC (S2022-8982) — adenocarcinoma, well differentiated.
      • IHC stains: p16 (-), vimentin (-), p53 (diffuse +), Napsin-A (-), PAX-8 (equivocal).
  • 2022-05-18 MRI - pelvis
    • Findings
      • Soft tissue tumor(2.5cm) in cerivcal region, suspected cervical malignancy.
      • Relative thickening posterior wall of urinary bladder.
      • Soft tissue tumor, 3cm in posterior wall of uterine body, suspected uterine myoma.
      • Presence of gallbladder stones.
    • Impression
      • Cervical tumor, suspected malignancy.
      • Suspected uterine myoma.
      • Relative thickening posterior wall of urinary bladder.
      • GB stones.
  • 2022-02-24 Gynecologic ultrasonography
    • suspect degeneration myoma
    • adenomyosis
  • 2022-02-18 CT - abdomen
    • Findings
      • There is mild enhancing lesion 1.5 cm in left side uterine cervix area. Please correlate with physical examination or hysteroscope.
      • There is no enlarged node in left common iliac chain.
      • Soft tissue tumor 2.6 cm in posterior aspect of uterine body myometrium is noted that may be myoma.
      • S/P double J catheter insertion, bilateral.
      • Left renal cyst, 1.2cm.
    • Impression
      • Mild enhancing lesion 1.5 cm in left side uterine cervix araa. Please correlate with physical examination or hysteroscope.
  • 2021-12-06 Gynecologic ultrasonography
    • EM: 7.5mm with fluid
    • Uterine myoma
  • 2021-11-24 MRI - pelvis
    • Cervical cancer s/p RT.
    • Relative thickening posterior wall of urinary bladder with adhesion with anterior uterine cervix. Residual tumor? Suggest cystoscopy follow up.
    • Suspected uterine myoma.
    • GB stones.
  • 2021-08-17 CT - abdomen, pelvis
    • Cervical cancer with lymph node in left common iliac region s/p, regression as compare with old CT study.
    • S/P double J catheter insertion, bilateral.
    • Suspected uterine myoma.
    • Left renal cyst.
  • 2021-05-02 Gynecologic ultrasonography
    • Uterine myoma
    • Clinical: cervical cancer VIIA under CCRT with massive vaginal bleeding
  • 2021-04-19 Pure Tone Audiometry, PTA
    • PTA: Reliability FAIR
    • Average RE 31 dB HL // LE 31 dB HL
    • RE normal to mild SNHL
    • LE normal to moderately severe SNHL
  • 2021-03-31 Pathology (Cardinal Tien Hospital)
    • Uterus, exocervix, biopsy — Adenocarcinoma.
  • 2021-03-30 Patho - endocervix curretage/biopsy
    • Uterus, endocervix, ECC — severe glandular dysplasia
    • Immunohistochemical stain reveals CK(-), VIMENTIN (-), p16(-) and CEA(+).
  • 2021-03-30 Patho - cervix biopsy
    • Cervix, biopsy— adenocarcinoma
    • Immunohistochemical stain reveals CK(+), p16(-), CEA(+), vimentin(-). CK20(-), GATA3(-)
  • 2021-03-23 CT (Cardinal Tien Hospital)
    • Findings
      • A 7 x 3.5cm mass in the uterine cavity and extension to the cervix and, to the posterior urinary bladder wall.
      • A 3.5cm cyst at the left adnexa. No definite iliac or paraaortic lymphadenopathy.
      • No abdominal fluid collection.
    • Imp:
      • Uterine tumor involving endometrial cavity and cervix with posterior, urinary bladder wall extension, suspect endometrial ca or cervical ca.
      • Small hepatic cysts in the right lobe, Left ovarian cyst, stage cT4N1M0.
  • 2021-03-22 IntraVenous Pyelography, IVP (Cardinal Tien Hospital)
    • suspect left bladder tumor with left side obstructive uropathy.
  • 2021-03-20 SONO - abdomen (Cardinal Tien Hospital)
    • Moderate fatty liver and fat infiltration the pancreas
    • Large gallstone
    • Left side moderate hydronephrosis and hydroureter

[consultation]

  • 2023-11-15 Rehabilitation
    • Q: for Lymphedema of left lower limb
    • A: The patient had undergone lymphedema treatment at Dr. Qiu JiaYi’s outpatient clinic. Please schedule a follow-up appointment with Dr. Qiu after discharge.
  • 2023-11-06 Dermatology
    • Q
      • for multiple lesion of left femoral biopsy
    • A
      • This patient suffered from multiple nodules on abd area for months.
      • Imp: R/O Malignat, skin meta
      • Suggestion: Arrange skin biopsy
  • 2023-11-03 Nephrology
    • Q
      • for BUN/Cr elevated, decrease of urine output step by step
      • This 61-year-old woman patient is a case of Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
      • We sincerely need your professional assistance!!
    • A
      • 61-year-old woman
      • Dx: Cervical cancer (adenocarcinoma), cT4N0M0, stage IVa post concurrent chemoradiotherapy with tumor recurrence s/p chemotherapy with Avastin(15mg/kg)/Taxol(175mg/m2)/Carboplatin(AUC:5) from 2022/08/12~2023/02/04(6 cycles), recurrence s/p chemotherapy with Taxol(175mg/m2)/Topotecan(0.75mg/m2) from 2023/09/28~ admitted for palliative chemotherapy.
      • O
        • BW 81-82.4
        • Urine output: ~580+loss
        • BUN: 23-24-39-43-53
        • CRE: 1.52 -> 2.30 -> 3.61 -> 5.26 within 1 mo
        • U-CRE: 112.09, U/O 350 cc(09/27)
        • Na/K: 138/3.5
        • HCO3: 32.4
        • Hgb: 8.1-8.6
        • Urinalysis -> NIL
        • Renal echo/Abd CT: bil. DBJ insertion
        • Pelvis MRI 09/07: R/O recurrent tumor in posterior urinary bladder, between right posterior urinary bladder and vaginal stump region.
        • Bil. DBJ in situ, inerted in 2023-07
        • Unable to obtain renal image
        • Medication history:
          • Diuretics: lasix #1 BID 40 mg/day + Budema #1 TID , aldactone -> U/O 580 + loss
          • DM: NIL
          • HTN:
          • Abx: Rocephin
          • Fluid: For drug
          • Other: Ketosteril, pentop
        • Accompanied by husband
        • Consciousness: E4V5M6, depressed
        • Bilateral lower limbs severe edema
        • Vital signs: 144/91 HR 102, SpO2 95% under N/C 2L
      • Impression AKI on CKD, progression in one month
      • Recommendation:
        • Please arrange renal echo first to r/o obstructive uropathy, consult GU for DBJ revision if hydronephrosis/hydroureter
        • Consider dialysis for fluid extraction if necessary by Dr. Wang but patien hesitated
        • Keep current medication use and correct infection status, keep recording I/O, avoid any nephrotoxic medications
        • f/u hemograms, electrolyte, BUN/CRE, blood gas routinely
        • Please feel free to contact us if any inquiries.
  • 2021-05-02 Obstetrics and Gynecology
    • Q
      • S: Abnormal viginal bleeding since yesterday
        • No TOCC
        • She just discharged from OBGYN ward 2 days ago due to 2nd course C/T of cervical cancer.
    • A
      • S
        • P1NSD1, 25 years ago. Adenocarcinoma of the uterine cervix, FIGO stage IVA under CCRT.
        • Denied TOCC
        • She just discharged from hematology ward 2 days ago due to 2nd course C/T of cervical cancer.
          • Family history: (mother: colon cancer, elder sister: breast cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
      • O
        • Endocervical adenocarcinoma; S/P radiotherapy due to cervical cancer.
        • PI: The patietn suffered from urinary frequence and post menopausal bleeding (uncertain duration).
          • GU cystoscopy – suspected meta adenocarcinoma in Cardinal Tien hospital. cervical biopsy as done in Cardinal Tien hospital, cervical cancer.
        • Previous RT Hx: (-)
        • Lab data: Hb=8.9 g/dL; CRP=1.7
        • Vaginal bleeding was noted in our ER.
        • Echo:
          • Uterus: 11.9x8.36 cm, EM: 1.3 cm with blood clot.
          • Uterine myoma 2.4x3.0 cm
      • A: Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • P: CCRT is indicated for this patient with the following indicators: FIGO stage IVA.
        • Plan:
          • Blood transfusion for anemia
          • Transamin and Ergometrine for hemostasis
          • OPD follow up
  • 2021-04-20 Obstetrics and Gynecology
    • Q
      • For vaginal bleeding
      • This 58 y/o woman was Adenocarcinoma of the uterine cervix, FIGO stage IVA, with bladder invasion.
      • She was admitted for per-chemotherapy examination and CCRT with weekly CDDP on 2021/04/15.
      • Vaginal bleeding was noted last night, we need your help for further mamagement, thanks a lot.
    • A
      • Blood clot was noted in vagina. No active bleeding right now.
      • Bosmin gauze was inserted for compression.
      • Conservative treatment, CCRT and Transamin IV were suggested.

[radiotherapy]

  • 2021-04-20 ~ 2021-06-17
    • 4500cGy/25 fractions (15MV photon) of the pelvic
    • 5400cGy/30 fractions (15MV photon) of the cervical tumor
    • 7020cGy/39 fractions (15MV photon) of the cervical tumor bed.

[immunochemotherapy]

  • 2023-12-12 - paclitaxel 80mg/m2 120mg NS 400mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-11-20 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 80mg/m2 120mg NS 500mL 3hr + topotecan 0.75mg/m2 1.2mg NS 40mL 30min D1-3 (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-28 - topotecan 0.75mg/m2 1.4mg NS 40mL 30min D1-3 (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - bevacizumab 15mg/kg 900mg NS 100mL 90min + paclitaxel 175mg/m2 295mg NS 500mL 3hr + carboplatin AUC 5 350mg NS 250mL 2hr (Xia HeXiong)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-11-10 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-10-21 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-09-01 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2022-08-12 - bevacizumab 15mg/kg 900mg 90min + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr (Xia HeXiong)

  • 2021-06-10 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-21 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-13 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-05-07 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-04-28 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

  • 2021-04-20 - cisplatin 40mg/m2 65mg 24hr (CCRT) (Xia HeXiong)

==========

2024-01-15

[levofloxacin dose adjust needed! eGFR 12 recommend 500mg QOD per Sanford Guide]

The Cravit (levofloxacin) dosage for this patient with an eGFR of 12.03 (2024-01-15) requires adjustment based on the Sanford Guide recommendations. While the current regimen uses 750mg QOD, the recommended regimen for this eGFR range is 750mg once followed by 500mg Q48H. Therefore, it is recommended to reduce the dose to 500mg QOD to align with the Sanford Guide for optimal safety and efficacy.

2024-01-03

Imaging and Disease Status: MRI (2023-09-07) and CT (2023-12-07) both indicate disease progression, aligning with the rising CEA levels over the past year.

  • 2024-01-03 CEA 69.11 ng/mL
  • 2023-10-11 CEA 69.94 ng/mL
  • 2023-09-20 CEA 51.92 ng/mL
  • 2023-08-30 CEA 48.75 ng/mL
  • 2023-08-01 CEA 39.69 ng/mL
  • 2023-07-05 CEA 24.40 ng/mL
  • 2023-06-07 CEA 25.70 ng/mL
  • 2023-05-10 CEA 13.94 ng/mL
  • 2023-04-12 CEA 7.26 ng/mL
  • 2022-11-22 CEA 2.85 ng/mL
  • 2022-11-02 CEA 4.12 ng/mL
  • 2022-10-19 CEA 2.82 ng/mL
  • 2022-10-04 CEA 2.11 ng/mL

Renal Function: Deteriorated in late Oct to early Nov 2023, with partial improvement but still not meet normal levels. Latest eGFR value was below 30 mL/min/1.73m2.

  • 2024-01-02 Creatinine 1.84 mg/dL (eGFR 29)
  • 2023-12-19 Creatinine 1.37 mg/dL
  • 2023-12-15 Creatinine 1.51 mg/dL
  • 2023-12-07 Creatinine 2.52 mg/dL
  • 2023-11-29 Creatinine 1.65 mg/dL
  • 2023-11-22 Creatinine 1.86 mg/dL
  • 2023-11-17 Creatinine 2.34 mg/dL
  • 2023-11-15 Creatinine 2.54 mg/dL
  • 2023-11-13 Creatinine 2.23 mg/dL
  • 2023-11-07 Creatinine 2.29 mg/dL
  • 2023-11-02 Creatinine 5.26 mg/dL

Medication Recommendations:

  • Continue Pentop (pentoxifylline) 400mg QD, as it’s already at the recommended maximum daily dose.
  • Consider reducing Promeran (metoclopramide) tab from TIDAC to BIDAC.
  • Closely monitor potassium levels due to ongoing potassium supplementation to avoid over-supplementation.

2023-11-16

[renal function follow-up]

On 2023-11-02, the patient’s serum creatinine reached a recent peak of 5.29 mg/dL and has since stabilized around the 2.2 - 2.5 mg/dL range. The patient, 61F, 62.9 kg, has a calcuated CrCl of 23 mL/min.

The current prescription of Tapimycin (piperacillin and tazobactam) at a dosage of 2.25g IVD Q6H is appropriate.

  • 2023-11-15 Creatinine 2.54 mg/dL
  • 2023-11-13 Creatinine 2.23 mg/dL
  • 2023-11-07 Creatinine 2.29 mg/dL
  • 2023-11-02 Creatinine 5.26 mg/dL (recent peak)
  • 2023-10-30 Creatinine 3.61 mg/dL
  • 2023-10-18 Creatinine 2.30 mg/dL
  • 2023-10-11 Creatinine 1.52 mg/dL
  • 2023-10-02 Creatinine 0.99 mg/dL

[rapid weight loss]

The patient experienced a rapid weight loss of over 20 kg within two weeks, dropping from 83.2 kg on 2023-11-01 to 62.9 kg by 2023-11-15.

Currently, the patient is being treated with furosemide and bumetanide, both of which are potent diuretics. Excessive use of these medications can result in significant diuresis, leading to water and electrolyte depletion. Consequently, close medical monitoring is essential, and the dosage and administration schedule should be tailored to the specific needs of the patient.

2023-10-31

[renal function]

2023-10-30 BUN 43 mg/dL, eGFR 13.62 mL/min/1.73m2, Cre 3.61 mg/dL -> CrCl 21 mL/min (Cockcroft-Gault).

For patients with a CrCl of 20 to 39 mL/minute, the recommended dose of topotecan is reduced to 0.75 mg/m2 - this was the dose administered on 2023-09-28.

While the manufacturer’s labeling does not provide dosage adjustments for CrCl <20 mL/minute, it can be inferred that the dosage restrictions for this range would be even more stringent. Given the patient’s consistent decline in renal function over time, it is crucial to exercise caution when using this medication and to closely monitor for any adverse reactions.

[rapid weight gain]

According to the HIS5 records, the patient’s body weight was 67.5kg on 2023-09-20 and increased to 83kg by 2023-10-30. This significant weight gain could suggest the presence of edema or potential heart failure. Further evaluation is recommended.

2022-12-02

  • There is no LVEF test result available in HIS5 currently. Since bevacizumab has been determined to be an agent that may either cause reversible direct myocardial toxicity or exacerbate underlying myocardial dysfunction (magnitude: moderate/major) (AHA [Page 2016]), It is recommended that a 2D cardiac sonography be ordered.
  • Other than a slightly elevated SBP, the vital signs are stable. Readings from the lab on 2022-12-01 were generally normal.

2022-11-11

  • Exforge (amlodipine 5mg + valsartan 160mg) QD has been prescribed by our cardiologist on 2022-10-01 for 28 days as a treatment for the patient’s primary hypertension.
  • Since the patient’s blood pressure remains elevated during this hospitalization, Exforge might be considered for reinstatement to replace current Diovan (valsartan).

2022-10-24

  • In the last 3 weeks, the serum creatinine level has increased (1.24 2022-10-19 <- 1.18 2022-10-04 <- 0.80 2022-09-26). Please monitor the renal function if it continues to decline.

2022-09-21

  • The patient’s SBP appeared to be between 146 and 197 when she arrived on the ward. The use of Sevikar (amlodipine + olmesartan) 1# QD or Exforge (amlodipine + valsartan) 1# QD might be considered to replace current Norvasc if hypertension (SBP > 150mmHg) for consecutive days is observed.

700823818

240115

[exam findings]

  • 2023-11-29 CT - abdomen
    • History: Adenocarcinoma of the pancreas with liver and left adrenal gland metastases, pT3N1M1, stage IV.
    • Findings: Comparison: prior CT dated 2023/07/14.
      • Prior CT identified lobulated cystic lesion 7 cm in the pancreatic body and tail is noted again, increasing in size to 10 cm.
        • It is c/w progressive disease.
      • Prior CT identified several metastases on both hepatic lobes are noted again, marked increasing in size and number that is c/w multiple liver metastases with progressive disease.
      • There are two newly developed soft tissue masses in the cranial and right lateral aspect of the upper described cystic pancreatic mass that are c/w metastatic nodes.
      • There is a soft tissue nodule 8 mm at RLL of the lung.
        • Follow up is indicated.
      • Ascites in the pelvis is highly suspected. Please correlate with sonography.
      • The entire colon shows mild distension and fecal material that is c/w chronic constipation.
      • Partial atelectasis in RML of the lung is suspected.
        • Please correlate with chest CT.
    • Impression:
      • Mucinous cystic adenocarcinoma of the pancreas with multiple liver metastases shows progressive disease. please correlate with clinical condition.
  • 2023-10-03 Uroflowmetry
    • Q max : poor
    • flow pattern : obstructive
  • 2023-09-26 Bladder sonography
    • PVR: 164 ml
  • 2023-09-04 KUB
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • Fecal material store in the colon.

[MedRec]

  • 2023-10-31 SOAP Rheumatology and Immunology Chen JunXiong
    • S: told has RA under ShuangHe Hosp. plaquenil
    • Prescription x3
      • Plaquenil (hydroxychloroquine 200mg) 1# QDCC 28D
  • 2023-08-25 ~ 2023-09-14 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stage IV
      • Oxacillin Resistant Staphylococcus aureus urinary tract infection
      • Cachexia
      • Hypokalemia
      • Hypertension
      • Constipation
      • Port-a insertion on 2023/09/07
    • CC
      • for pain control and future treatment
    • Present illness
      • The 74 y/o woman has adeno of panceras with liver and left adrenal gland metastases, pT3N1M1, stage 4 under Gemicitabin on 2023/06/10 and 2023/06/21 at TSGH. Port-a was removed due to infection.
      • Due to abdominal pain, she has Fentanyl 75mcg + Noxycodone 1# prnq6h + Painkyl 1 patch prnq4h.
      • Her BW loss 6kg in 3 months and poor intake bother her.
      • Under the impression of adenocarcinoma of panceras with liver and left adrenal gland metastases, pT3N1M1, stable 4 with cachexia, so she was admitted on 2023/08/25.
    • Course of inpatient treatment
      • After admission, we taper nacrotic for con’s confuse and severe weakness.
      • Foley catheter insertion for ICP > 500ml.
      • PPN supplement by selfpay for cachexia and poor intale.
      • Antibiotic as Rocephin for UTI treatment.
      • We gave Promeran, Through, Lactulose and Dulcolax for severe constipation.
      • IVF with NAKO NO.5 500 mL qd supplement.
      • Adjust narcotic with Fentanyl 62.5mcg + morphine 1# prnq4h.
      • Fortunately, her performance improvement and ADL well during hospitalization.
      • Her antibiotic shifted to Avelox for ORSA UTI on 2023/08/30. Foley was removed on 2023/09/01.
      • Sudden onset, fever without chills on 2023/08/31, check lab data showed PCT 0.05, but no bacteremia.
      • GS was consulted for port-a insertion on 2023/09/07.
      • C1D1 Gemzar + Abraxane on 2023/09/12.
      • She can be tolerance without side effect, MBD is arranged on 2023/09/14.
    • Discharge prescription
      • morphine 15mg 1# PRNQ4H 7D if pain
      • Alpraline (alprazolam 0.5mg) 1# HS 7D
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • Lactul (lactulose 666mg/mL) 20mL TID 7D
      • Neurontin (gabapentin 100mg) 1# TID 7D
      • Oxbu ER (oxybutynin 5mg) 1# QD 7D
      • Norvasc (amlodipine 5mg) 1# QD 7D
      • Through (sennoside 12mg) 2# HS 7D
      • Wecoli (bethanechol 25mg) 1# TIDAC 7D
      • bisacodyl supp 10mg/pill2# QOD RECT 7D
      • Durogesic (fentanyl 12ug/h 2.1mg/patch) 1# Q3D EXT 7D
      • fentanyl Transdermal Patch 50ug/h 5mg/patch 1# Q3D EXT 7D
      • Const-K ER (potassium chloride 750mg/10mEq/tab) 1# BID 3D
  • 2023-08-24 SOAP Hemato-Oncology Gao WeiYao
    • S: She was diagnosed to have pancreatic adenocarcinoma with liver metastase in May 2023 and diagnosed at TSGH. She experienced sepsis after 1 dose of chemotherapy. Port-A was removed.
    • A: BW 34 (originally 50 kg; admission 38.8 kg in May 2023), Under fentanyl

[chemotherapy]

  • 2024-01-12 - irinotecan liposome 70mg/m2 87mg D5W 250mL 1.5hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3515mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-29 - irinotecan liposome 70mg/m2 84mg D5W 250mL 1.5hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2800mg/m2 3300mg NS 500mL 46hr (Onivyde + 5-FU. Gao WeiYao)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-14 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-31 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-17 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-10-03 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 150mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-19 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-09-12 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + nab-paclitaxel 125mg/m2 153mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Liposomal Irinotecan drug information - 2024-01-15 - https://www.uptodate.com/contents/liposomal-irinotecan-drug-information

  • Dosing - Adult - Pancreatic adenocarcinoma, metastatic:
    • IV: 70 mg/m2 once every 2 weeks (in combination with fluorouracil and leucovorin); continue until disease progression or unacceptable toxicity (Wang-Gillam 2016).
      • Note: Reduce initial starting dose to 50 mg/m2 in patients known to be homozygous for the UGT1A1*28 allele; the dose may be increased to 70 mg/m2 as tolerated in subsequent cycles.

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer - 2023-12-25 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

  • Cycle length: 4 weeks.

  • Regimen

    • Nabpaclitaxel
      • 125 mg/m2 IV
      • Administer undiluted over 30 minutes.
      • Days 1, 8, and 15
    • Gemcitabine
      • 1000 mg/m2 IV
      • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
      • Days 1, 8, and 15
  • Pretreatment considerations:

    • Emesis risk
      • MODERATE.
    • Vesicant/irritant properties
      • Nabpaclitaxel can cause significant tissue damage; avoid extravasation.
    • Prophylaxis for infusion reactions
      • Premedication to prevent hypersensitivity reactions is generally not needed. Premedication may be needed in patients who have had a prior hypersensitivity reaction to nabpaclitaxel.
    • Infection prophylaxis
      • The incidence of febrile neutropenia with this regimen is 3%. Primary prophylaxis with G-CSF is not indicated.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose for gemcitabine and nabpaclitaxel may be needed for patients with liver impairment. Do not administer nabpaclitaxel to patients with pancreatic cancer and moderate to severe liver impairment (AST <10 times the ULN and total bilirubin >1.5 times the ULN OR AST >10 times the ULN OR bilirubin >5 times the ULN).
  • Monitoring parameters:

    • CBC with differential and platelets weekly during treatment.
    • Assess comprehensive metabolic panel prior to each cycle or when clinically indicated during treatment.
    • Monitor for infusion reactions.
    • Monitor for extravasation.
    • Sensory neuropathy occurs frequently with nabpaclitaxel; assess for changes in neurologic function prior to each treatment cycle.
    • Monitor for signs and symptoms of pneumonitis.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • Do not administer nabpaclitaxel and gemcitabine on day 1 of each new cycle unless ANC is >1500/microL and platelet count is >100,000/microL. For patients who develop neutropenic fever OR ANC <500/microL for >7 days or delay of next cycle by >7 days or thrombocytopenia, withhold treatment until counts recover to an ANC of at least 1500/microL and platelet count of at least 100,000/microL on day 1, or to an ANC of at least 500/microL and platelet count of at least 50,000/microL on days 8 or 15 of the cycle. Upon resumption of therapy, reduce both drugs by 20 to 25% upon the first occurrence, an additional 20 to 25% on the second recurrence, and discontinue treatment for a third occurrence.
    • Sepsis
      • Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). Initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/microL, then resume at lower doses.
    • Thrombotic microangiopathy
      • Thrombotic microangiopathy (TMA; also sometimes called thrombotic thrombocytopenic purpura [TTP] or hemolytic uremic syndrome [HUS]) has been associated with gemcitabine in individuals who have received a large or small cumulative dose. Consider the possibility of TMA if the patient develops Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings. Management consists of drug discontinuation and supportive care, without plasma exchange, as long as there is high confidence in a drug-induced etiology rather than TTP.
    • Peripheral neuropathy
      • For days 1,8, and 15: withhold nabpaclitaxel for grade 3 or 4 neuropathy. Resume nabpaclitaxel at 20 to 25 percent reduced doses when peripheral neuropathy improves to grade ≤2 or completely resolves. Upon resumption of therapy, reduce nabpaclitaxel by 20 to 25% for the first occurrence of grade 3 or 4 peripheral neuropathy, and an additional 20 to 25% for the second occurrence. Discontinue treatment for a third occurrence. For grade 2 peripheral neuropathy, decrease nabpaclitaxel dose by 20 to 25%.
    • Hepatotoxicity
      • Gemcitabine is commonly associated with a transient rise in serum transaminases, but these are seldom of clinical significance. There is insufficient information from clinical studies to allow clear gemcitabine dose recommendations in these patients.
      • Reduced starting doses of nabpaclitaxel are recommended for individuals with pre-existing moderate to severe hepatic impairment; the need for further dose adjustments in subsequent courses based upon ongoing hepatotoxicity should be based on individual tolerance and clinician judgment.
      • One protocol recommends the following: on days 1, 8, and 15, for serum bilirubin elevations ≥grade 2, withhold both drugs until toxicity resolves to grade ≤1; resume treatment at the same dose as before. If not resolved, discontinue therapy.
    • Pulmonary toxicity
      • A variety of manifestations of pulmonary toxicity have been reported with gemcitabine. Pneumonitis has occurred with the use of nabpaclitaxel in combination with gemcitabine. Permanently discontinue treatment with both agents.
    • Other toxicity
      • On days 1, 8, and 15: for grade 3 cutaneous toxicity, hold both drugs until recovered to <= grade 2, and reduce nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%. For grade 3 mucositis or diarrhea, withhold therapy until it improves to ≤grade 1, then resume with reduction of nabpaclitaxel dose by 20 to 25% and gemcitabine dose by 20%.

Treatment protocols for pancreatic cancer - 2023-12-25 - https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

==========

2024-01-15

[reconciliation]

This patient was admitted for her second dose of the liposomal irinotecan + leucovorin + fluorouracil regimen on 2024-01-14. She tolerated the treatment.

Her hypokalemia, which was low at 2.5 mmol/L on 2024-01-12, improved to 3.6 mmol/L by 2024-01-15. No medication discrepancies were identified.

2023-12-25

[revise nab-paclitaxel sequence to ensure treatment efficacy]

Concerns have arisen regarding a deviation from the established administration sequence for the gemcitabine plus nab-paclitaxel regimen. The protocol explicitly mandates administering nab-paclitaxel first, followed by gemcitabine. However, recent administrations reversed this sequence, potentially compromising treatment efficacy. To ensure optimal outcomes, it is recommended to revert to the original protocol’s sequence.

Ref: Increased survival in pancreatic cancer with nab-paclitaxel plus gemcitabine. N Engl J Med. 2013 Oct 31;369(18):1691-703. doi: 10.1056/NEJMoa1304369. Epub 2013 Oct 16. PMID: 24131140; PMCID: PMC4631139.

[disease progress: comfort first, intensive chemo might not fly]

A recent CT scan on 2023-11-29 unfortunately indicated disease progression.

There is an article reporting a comparative effectiveness cohort study, FOLFIRINOX was associated with improved survival of approximately 2 months compared with gemcitabine plus nab-paclitaxel and was also associated with fewer posttreatment complications. A randomized clinical trial comparing these first-line treatments is warranted to test the survival and posttreatment hospitalization (or complications) benefit of FOLFIRINOX compared with gemcitabine plus nab-paclitaxel. Ref: Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022 Jun 1;5(6):e2216199. doi: 10.1001/jamanetworkopen.2022.16199. PMID: 35675073; PMCID: PMC9178436.

Given the patient’s currently compromised performance status (ECOG PS 4 as of 2023-12-25 progress note), intensive chemotherapy might not be the most suitable option. Therefore, best supportive care or a less intensive regimen like mFOLFOX6 might be more appropriate at this time.

2023-08-30

According to PharmaCloud, this patient has only received medical treatment at TSGH in the last three months. However, the last date of treatment was on 2023-06-21, and there are currently no active prescriptions from TSGH. Therefore, no medication reconciliation issues have been found.

701361664

240115

[exam findings]

  • 2024-01-02 EGD
    • Diagnosis:
      • Esophageal varices, F1-2CbLi. RCS(+) White nipple sign(-), s/p EVLx4 with super 7.
      • Reflux esophagitis LA Classification grade A (minimal)
      • Portal hypertensive gastropathy
      • Gastric ulcers, antrum and angle
      • Gastric varix, cardia
      • Duodenal shallow ulcers, bulb and SDA
    • CLO test: not done
    • Suggestion:
      • Cold and liquid diet for 1-2 days
      • Monitor the signs of GI bleeding
  • 2023-12-29 CT - abdomen
    • Findings: Comparison prior CT dated 2023/10/20.
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly (the greatest cranial-caudal dimension: 17.7 cm).
      • Left renal cyst, 0.9cm
      • There is mild ascites in the pelvis.
    • Impression:
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
  • 2023-12-29 ECG
    • Normal sinus rhythm
    • Incomplete right bundle branch block
    • Borderline ECG
  • 2023-10-20 CT - abdomen
    • Findings: Comparison prior CT dated 2023/09/04.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stable in size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
  • 2023-09-04 CT - abdomen
    • Findings
      • Stable condition of gastric cancer, LNs and liver metastases.
      • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
      • Left renal cyst (8mm). Minimal ascites.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Stable condition of gastric cancer, LNs and liver metastases.
      • Liver cirrhosis with portal vein and splenomegaly. Mild small bowel ileus.
  • 2023-06-05 CT - abdomen
    • Indication: Gastric cancer with liver mets
    • Abdominal CT with and without enhancement revealed:
      • Lobulated low density lesion at S5/6/7/8 of liver measuring 9.8cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2023-02-24, the lesion progressed slightly.
      • Chains of lymphadenopathy at gastrohepatic ligment and perigastric region is found. In enlargement.
      • The GB is well distended without soft tissue lesion
      • Wall thikening at gastric antrum is found. Compatible with gastric cancer.
      • Splenomegaly is found.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Gastric cancer with regional lymphadenopathy and liver meta. In progression.
  • 2023-06-01 All-RAS + BRAF mutation
    • Cellblock No. S2023-03168
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-04 EGD
    • Diagnosis:
      • Gastric cancer, Borrmann type III, antrum, AW
      • Reflux esophagitis LA grade A
      • Esophageal varices, F1CbLi. RCS(-)
      • Superficial gastritis
      • Duodenal ulcer, Forrest type IIc, bulb and pylorus
      • Deformed antrum
    • CLO test: not done
    • Suggestion:
      • Oral PPI use
      • If bleeding continued, suggest ER visit.
  • 2023-02-24 CT - abdomen
    • History: gastric cancer.
    • Indication: for clinical trail
    • Findings: Comparison prior CT dated 2023/01/13.
      • Prior CT identified wall thickening at the gastric antrum is noted again, mild increasing in size. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, increasing in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
    • Impression:
      • Metastases on both hepatic lobes and metastatic lymph nodes in the gastrohepatic ligament and hepatoduodenal ligament show increasing in size that is c/w progressive disease. please correlate with clinical condition.
  • 2023-01-13 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/12/09.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.9cm
    • Impression:
      • Liver metastases on both lobes show increasing in size, please correlate with clinical condition.
  • 2022-12-09 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/10/28.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size. There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Left renal cyst, 0.7cm
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases (mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
  • 2022-10-28 CT - abdomen
    • Findings: Comparison: prior CT dated 2022/09/14.
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary. Please correlate with gastroscopy.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stable in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, stable in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size.
      • Left renal cyst, 0.7cm
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases(mild increasing in size), and portal venous thrombosis S/P C/T show stable disease. Follow up is indicated.
  • 2022-09-14, -08-03, -06-22 CT - abdomen
    • Gastric cancer with lymph nodes and liver metastases, and portal venous thrombosis S/P C/T show stable disease.
    • Follow up is indicated.
  • 2022-05-20 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
      • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, mild decreasing in size.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, marked decreasing in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 16.1 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, decreasing in size.
      • Left renal cyst, 0.7cm
      • Minimal ascites in the lower pelvis is suspected.
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis S/P C/T show partial response.
  • 2022-03-18 CT - abdomen
    • Findings:
      • Prior CT identified wall thickening at the gastric antrum is noted again, stationary that is c/w gastric cancer.
      • Prior CT identified multiple metastatic nodes nodes in the gastrohepatic ligament and hepatoduodenal ligament are noted again, stationary.
      • Prior CT identified thrombosis at both lobe and main trunk portal vein are noted again, increasing in size.
        • There is splenomegaly and the greatest cranial-caudal dimension measuring about 14.8 cm in length.
      • Prior CT identified several metastases on both hepatic lobes are noted again, mild increasing in size. However, the tumor margin is hard to define. Please correlate with MRI.
      • Left renal cyst, 0.7cm
      • Minimal ascites in the lower pelvis is suspected.
    • Impression:
      • Gastric cancer with lymph nodes and liver metastases, and portal venous tumor thrombosis. cT3N2M1. cstage:IVb.
  • 2022-03-16 MRI - brain
    • No intracranial metastasis.
  • 2022-03-11 Tc-99m MDP bone scan
    • Increased activity in the lower C-spines and L5 spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • A hot spot in the posterolateral aspect of left rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and right knee, compatible with benign joint lesions.
  • 2022-03-01 CT - abdomen gastric filling with water
    • Clinical history: 42 y/o male patient with gastric cancer was suspected.
    • With and without contrast enhancement CT of abdomen - whole:
      • Thickening wall at the gastric antrum, r/o gastric malignancy.
      • There are multiple enlarged perigastric lymph nodes, could be due to lymph nodes metastasis.
      • Presence of thrombosis at main portal vein.
      • Left renal cyst, 0.7cm.
      • There are multifocal poor enhancing lesions in both lobes of liver, R/O liver metastasis.
      • Presence of some ascites in the pelvic cavity.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • R/O gastric malignancy with lymph nodes metastasis, portal venous invasion/thrombosis.
      • Suspicious liver metastasis. if proven metastasis, cstage T3N2M1. IVb.
  • 2022-02-25 Patho - stomach biopsy (Y1)
    • Stomach, antrum, AW side, biopsy — moderately differentiated adenocarcinoma
    • Microscopically, it shows moderately differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical study reveals CK(+), CD56(-), SOX10(-), S100(-) and Ki-67 50%.
    • IHC stain — Her2/neu: negative (0/1+)

[chemotherapy] (not completed)

  • 2023-12-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-11-29 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-31 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-17 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-09-26 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-09-12 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-08-22 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 150mL 10min + fluorouracil 2400mg/m2 4300mg NS 250mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-08-08 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-07-25 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-11 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-20 - docetaxel 35mg/m2 60mg NS 200mL + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4400mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-05-10 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-04-20 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-03-29 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-03-09 - oxaliplatin 130mg/m2 240mg D5W 500mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2023-02-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2023-02-01 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2023-01-04 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-12-14 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-11-23 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-11-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-10-12 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-09-21 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-08-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + capecitabine 500mg PO 3# QD 4# QN D1-14
  • 2022-08-10 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-08-03 - oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-07-27 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-06-29 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 239mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-06-02 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 236mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-04-28 - oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 2# QD 3# QN D1-14
    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3 + NS 250mL
  • 2022-04-22 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr
  • 2022-03-31 - NS 50mL 300mL/hr + tislelizumab 200mg NS 100mL 30min + NS 25mL 50mL/hr + ociperilimab 900mg NS 100mL 30min + NS 25mL 50mL/hr + oxaliplatin 130mg/m2 230mg D5W 500mL 2hr + capecitabine 500mg PO 3# QD 4# QN D1-14

==========

701492350

240115

[exam findings]

  • 2023-09-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 25) / 80 = 68.75%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Mild MR, TR
  • 2023-08-14 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-08-14 CT - chest
    • Indication: right breast cancer, diagnosed at Feng Rong Hospital, CNB: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
    • Findings:
      • Lungs:a subleural bulla or lung cyst at RML 16mm.
        • a reticular opacity over RLL may represents atelectasis or r/o fibrosis. normal appearance of Lt lung.
      • Vessels: the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Chest wall and visible lower neck: a Rt axillary enlarged LN (25mm in longest axial dimension). two enhancing nodules at UOQ of Rt breast measuring up to 14mm.
      • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries. small and large bowels grossly unremarkable.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Rt breast cancer T1c or T2 N1
  • 2023-07-31 Patho - lymphnode biopsy
    • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
    • Section shows cores of lymphoid tissue with metasatic irregular neoplastic glands. The immunohistochemical stain of GATA3 is positive.
    • IMMUNOHISTOCHEMICAL STUDY
        1. ER (Ab): Positive (>90%, strong)
        1. PR (Ab): Positive (10%, moderate)
        1. Her-2/neu (Ab): Equivocal (2+)
        1. Ki-67: 15%
  • 2023-07-31 Her-2/neu - DISH
    • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 2.9
      • Average number of CEP17 signals per cell: 2.6
      • HER2/CEP17 ratio: 1.12
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-15086
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • APPENDIX:
      • ASCO/CAP scoring criteria (2018):
        • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
        • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
        • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
        • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
        • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
      • Negative:
        • Group 5
        • Group 2 and concurrent IHC 0-1+ or 2+
        • Group 3 and concurrent IHC 0-1+
        • Group 4 and concurrent IHC 0-1+ or 2+
      • Positive:
        • Group 2 and concurrent IHC 3+
        • Group 3 and concurrent IHC 2+ or 3+
        • Group 4 and concurrent IHC 3+
        • Group 1

[MedRec]

  • 2023-09-01 ~ 2023-09-07 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Right breast invasive ductal carcinoma, ER(+), PR(+), HER-2(-), T1N1M0, stage IIA s/p chemotherapy with EC by T from 2023/09/06~
    • CC
      • For prepare chemotherapy.
    • Present illness
      • This 60-year-old woman patient suffered from right breast tumor in 2022/05. Sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla. MMG at LMD showed heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area. Right breast cancer, diagnosed at Feng Rong Hospital. CNB at Feng Rong Hospital showed invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67: <5%, refer for further management.
      • Right axilla lymph node core needle biopsy on 2023/07/31 pathology showed metastatic carcinoma, consistent with breast origin, ER: Positive(> 90%, strong), PR: Positive(10%, moderate), Her-2/neu: Equivocal(2+), Ki-67: 15%. Chest CT on 2023/08/14 showed right breast cancer T1c or T2 N1. Whole body bone scan on 2023/08/14 showed no strong evidence of bone metastasis. Colonoscopy on 2023/08/22 showed colon polyp and mixed hemorrhoid. Breast sona on 2023/09/01 showed right 10 o’clock / 4 cm, size: 1.44 x 0.90 x 1.42cm, right 10 o’clock / 3 cm, size: 0.72 x 0.71 x 0.81cm, highly suspicious of malignancy, with sonographic positive axillary LAP. Now, she was admitted to ward for prepare chemotherapy with EC * 4 followed by docetaxel * 4 followed by OP.
    • Course of inpatient treatment
      • After admitted, 2D echo on 2023/09/01 showed M-mode (Teichholz) = 68, 1. Preserved LV and RV systolic function with normal wall motion; 2. Normal chamber size; 3. Mild MR, TR. Consult GS for Port-A catheter insertion on 2023/09/05.
      • Chemotherapy with EC by T(Epirubicin 90mg/m2, Cyclophamide 600mg/m2)(C1) on 2023/09/06.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/07 and OPD followed up later.     
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2023/07/31 Her-2/neu - DISH
        • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • P
      • EC * 4 followed by docetaxel * 4 followed by OP
      • Admission for Port-A (if not done), Heart echo and then C/T
  • 2023-08-19 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • O
      • 20230819 CT: no liver metastasis, no bone metastasis
      • bone scan: no bone metastasis
    • A/P
      • right breast cancer, multifocal, luminal A, cT1N1, stage 2
      • suggest: neoadjuvant chemotehrapy with following operation
      • arrange port-A implantation on 9/7
      • refer to oncologist for neoadjuvant chemotherapy
  • 2023-08-08 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S:
      • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
    • O:
      • no palpable breast tumor, no large movable LAP over right axilla
      • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
      • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
      • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla
      • 2023/07/31 PATHO-lymphnode biopsy
        • Lymph node, right axilla, core needle biopsy — Metastatic carcinoma, consistent with breast origin
          1. ER (Ab): Positive (> 90%, strong)
          1. PR (Ab): Positive (10%, moderate)
          1. Her-2/neu (Ab): Equivocal (2+), FISH (-)
          1. Ki-67: 15%
      • no neurological sign
      • no bone pain
    • A
      • right breast cancer, multifocal, luminal A, cT1N1
  • 2023-07-29 SOAP General and Gastrointestinal Surgery Chen YenZhi
    • S:
      • right breast cacner, diagnosied at Feng Rong Hospital, refer for further management
    • O:
      • no palpable breast tumor, no large movable LAP over right axilla
      • CNB at Feng Rong Hospital: invasive ductal carcinoma, ER(+), PR(+), HER-2(-), Ki-67<5%
      • MMG at LMD: heterogenous dense breast tissue with a small hyperdense lobular mass at right UOQ retroglandular area
      • sono by myself: two hypoechoi lesions over right 10’ region, 1.41x0.76x1.08 and 0.79x0.60x0.72 respectively, LAP(+) over right axilla

[chemotherapy]

  • 2024-01-13 - docetaxel 60mg/m2 90mg NS 250mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-12-22 - docetaxel 60mg/m2 90mg NS 250mL 1hr
    • dexamethasone 4mg PO + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-24 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-30 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-27 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - epirubicin 90mg/m2 130mg NS 100mL 30min + cyclophosphamide 600mg/m2 850mg NS 500mL 1hr
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2024-01-15

Lab results on 2024-01-12 were grossly normal with no evidence of a contraindication to docetaxel administration.

701174678

240112

[exam findings]

  • 2023-10-31 ECG portable 7 days
    • Findings
      • Baseline was persistent AFIB with SVR
        • MAX HR: 82 bpm
        • Avg HR: 54 bpm
        • MIN HR: 32 bpm
      • Ventricular Ectopy: 359
      • 1 episode of short-run VT (7 beats, 109bpm)
      • 1 episode of long pause, max 2.00 sec, related to AFIB SVR
      • 1 test events at begining, ECG showed persistent AFIB
    • Conclusion
      • Baseline was persistent AFIB with SVR
      • Rare isolated VPC
      • 1 episode of short-run VT (7 beats, 109bpm)
      • 1 episode of long pause, max 2.00 sec (related to AFIB SVR)
  • 2023-10-24 MRA - brain
    • Focal old ischemic cortical infarct over right medial occipital lobe.
    • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
    • Short segmental severe stenosis of left distal ICA (ophthalmic segment) with post-stenotic dilatation.
    • Paranasal sinusitis.
  • 2023-10-24 CXR
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • patchy opacity at medial RUL
  • 2023-10-23 ECG portable 24hr
    • Baseline was incessant AFIB with SVR (Average HR: 57bpm, range between: 51-70 bpm)
    • A few isolated VPCs / VPC couplets
    • 1 episode of non-sustained VT (5 beats, 120 bpm)
    • No long pause
  • 2023-10-20 ECG
    • Atrial fibrillation
    • Abnormal ECG
  • 2023-09-25 Neurosonography
    • Moderate atheromatous lesion in R CCA bifurcation with ulcerated plaqaue; mild to moderate atheromatous lesions in R ICA; L middle CCA and L CCA bifurcation; mild atheromatous lesions in R subclavian artery; irregular bradycardia with heart rate between 31 and 53 BPM.
    • Elevated flow velocities in bilateral MCAs (PS/ED: R = 207/49, L = 295/59 cm/s), suggesting bialteral MCA stenosis.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows. 4) Normal bilateral ophthalmic arterial flows.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
  • 2023-09-11 C-spine AP + Lat
    • mild anterior and posterior spur formation at the lower C-spine.
    • mild decreased disc space in the C6/7 disc.
  • 2023-06-16 MRI - prostate
    • Clinical history: 75 y/o male patient with 112/05/02, high PSA 41.5, he prefer TRUS-P biopsy after discussion (2023/05/11)
      • 2023/05/11, DRE: no hard nodule, TRUS-P biopsy 12 cores, educate further care, 2023/05/18, pathology showed
        • Histologic Type: Prostatic acinar adenocarcinoma
        • Histologic Grade: Gleason score = 7 (4 + 3).
      • arrange MRI and bone scan for staging
    • Imaging Report Form for Prostate Carcinoma
      • Impression (Imaging stage): T:T3b(T_value) N:N0(N_value) M:Mo(M_value) STAGE: IIIB (Stage_value)
    • Impression
      • Prostate cancer (in body, base and apex, mainly in left lobe with abutting left seminal vesicle base), r/o seminal vesicle involvement. cstage T3bN0M0.
  • 2023-05-24 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, and knees.
  • 2023-05-11 Patho - prostate needle biopsy
    • PATHOLOGIC DIAGNOSIS
      • Prostate, right, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 5 of 6 strips of prostatic tissue by the number of involved strips or 70 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
      • Prostate, left, needle biopsy — Prostatic acinar adenocarcinoma (Gleason score 7 = 4 + 3) involving 6 of 6 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen. The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic acinar adenocarcinoma
      • Histologic Grade: Gleason score = 7 (= 4 + 3 ).
  • 2023-05-02 Low dose CT, LDCT - chest
    • Mild subpleural fibrosis both lower and upper lobes.
    • extensive 3V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries
  • 2023-05-02 ECG 8C
    • Atrial fibrillation with slow ventricular response with premature ventricular or aberrantly conducted complexes
    • Incomplete left bundle branch block
  • 2023-05-02 SONO - abdomen
    • GB polyp, tiny
    • Pancreas not shown
  • 2022-11-30 EGD
    • Reflux esophagitis LA Classification grade A-
    • R/o intestinal metaplasia, antrum to body
    • Superficial gastritis
    • Post clipping, LC of low body
  • 2022-10-03 Patho - colorectal polyp
    • Diagnosis
      • Intestine, large, rectum, polypectomy — tubular adenoma
      • Intestine, large, transverse colon, polypectomy — tubular adenoma
      • Intestine, large, ascending colon, 100 cm from anal verge, polypectomy — tubular adenoma
  • 2022-08-12 SONO - nephrology
    • Chronic parenchymal renal disease
  • 2022-07-18 CT - chest
    • Findings
      • Lungs:
        • with areas of patchy expiratory air-trapping in both lower lobes and posterior both upper lobes.
        • patchy ground glass opacities with septal thickening in bilateral lungs RUL most prominent..
      • Mediastinum and hila: the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels: moderate calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and RA, and LVH.
      • Pleura: trace effusion.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: a tiny calcification over pancreatic tail.
        • Atherosclerotic change of the abdominal aorta.
      • Visualized bones: multiple marginal spurs of vertebrae.
    • Impression:
      • interstitial lung process or infection.
      • obstructive small airways disease.
      • moderate 3V-CAD.
  • 2022-07-13 CXR erect
    • hazy areas of increased opacity (ground-glass opacities) over and Lt perihilar midlung zone
    • reticular opacities over RUL
    • mild enlarged cardiac silhoutte
    • Costophrenic angles are preserved
  • 2022-05-31 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the anteroseptal wall.
  • 2022-05-30 ECG portable 24hr
    • Baseline was sinus bradycardiawith 1st degree AVB (average HR: 44-59 bpm)
    • Occasional junctional esacape beats noted (13:20)
    • Paroxysmal AFIB noted
    • A few isolated VPCs
    • Frequent isolated APCs / APC couplets (burden 2%)
    • 22 episodes of long pause, max 2.304 sec, related to blocked APC +/- junctional escape beats
  • 2022-05-25 Neurosonography
    • Mild to moderate atheromatous lesions in bilateral distal CCAs and bilateral CCA bifurcations; mild atheromatous lesions in bilateral middle CCA and R ICA.
    • Normal extracranial carotid and vertebral arterial flows.
  • 2022-05-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 19) / 104 = 70.49%
      • LVEF (%) = 82
      • M-mode (Teichholz) = 82
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 3 (restrictive pattern).
      • Normal RV systolic function.
      • Mild to moderate MR; moderate to severe TR; mild PR; mild aortic valve sclerosis (NCC).
      • Possible severe pulmonary hypertension, estimated PASP 78 mmHg.
  • 2022-04-18 ECG
    • Sinus rhythm with 1st degree A-V block with Premature atrial complexes
  • 2022-01-14 SONO - nephrology
    • Chronic parenchymal renal disease
  • 2021-03-26 EGD
    • Diagnosis:
      • Extensive intestinal metaplasia, antrum to body
      • Atrophic gastritis, antrum, s/p CLO test
      • Gastric polyp, 0-Is, LC of lower body, favor adenomatous or inflammatory polyp, s/p cold-snaring polypectomy(A), s/p hemoclipping
      • Gastric ulcer, H2, LC of lower body, s/p biopsy(B)
      • duodenal ulcer scar, GC of bulb
    • CLO test: Positive
    • Suggestion:
      • Please monitor bleeding and pursue pathology report, CLO test results.
      • Consider EGD FU for extensive IM change
  • 2021-01-08 EGD
    • Diagnosis
      • Hypertrophic fold, body, s/p biopsy (A)
      • Gastric polyp, prob. adenoma, angularis, s/p biopsy (B)
      • Atrophic gastritis, body
      • Reflux esophagitis LA Classification grade A
      • gastritis, antrum s/p CLO test negative
  • 2020-12-25 SONO - abdomen
    • Suspected liver hemangioma, right
    • Pancreas not shown
  • 2019-07-22 MRA - brain
    • Mild general brain atrophy.
    • Mild intracranial arteriosclerosis.
  • 2019-06-27 Color Transcranial Sonography
    • Moderate to severe atherosclerosis in Rt ICA (with diameter stenosis of 33.1%), Rt CCA (with diameter stenosis of 38.8%), Rt Bifurcation (with diameter stenosis of 50.3%), Rt Subclavian Artery, & Lt CCA (with diameter stenosis of 52.7%), Lt Bifurcation (with diameter stenosis of 51%).
    • Normal RI in bilateral ICA.
    • Elevated PI in Rt ACA, Rt MCA, Rt PCA, & Lt ACA, Lt MCA, indicating distal stenosis.
    • Increased PSV in bilateral MCA, suggesting focal stenosis.
    • Adequate total VA flow volume (199 ml/min), indicating absence of Vertebrobasilar insufficiency.
    • Suggest MRA (neck+intracranial arteries) for further study if no contraindication.
    • Advise clinical correlation.
  • 2019-04-09 Transrectal Ultrasound of Prostate, TRUS-P
    • CC: nocturia, right inguinal mass, weak stream.
    • Prostate   - Size of prostate: 4.71(T)cm x1.99(L)cm x4.46(AP)cm=21.8cc   - Size of adenoma: 2.87(T)cm x1.37(L)cm x2.55(AP)cm=5.2cc   - Calculi: No   - Cyst:(Max) No   - Intravesical growth: No
    • Seminal vesicles   - Size: L’t 1.95x0.685cm   - Cyst: No
      • Abscess: No    - Tumor: No
          - Size: R’t 1.36x0.698cm
      • Cyst: No    - Abscess: No
      • Tumor:No
    • Diagnosis   - Benign prostatic hyperplasia

[medication]

  • 2023-10-21 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC
  • 2023-07-27 - CELIG - Eligard (leuprorelin acetate 22.5mg) Q3M SC

700268312

240110

[exam findings]

  • 2023-12-29 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion, bil meatus purulency
      • Nasopharynx: smooth purulent PND
      • Oropharynx: no tumor lesion
      • Larynx: no tumor lesion, bilateral vocal movement: symmetric
      • Hypopharynx: no tumor lesion
    • Diagnosis/conclusion
      • sinusitis
  • 2023-12-21 CT - abdomen
    • History and indication: Adenocarcinoma of ascending colon cT4bN2M0 IIIC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A-colon cancer s/p operation.
      • Colonic diverticula.
      • Liver cysts (up to 6.7cm).
      • S/P right THR.
      • Atherosclerosis of aorta, iliac and visceral arteries.
      • Increased density at bilateral basal lungs.
    • IMP:
      • A-colon cancer s/p operation. No evidence of tumor recurrence.
  • 2023-10-23 All-RAS + BRAF mutation
    • Cellblock No. S2023-18526 A5
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>TGT, p.G12C)
      • BRAF: Detected (BRAF codon 600 GTG>GAG, p.V600E)
  • 2023-09-15 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, ascending colon, right hemicolectomy —- Adenocarcinoma, poorly differentiated
      • Small intestine, terminal ileum, right hemicolectomy —- Negative for malignancy
      • Omentum, right hemicolectomy —- Adenocarcinoma, metastatic
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Metastatic adenocarcinoma (1/22)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IVA, pT3N1aM1a or pStage IVC, pT3N1aM1c, Please discussion the tumor stage in tumor board.
    • Gross Description:
      • Operation procedure: right hemicolectomy;
      • Specimen site: ascending colon
      • Specimen size: Colon: 9.3 cm in length; Terminal ileum: 4.0 cm in length; Omentum: 6.2 x 5.3 x 2.3 cm with a metastatic tumor, measuring 3.5 x 3.0 x 2.3 cm; Appendix: not found
      • Tumor size: 8.0 x 4.5 x 1.7 cm
      • Tumor location: 5.5 cm and 5.0 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: Several diverticula are found in ascending colon.
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: proximal resection margin; A2: distal resection margin; A3: ileocecal valve; A4: diverticula; A5-9: tumor; A10: colon; A11-13: lymph node, mesocolic; A14: metastatic tumor in omentum.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G3: Poorly differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: very close, <0.1 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 1/22
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply) :not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1a: One regional lymph node is positive
        • Distant Metastasis (pM):
          • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis or
          • pM1c: Metastasis to the peritoneal surface is identified alone or with other site or organ metastases
      • Additional Pathologic Findings (select all that apply): Diverticula are found.
  • 2023-09-12 Flow Volume Loop Chart
    • Mild restrictive ventilatory impairment
  • 2023-09-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (61 - 18) / 61 = 70.49%
      • 2D (M-Simpson) = 70
    • Conclusion:
      • Indeterminated LV filling pressure and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with trivial AR; mild MR; mild PR.
      • Mild aortic root calcification with small protruding atheroma (3.4 mm of thickness).
  • 2023-08-29 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • Segmental wall thickening at ascending colon with abutting to adjacent liver and regional peritoneal mass. R/O asending colon malignancy.
      • Liver cysts, up to 6.6cm in right lobe.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • Enlarged lymph nodes in pericolnic region.
      • No ascites.
      • Outpouching lesions in sigmoid colon, suggesting sigmoid colon diverticula.
      • Post-op at right hip.
      • T11 compression fracture.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
    • Impression:
      • Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0.
      • Sigmoid colon diverticula.
      • Liver cysts.
  • 2023-08-28 Patho - colon biopsy
    • Colon, ascending, 67-70 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Specimen submitted in formalin consists of 5 pieces of tan, irregular tissue measuring up to 0.3 x 0.1 x 0.1 cm. All for section in one cassette.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands and extravasated mucin.
    • The immunohistochemical stains reveal EGFR(+), PMS2(-), MLH1(-), MSH2(+), and MSH6(+).
  • 2023-08-28 EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Duodenal ulcer scar, bulb
  • 2023-08-24 MRA - brain
    • Short segmental severe stenosis of left distal VA. Suggest PTA and stenting.
    • Short segmental moderate stenosis of left distal ICA (cavernous segment).
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
  • 2023-08-18 Neurosonology
    • moderate atheroma on right carotid bifurcation and left CCA, ICA with diameter reduction of 33-47%, severe atheroma on left carotid bifurcation with diameter reduction of 64%,
    • higher peak systolic velocities (166/23 cm/s) on left carotid bifurcation, (185/37 cm/s) on left ICA, may suggest focal severe stenosis (50-69%)
    • antegrade of bil. ophthalmic a. flows

[MedRec]

  • 2023-09-12 ~ 2023-09-19 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Adenocarcinoma of ascending colon, cT4bN2bM0, IIIC status post single-incision laparoscopic right hemicolectomy on 2023/09/14, pT3N1aM1a(1/22), G3, LVI(+), PNI(+), CRM(-), stage IVa (metastastic tumor on omentum), stage IVa
    • CC
      • tarry stool for around one month
    • Present illness
      • This is a 82 y/o female with underlying disease of anemia, syncope episode and insomnia. This time she was admitted due to tarry stool for around one month.
      • According to the patient statement, she suffered from tarry stool for around one month with iFOB positive and HGB = 8.2 g/dL. She denied nausea/vomiting, fever, abdominal pain, constipation, diarrhea, dyspnea or dysuria. Due to above symptoms, she went to our GI OPD on 8/22.
      • Upper GI endoscopy showed Reflux esophagitis LA Classification grade A (minimal) and Duodenal ulcer scar, bulb.
      • And colonoscopy showed suspected ascending colon cancer. Pathology showed adenocarcinoma.
      • Abdominal CT on 8/29 showed 1. Ascending colon cancer with regional lymph nodes, cstage T4bN2bM0, IIIc. 2. Sigmoid colon diverticula. 3. Liver cysts.
      • Under impression of Adenocarcinoma of A-colon, she was admitted for further evaluation and surgical intervention.
    • Course of inpatient treatment
      • This 82 years old female patient was a case of Adenocarcinoma of A-colon. She underwent single-incision laparoscopic right hemicolectomy on 2023/09/14. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. She started semi liquid diet on 9/17 and JP drain was removed on 9/19. She was discharged on 112/9/19 and will follow up in our out-patient department next week.
    • Discharge prescription
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS

[surgical operation]

  • 2023-09-14
    • Surgery
      • Laparoscopic right hemicolectomy (Glove port use)      
    • Finding
      • A locally advanced 5-6cm tumor is located at proximal A-colon with suspected a 2cm tumor deposit (seeding) on nearly omentum    
      • Right hemicolectomy was achieved smoothly. Blood loss was about 30ml.    
      • Anastomosis was performed using endo-GIA for both ends and side-to-side sutures with 4/0 PDS+ seromuscular retention    
      • A drain in Morrison’s pouch    

[chemotherapy]

  • 2024-01-09 - irinotecan 180mg/m2 195mg D5W 250mL 90min + leucovorin 400mg/m2 435mg NS 250mL 2hr + fluorouracil 2800mg/m2 3050mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-19 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-12-01 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-10 - irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2000mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU <70%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-23 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 425mg NS 250mL 2hr + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI, Iri 80%, Covorin 80%, 5FU 80%; Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

==========

2024-01-10

[reconciliation]

The patient received repeat prescriptions for Rivotril (clonazepam) and Mirtapine (mirtazapine) at NTUH on 2023-11-13, followed by refills on 2023-12-07 and 2024-01-01. However, these medications are currently not listed as active in her medication record. Here are some possible explanations:

  • The patient may no longer require these medications. To confirm this, it would be helpful to review the reason for their initial prescription and any recent clinical assessments.
  • There may be an error in the medication record. Please double-check the patient’s active medication list and compare it to available PharmaCloud records.
  • The patient may not be taking the medications as prescribed. This could be due to various reasons, such as side effects, lack of perceived benefit, or forgetting to take them.

Therefore, it is recommended to understand the reason for the non-use of the prescribed medications will help determine the most appropriate course of action.

2023-12-04

Currently, PharmaCloud access is unavailable.

Following the initiation of a dose-reduced FOLFIRI regimen, with the 3rd session starting on 2023-12-01, the patient has not experienced vomiting or nausea and reports good sleep and appetite.

No discrepancies in medication have been identified in the HIS5 records.

700274792

240110

[MedRec]

  • 2024-01-05 SOAP Hemato-Oncology Gao WeiYao
    • A: CML
      • 2024/01/05 BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation
    • Diagnosis
      • C92.10 - Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
      • D47.1 - Chronic myeloproliferative disease
      • D72.829 - Elevated white blood cell count, unspecified
    • Prescription
      • Tasigna (nilotinib 150mg) 2# Q12H 14D

[chemotherapy]

Comparison of tyrosine kinase inhibitors used for chronic myeloid leukemia - 2024-01-10 - https://www.uptodate.com/contents/image?imageKey=HEME%2F89930

Agent Dosing frequency and timing in relation to food Dose adjustments for baseline kidney/liver dysfunction Major toxicities Other
Imatinib Daily (or twice daily) with food Yes (kidney, liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hepatotoxicity. Longest record of safety data
Nilotinib Twice daily without food Yes (liver) Bone marrow suppression; cardiovascular events; electrolyte imbalance; hepatotoxicity. Black box warning: QT prolongation (screening required). _
Dasatinib Daily with or without food No Bone marrow suppression; pleural/pericardial effusions; pulmonary arterial hypertension; QT prolongation; aspirin-like effect. _
Bosutinib Daily with food Yes (kidney, liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects. _
Ponatinib Daily with or without food Yes (liver) Bone marrow suppression; fluid retention/edema; gastrointestinal effects; heart failure; hypertension; pancreatitis; aspirin-like effect; arterial thrombosis. Black box warning: cardiovascular events; hepatic toxicity. Active against BCR::ABL1 T315I mutation; limited long-term safety data
Asciminib Daily or twice daily without food No Upper respiratory tract infections; musculoskeletal pain; fatigue; nausea; rash; and diarrhea. Hypertriglyceridemia; cytopenias; elevated creatine kinase; hepatotoxicity; pancreatitis. Active against BCR::ABL1 T315I mutation; limited long-term safety data

==========

2024-01-10

[nilotinib]

This patient is newly diagnosed with CML.

Lab data: 2024/01/05 - BCR/abl Philadelphia chromosome (qualitative) - Presence of mutation.

  • 2024-01-10 WBC 41.60 x10^3/uL
  • 2024-01-05 WBC 72.21 x10^3/uL
  • 2023-12-25 WBC 73.26 x10^3/uL
  • 2023-12-08 WBC 94.03 x10^3/uL

Absence of blasts in recent WBC DC makes the diagnosis of advanced CML (accelerated phase or blast phase) highly improbable. Chronic phase CML is therefore the most likely diagnosis.

BCR-ABL1 tyrosine kinase inhibitors (TKIs) are the first-line therapy for all CML phases, except for specific contraindications like pregnancy.

Initial CML treatment typically employs either imatinib or a second-generation TKI (dasatinib, nilotinib, bosutinib). Other TKIs (ponatinib, asciminib) are reserved for refractory patients or those with specific mutations (e.g., T315I). Notably, nilotinib is currently the patient’s TKI of choice.

Nilotinib is known to prolong the QT interval. Monitoring for and correcting hypokalemia, hypomagnesemia, and pre-existing QTc prolongation are crucial before and during nilotinib treatment. Regular ECGs (baseline, 7 days after initiation, periodic) are essential to track QTc, especially after dose adjustments.

Sudden deaths have been reported with nilotinib. Contraindications include hypokalemia, hypomagnesemia, and long QT syndrome. Concomitant medications that prolong the QT interval or strongly inhibit CYP3A4 should be avoided. Nilotinib intake should be separated from food by at least 2 hours (before) and 1 hour (after).

[reconciliation]

This patient’s primary hospital is New Taipei City Hospital according to PharmaCloud database. On 2024-01-09, refills were prescribed for several medications: Gaslan, Periscon (mosapride), Vesicare (solifenacin), Harnalidge (tamsulosin), Eurodin (estazolam), Meptin-Mini (procaterol hydrochloride hemilydrate), Colin Soln (chlorpheniramine maleate), and Allevo (levocetirizine dihydrochloride).

However, these refilled medications are not currently listed as active in the patient’s record. Please verify with the patient whether he still require these medications and, if clinically necessary, ask him or his family member to bring them to the hospital.

Note that Tasigna (nilotinib 150mg) 2# Q12H prescribed on 2024-01-05 in the outpatient clinic is currently being used without any identified issues.

701337994

240110

[exam findings]

  • 2023-12-12 CT - chest
    • Adenocarcinoma of lung (ROS: mutation) with LNs mets & disease progression
    • Comparison was made with CT dated on 2023/08/25
      • Lungs: no interval change in size of LUL spiculated tumor (2.1 cm srs/img302/51), associated interlobular septal thickening, and with regression of radiation pneumonitis in upper and midlung zonesas compared with CT on 2023/08/25
      • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
      • Pleura: minimal Lt-sided effusion..
      • segmental OPLL at T2-T4 levels.
    • Impression:
      • LUL cancer with hilar LAP, post treatment, stationary with regression of radiation penumonitis as compared with CT on 2023/08/25
  • 2023-08-25 CT - chest
    • Malignant neoplasm of upper lobe, left bronchus or lung
      • MRA: Brain (2023-07-19): multiple brain met.
      • RT (2023-7-27 ~ 2023-8-10) Completion of radiotherapy on 2023-8-10.
    • Comparison was made with previous CT dated on 2023/5/6
      • Lungs: no interval change size of LUL spiculated tumor (2 cm srs/img202/28), associated interlobular septal thickening, and with extensisve radiation pneumonitis in upper and midlung zones as compared with CT on 2023/05/06
      • Mediastinum and hila: stationary of metastaic LAP at Lt hilum
      • Pleura: minimal Lt-sided effusion..
    • Impression:
      • LUL cancer stationary with radiation penumonitis as compared with CT on 2023/05/06
  • 2023-07-19 MRA - brain
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • punctate white matter gliosis in the supratentorial brain; nodular lesions in the left posterior frontal lobe, left superior parietal lobe, left occipital lobe and left pons. r/o metastasis. PLeaes correlate with contrast-enhanced study.
    • IMP:
      • r/o brain metastasis. Please correlate with contrast-enhanced study.
  • 2023-05-06 CT - chest
    • Progression of left lung lesions.
    • Stable of right lung lesions.
  • 2023-01-30 CT - chest
    • Progression from adenocarcinoma of lung with left supraclavicular lymph node metastases post Iressa (since 2011 to 2022), stage T4N3M0, stage III on MK 2009/10/01 Poar LIUMR c6D1 on MK 2010/02/09AFU6, local recurrent
    • Comparison was made with previous CT dated on 2022/8/18
      • Lungs: interval significant decreased LUL spiculated tumor (3.9 cm srs/img302/25) and decreased numbe and size of small nodules in both lungs as compared with CT on 2022/08/18.
      • Mediastinum and hila: signficant regresion of metastaic LAP as compared with previous CT son 2022/0/18
      • Pleura: trace Lt-sided effusion.
    • Impression:
      • LUL cancer T4N3M1a, signficant in regression as compared with previous CT study on 2022/08/18
  • 2022-11-03 Tc-99m MDP bone scan
    • Some hot spots in the skull and right rib cage and increased activity in the distal portion of left humeral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
    • Mildly increased activity in some T- and L-spines and sacrum. Degenerative change is more likely.
    • Increased activity in bilateral shoulers, hips, knees and feet. Benign joint lesions may show this picture.
  • 2022-08-18 CT - chest
    • Indication: follow up progessive Rt lung adenocaricnoma with ALK-positive under TKI. Evaluate tumor response to TKI
    • Chest CT with and without IV contrast ehnancement shows:
      • Huge soft tissue mass at left upper lobe with regional consolidation is found. The left upper lobe bronchus is partially obstructed by the mass. Lung cancer is considered. In comparison with CT dated on 2022-02-22, the lesion enlarged with broader extension.
      • Lymphadenopathy at mediastinum is found.
      • Left mild pleural effusion is found.
      • Minimal pericardial effusion is also found.
      • Mild pericardial effusion is found.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy and consolidation over left upper lobe, in progression.
  • 2022-05-16 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2022-6896
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-04-21 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-02-22 CT - chest
    • History of adenocarcinoma of lung with Lt supraclavicular LN metastases post Iressa
      • Initial stage T4N3M0, stage III on MK 2009/10/01
      • Poar LIUMR X6D1 on MK follow up ca of lung status under Iressa
    • Comparison made with previous CT dated on 2021/11/19
      • Lungs:
        • the LUL spiculated tumor with pleural tails is 2.84 cm in longest axial dimension (srs/img10/22).
        • small nodule in anterior LUL (srs/img10/23 and a tiny centrilobular nodule in LLL (srs/img10/73)
      • Mediastinum and hila: heterogeneous enhancing left hilar lymphadenopathy (24 mm) and several small LNs in both sides of visceral space, increase in size as compared with previous CT study on 2021/11/19.
    • Impression:
      • LUL cancer T4N3, seems slightlt in progression as compared with previous CT study on 2021/11/19.
  • 2021-11-19 CT - chest
    • History of lung Ca under Iressa TKI treatment, evaluate tumor status
    • Chest CT with and without IV contrast ehnancement shows:
      • Spicualted mass at left upper lobe up to 2.61cm in largest dimension is found.
      • Enlarged lymph nodes are found at left hilar region. Non-specific lymph nodes are found at paratracheal region is found.
    • Imp:
      • Left upper lobe lung mass with left hilar lymphadenopathy, T2N1-2Mx.

[consultation]

  • 2023-09-19 Ear Nose Throat
    • Q
      • The 67 years old woman has adenocarcinoma of lung cancer with brain mets. Due to vertigo frequency in 1+ months, so we need your help for management. Thanks!
    • A
      • Hx of adenocarcinoma of lung cancer with brain mets
      • Vertigo (unsteadiness, exacerbated when sitting up and standing up, lasted for hours) for a month.
        • Ear drum: bil intact
        • EAC: clean
        • FNF: ok
        • HINTS: normal VOR, no nstagmus, normal test of skew
      • Imp: Vertigo, nature?
      • Plan:
        • May try Diphenidol (patient mentioned s/s improved under Diphenidol, and she claimed she had drugs)
        • ENT OPD f/u for inner ear battery test

[radiotherapy]

[chemotherapy]

  • 2024-01-09 - vinorelbine 20mg 1# PO + carboplatin AUC 5 400mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-13 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-14 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-17 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-21 - vinorelbine 20mg 1# PO + carboplatin AUC 5 300mg NS 250mL (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-16 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-26 - docetaxel 75mg/m2 110mg NS 150mL 1hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-21 - pemetrexed 500mg/m2 745mg NS 100mL 10min + carboplatin AUC 5 365mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-23 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-24 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 280mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - pemetrexed 500mg/m2 727mg NS 100mL 10min + carboplatin AUC 5 275mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-05 - pemetrexed 500mg/m2 730mg NS 100mL 10min + [NS 500mL 2hr + diphenhydramine 30mg + NS 250mL] (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-13 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-22 - pemetrexed 500mg/m2 730mg NS 100mL 10min + NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 350mL + NS 500mL 2hr (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Vinorelbine - 2024-01-10 - https://www.uptodate.com/contents/vinorelbine-drug-information

  • Dosing - Adult
    • Non–small cell lung cancer:
      • Metastatic (single-agent therapy): IV: 30 mg/m2 once a week.
      • Locally advanced or metastatic (in combination with cisplatin): IV: 25 mg/m2 on days 1, 8, 15, and 22 of a 28-day cycle or 30 mg/m2 once a week.
      • Advanced disease (off-label dosing): IV: 25 to 30 mg/m2 days 1, 8, and 15 every 28 days (in combination with gemcitabine) for 6 cycles or until disease progression or unacceptable toxicity.
    • Small cell lung cancer, refractory (off-label use):
      • IV: 25 or 30 mg/m2 every 7 days until disease progression or unacceptable toxicity.

==========

not posted

dosage not correct?

700043422

240109

[exam findings]

  • 2023-09-01 All-RAS + BRAF gene mutation analysis
    • Cell Block No. S2023-12334
    • RESULTS:
      • ALL-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V)
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-08-27 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Prolonged QT
    • Abnormal ECG
  • 2023-08-26 CT - abdomen
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P ileostomy with incisional hernia. Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
      • Small stones in left kidney.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • GGO at right basal lung.
    • IMP:
      • S/P ileostomy with incisional hernia.
      • Progression of A-colon cancer (10.3x11.6x15.4cm) with right lateral abdominal wall and psoas muscle invasion.
      • Some lymph nodes at RLQ.
      • GGO at right basal lung.
  • 2023-08-26 CT - brain
    • Non-contrast brain CT revealed:
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP:
      • Brain atrophy.
  • 2023-06-26 ECG
    • Sinus rhythm with occasional atrial-paced complexes and Fusion complexes
    • Low voltage QRS
    • Prolonged QT
  • 2023-06-21 Patho - colon biopsy
    • Colorectum, ascending colon, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-06-16 CT - abdomen
    • CC: general weakness, poor appetite,
    • PHx: COPD, HTN, DM, colon cancer diagnosed by Cardinal Tien Hospital
    • Findings:
      • There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b).
        • The differential diagnosis includes adenocarcinoma associated with tumor necrosis and abscess formation.
        • please correlate with clinical condition.
        • In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a).
      • S/P ileostomy at right upper pelvis.
      • Hyperplasia of left adrenal gland is noted.
    • Imaging Report Form for Colorectal Carcinoma
  • 2023-06-16 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2023-06-16 CXR
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.

[MedRec]

  • 2023-06-16 ~ 2023-06-20 POMR Colorectal Surgery Lv ZongRu
    • Discharge diagnosis
      • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
      • Hypertension
      • Diabetes mellitus
      • Hyperlipidemia
      • Chronic obstructive pulmonary disease
    • CC
      • complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital
    • Present illness
      • This is a 58 year-old men had history of
        • hypertension with medicin control over 10 years;
        • diabetes mellitus with medicin control over 10 years;
        • hyperlipidemia with medicin control over 10 years;
        • Chronic Obstructive Pulmonary Disease with medicin control for many years;
        • Gastroesophageal reflux disease with medicine control for many years.
        • Diangosised of Malignant tumor in ascending colon with right psoas muscle invasion on 2023/05 by Cardinal Tien Hopital.
        • port-A insertion on 2023/05/15 at Cardinal Tien Hospital.
        • ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
      • He denied any TOCC histories in recent 3 months.
      • According the patient statement, discharge on 2023/05/18 at Cardinal Tien Hospital. Due to he had watery diarrhea off and on for about month,and intermittent right back pain over 1 years. Poor intake about 1 month and body weight loss over 20 kg. During hospitalization, diangosised of Malignant tumor in ascending colon with right psoas muscle invasion. Port-A insertion and ileostomy post operation on 2023/05/15 at Cardinal Tien Hospital.
      • PET 2023/05/23 showed 1). Malignant tumor in ascending colon with right psoas muscle, invasion; cT4bN0M0, c-stage IIC., 2). Bilateral pleural effusion., 3). Post colostomy in RUQ.
      • Brain MRI showed no organic brain lesion and no evidence of metastasis on 2013/05/27.
      • Due to the complaint of no hospital bed for chemotherapy in Cardinal Tien Hospital, the patient visited our emergency room for his disease.
      • At emergency room, Abdominal CT showed There is a well-defined heterogeneous enhancing mass in the ascending colon, measuring 15 cm (the largest dimension), and direct invasion right psoas muscle and duodenum 2nd-3rd junction that is c/w adenocarcinoma of the ascending colon (T4b). In addition, there are four enlarged nodes in the right side mesocolon that are c/w metastatic nodes (N2a). no distant metastasis. Laboratory data showed WBC: 12.80 x10^3/uL, CRP: 12.5 mg/dL.
      • After consultation to proctologist and initial management, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, highly suspect ascending colon cancer with local advanced invasion. Paliative chemotherapy + radiotherapy first, but insufficient information of pathology report in other hospital. Thus, colonscopy biopsy was performed on 2023/06/20. Under the stable condition, he was discharged today and the final report will be follow up in OPD.
    • Discharge prescription
      • Curam (amoxicillin 875mg, clavuanic acid 125mg) 1# Q12H
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQID
  • 2023-08-27 Colorectal Surgery
    • Q
      • Family members said that when the patient wanted to get up to change his stoma, he collapsed and fell to the ground, not sure where he hit.
      • denied fever, tarry stool, chocking recently.
      • Hx
        • Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1.
        • Hypertension
        • Diabetes mellitus
        • Hyperlipidemia
        • Chronic obstructive pulmonary disease
    • A
      • This is a Advance ascending colon cancer with psoas muscle invasion post loop ileostomy, cT4bN2aM0, stage IIIC. ECOG:1. with conscious change this morning
      • GCS: E3M5V2
      • A/P: admission for antibioitc drugs treatment
      • please check BZD drug overdose problem
      • thanks for your consultation

[immunochemotherapy]

  • 2024-01-08 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3875mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-12-25 - bevacizumab 5mg/kg 150mg NS 100mL 60min + irinotecan 180mg/m2 198mg D5W 250mL 90min + leucovorin 400mg/m2 440mg NS 250mL 2hr + fluorouracil 2800mg/m2 3000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-12-11 - bevacizumab 5mg/kg 150mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-11-27 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 235mg D5W 250mL 90min + leucovorin 400mg/m2 524mg NS 250mL 2hr + fluorouracil 2800mg/m2 3670mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-11-14 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 422mg NS 250mL 2hr + fluorouracil 2800mg/m2 2960mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. dose reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-31 - bevacizumab 5mg/kg 100mg NS 71mL 60min + irinotecan 180mg/m2 257mg D5W 250mL 90min + leucovorin 400mg/m2 572mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 1000mL 46hr (Avastin + FOLFIRI; Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-16 - irinotecan 180mg/m2 276mg D5W 250mL 90min + leucovorin 400mg/m2 615mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 1000mL 46hr (FOLFIRI Q2W. doce reduced) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-10-02 - irinotecan 180mg/m2 294mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4500mg NS 1000mL 46hr (FOLFIRI Q2W. doce increased) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-09-18 - irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4172mg NS 1000mL 46hr (FOLFIRI Q2W) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-08-14 - oxaliplatin 85mg/m2 112mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2800mg/m2 3700mg NS 1000mL 46hr (FOLFOX Q2W) (Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-02 - (FOLFOX Q2W) (Lv ZongRu)
  • 2023-07-17 - (FOLFOX Q2W) (Lv ZongRu)
  • 2023-07-03 - (FOLFOX Q2W) (Lv ZongRu)

==========

2024-01-09

[anemia]

Compared to the previous session on 2023-12-25, the dosage of Irinotecan and fluorouracil administered during this session on 2024-01-08 was increased.

The patient’s HGB level remains low at 7.8g/dL as of 2024-01-08. Available lab data indicates persistent anemia since at least June 2023, with no recovery to normal levels. If the anemia becomes symptomatic, RBC transfusion may be necessary.

The patient has already received several blood transfusions throughout the previous months, specifically on 2023-08-30, 2023-11-13, and 2023-12-11.

2023-12-27

[anemia]

Hemoglobin has been around 7 to 8 g/dL for the past two months. The FOLFIRI dose has been reduced during this hospitalization. If anemia is symptomatic, please perform RBC product transfusion as clinically indicated.

  • 2023-12-25 HGB 7.3 g/dL
  • 2023-12-11 HGB 7.1 g/dL
  • 2023-11-27 HGB 8.3 g/dL
  • 2023-11-13 HGB 7.2 g/dL
  • 2023-10-30 HGB 8.9 g/dL

2023-12-13

[anemia]

In the pharmacist note dated 2023-11-16, the following assessment was made: Considering the already reduced dose of the FOLFIRI regimen, further alleviation of anemia severity might necessitate lengthening the treatment intervals, potentially impacting the expected therapeutic effectiveness. In the recent two administrations (irinotecan on 2023-11-27 and 2023-12-11: 235mg; 5-FU on 2023-11-27 and 2023-12-11: 3670mg), both irinotecan and 5-FU doses were increased compared to the previous administration (irinotecan on 2023-11-14: 190mg; 5-FU on 2023-12-11: 2690mg), while maintaining a biweekly interval. Recent data may indicate that the rate of hemoglobin supplementation is not keeping pace with the anemia caused by the treatment. Consequently, in subsequent therapy sessions, blood transfusions may become a necessary adjunct to the treatment regimen.

  • 2023-12-11 HGB 7.1 g/dL BT
  • 2023-11-27 HGB 8.3 g/dL
  • 2023-11-13 HGB 7.2 g/dL BT
  • 2023-10-30 HGB 8.9 g/dL
  • 2023-10-16 HGB 10.6 g/dL

2023-11-16

[anemia]

Laboratory data indicated episodes of anemia. Blood transfusions were appropriately administered to the patient on 2023-08-30 and 2023-11-13.

  • 2023-11-13 HGB 7.2 g/dL BT
  • 2023-10-30 HGB 8.9 g/dL
  • 2023-10-16 HGB 10.6 g/dL
  • 2023-10-02 HGB 10.1 g/dL
  • 2023-09-18 HGB 10.1 g/dL
  • 2023-09-04 HGB 9.7 g/dL
  • 2023-08-30 HGB 8.1 g/dL BT
  • 2023-08-27 HGB 9.5 g/dL
  • 2023-08-26 HGB 10.6 g/dL
  • 2023-08-14 HGB 9.3 g/dL
  • 2023-08-01 HGB 10.5 g/dL
  • 2023-07-17 HGB 8.8 g/dL
  • 2023-07-03 HGB 9.4 g/dL
  • 2023-06-19 HGB 8.8 g/dL
  • 2023-06-16 HGB 9.3 g/dL
  • 2021-09-03 HGB 13.7 g/dL

The patient is currently being treated with Avastin and a reduced dose of the FOLFIRI regimen. Bevacizumab is less commonly associated with anemia. Given that the dose of the FOLFIRI regimen has already been reduced, further mitigation of the severity of anemia might require extending the treatment intervals, which could potentially affect the anticipated therapeutic efficacy.

700359263

240109

==========

2024-01-09

Lab results:

  • 2024-01-08 NT-proBNP > 35000.0 pg/mL

  • 2024-01-08 CKMB 5.5 ng/mL

  • 2024-01-08 hs-Troponin I 62.9 pg/mL

  • 2024-01-08 CK 86 U/L

  • 2024-01-08 ECG

    • Sinus rhythm with 1st degree A-V block
    • Non-specific intra-ventricular conduction block
    • T wave abnormality, consider inferolateral ischemia
  • 2024-01-08 CXR

    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • moderate enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad /supine position
    • Rt and Lt subpulmonary effusion
    • Linear band subsegmental atelectasis at lung bases
    • marginal spurs of multiple vertebral bodies

Potential causes:

  • Heart failure remains a likely cause, strongly supported by the significantly elevated NT-proBNP and the enlarged cardiac silhouette on CXR.
  • Myocardial infarction (heart attack) is still a possibility, given the elevated hs-Troponin I and T wave abnormality on ECG. Further investigations like a repeat ECG and echocardiography would be crucial to confirm or rule out this diagnosis.
  • Acute coronary syndrome (ACS) is also a possibility due to the potential for ischemia suggested by the ECG findings.
  • Other potential contributing factors:
    • Atherosclerosis, as evidenced by the calcified changes in the aorta on CXR.
    • Possible pulmonary congestion or effusions, as indicated by the subpulmonary effusions on CXR.

It might be beneficial to consult a cardiologist.

700817160

240109

[lab data]

2023-12-04 FKLC 135.0 mg/L
2023-12-04 FLLC 178.0 mg/L

2023-11-28 Protein, total 5.9 g/dL
2023-11-28 Albumin 35.2 %
2023-11-28 Alpha-1 2.3 %
2023-11-28 Alpha-2 14.6 %
2023-11-28 Beta 21.9 %
2023-11-28 Gamma 26.0 %
2023-11-28 M-peak Positive
2023-11-28 A/G Ratio 0.50

[MedRec]

  • 2023-12-09 ~ 2023-12-12 POMR Nephrology Lin DingYun
    • Discharge diagnosis
      • Nephrotic syndrome with other morphologic changes
      • Type 2 diabetes mellitus with diabetic chronic kidney disease
      • Essential (primary) hypertension
      • Idiopathic gout, unspecified site
      • Pure hypercholesterolemia
      • Anemia, unspecified
      • Cyst of kidney, acquired
    • CC
      • Lower limbs edema for 2 months
    • Present illness
      • This is a 65 years old male with underlying disease of type 2 DM, hypertension, gouty arthritis, CKD stage 4, was admitted for lower limbs edema for 2 months.
      • The patient was in his usual health status, until the end of Sep 2023, when he was infected with COVID-19 infection. He noted that lower limbs edema developed gradually thereafter. His general appetite and spirit also became worsen. He denied use of NSAIDs recently. There was no fever, chills, dyspnea, decreasing urine output.
      • He visted the nephrologist OPD on 2023-10-28, and low serum albumin was noted, 2.9 to 2.1 mg/dL. Urine protein was also increased, UACR 1.98 to UPCR 9.3. Renal function was relative stable, around 2.67~3.3mg/dL.
      • Relevant studies for proteinuria showed presence of M-protein on protein EP and IFE, suspected to be IgG + Kappa. Under the impression of nephrotic syndrome with unclear cause, he was admitted for kidney biopsy.
    • Course of inpatient treatment
      • After admission, we have checked the CBC, coaggulation and bleeding time, and we also adjusted anti-hypertensive agents for blood pressure control.
      • Due to anemia (HB 8.5g/dL), blood transfustion with LPRBC 2U was done on 12/09 and 12/10.
      • Desmopressin was given for preventing bleeding before kidney biopsy on 12/11.
      • The patient stood well during the whole procedure, and follow-up renal echo showed minimal hematoma and stable hemogram level.
      • Due to stable condition, he was discharge on 2023/12/12.
    • Discharge prescription
      • Budema (bumetanide 1mg) 1# QD
      • Feburic (febuxostat 80mg) 0.5# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • colchicine 0.5mg 0.5# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID

700867511

240109

[exam findings]

  • 2024-01-07 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
  • 2023-12-08 ECG
    • Normal sinus rhythm
    • Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2023-11-22 Peipheral Vascular Test - AV fistula
    • Result: Adequate size of RIJV
  • 2023-11-17 PET scan
    • Glucose hypermetabolism in multipe bones as mentioned above, suggesting multiple bone metastases.
    • Glucose hypermetabolism in some left supraclavicular lymph nodes, bilateral pulmonary lymph nodes and multiple bilateral mediastinal lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the lower portion of the esophagus. Inflammation is more likely. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-11-10 Tc-99m MDP bone scan
    • The scintigraphic findings suggest multiple bone metastases.
  • 2023-10-26 T-spine AP + Lat.
    • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at T8.
  • 2023-10-16 Patho - bone fragment/pathologic fracture
    • T8 vertabrae, biopsy — Metastatic adenocarcinoma and see description
    • The specimen submitted consists of three strips of brown-gray bony tissue, labeled T8 vertebrae, measuring up to 1.2 x 0.2 x 0.2 cm. All for section.
    • The sections show a picture of metastatic adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells, arragned in glandular and cribrifrom patterns with muicin secretion.
    • IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-). Suggest check respiratory tract and pancreaticobiliary tract.
  • 2023-10-14 ECG
    • Anteroseptal infarct, age undetermined
  • 2023-10-14 CXR
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture at T8, mets or multiple myeloma?
  • 2023-09-15 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx
    • Diagnosis: multiple bone metastasis
  • 2023-09-01 MRI - T-spine
    • Diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
  • 2023-08-24 CT - abdomen
    • R/O vascular thrombosis of bil. lower lungs.
    • Enlargement of prostate.
  • 2023-08-24 T spine AP + Lat
    • T8 compression fracture
    • General osteoporosis
    • Concave vertebrae of T-L spine
  • 2023-08-16 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T0(T_value) N:N0(N_value) M:M1c(M_value) STAGE:IVB(Stage_value)
    • Findings
      • Lungs:
        • extensive, bilateral, upper lobes predominant, centrilobular emphysema, in the lungs.
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
        • areas of septal thickening at S6 and S10 of LLL and central bronchial
        • wall thickening at both lower lobes.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: mild coronary arterial calcification
      • Thoracic aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Pleura: no effusion
      • Visible abdominal contents: no abnormal density in visible portion of the the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys.
      • Visualized bones: lytic or blastic change with compression fracture of T8 vertebral body.
    • Impression:
      • extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18.
      • no obvious solid lung tumor.
  • 2023-05-31 Bronchodilator Test
    • severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III.
  • 2022-11-03 CXR erect
    • Increased lung volume and areas of hyperlucency/decreased vascular markings due to emphysematous change
  • 2022-11-03 Bronchodilator Test
    • moderate obstructive impairment; non-significant bronchodilator response; compatible with GOLD stage II
  • 2022-10-24 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the apex, middle to basal inferior wall, and inferoseptal wall (LAD and RCA territories) of LV.
    • Mild dilatation of LV is noted on post-stress images.
  • 2022-08-11 ECG
    • Anteroseptal infarct, age undetermined
  • 2022-05-19 Bronchodilator Test
    • compatible with GOLD stage II
  • 2022-05-04 Bruce ECG
    • Findings
      • The patient exercised according to the BRUCE for 07:05 min:s, achieving a work level of max METS: 8.6.
      • The resting heart rate of 91 bpm rose to a maximal heart rate of 144 bpm.
      • This value represents 92 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 113/76 mmHg, rose to a maximum blood pressure of 208/95 mmHg.
      • The exercise test was stopped due to Target heart rate [85-99% MHR], Dyspnea, Fatigue.
    • Conclusion
      • Probably negative for myocardial ischemia (baseline Q wave at V1-3)
  • 2022-04-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 27) / 67 = 59.70%
      • M-mode (Teichholz) = 58
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy; LV diastolic dsyfunction, Gr 1
      • Trivial MR and trivial TR
      • Preserved RV systolic function

[MedRec]

  • 2023-12-08 ~ 2023-12-12 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Adenocarcinoma of lung cancer with multiple bone metastasis, stage IV
      • Chronic obstructive pulmonary disease
      • Anterolateral infarct
      • Chronic ischemic heart disease
      • Essential (primary) hypertension
      • Mixed hyperlipidemia
    • CC
      • for chemotherapy and pain control
    • Present illness
      • The 67 y/o man has BPH, COPD (smoking 1.5 PPD for 50 years and Lung function: severe obstructive impairment after bronchodilator; non-significant bronchodilator response; compatible with GOLD stage III on 2023/05/31), HTN, Hyperlipidemia and CAD under ASA and Coxine since 2022/11-2023/12/7.
      • Due to he has dyspnea on exercise, the chest CT was done from CM OPD on 2023/08/16, report showed extensive emphysema with lower lobes bronchitis, LLL interstitial infiltration r/o edema, and pathological compression fracture of T18. no obvious solid lung tumor.
      • He was refered to ONC OPD for T8 pathologic fracture, so he did the MM survey and the T-spine MRI was done on 2023/09/01, report showed diffuse bony metastases involving vertebral column, including T1-4, T6-9, T11-12, L1-3, L5 and S2 vertebral body.
      • ENT OPD for suspect unknown primary and multiple bone mets survey, but no evidence of NPC.
      • The EGD also was done for primary unknown on 2023/09/26, report showed Reflux esophagitis LA Classification grade A(minimal), Gastric erosions, antrum, s/p biopsy(B) and Gastric shallow ulcers, bulb, s/p biopsy(A), but all of pathology showed not cancer.
      • On 2023/10/16, the bone pathology showed metastatic adenocarcinoma, IHC shows: CK7(+), CK20(-), CDX2(-), TTF1(-) and PSA(-).
      • The bone scan and self paid of PET were showed multiple bone metastases on 2023/11.
      • ONC OPD gave pain killers as Fentanyl 12 mcg, Ultracet 1# q6h and Cataflam 75mg qd, but in vain.
      • Under the impression of metastatic adenocarcinoma, primary origin suspect lung, so he was admitted for chemotherapy and pain control on 2023/12/08.
    • Course of inpatient treatment
    • After admission, he received pain control with Durogesic 12mcg/h, 2.1mg/patch 2 patch q3d. B12 IM and MultiVit on 2023/12/11. First chemo as Alimta + Cisplatin on 2023/12/12. Under the stable condition, he can be discharged on 2023/12/12. OPD follow up is arranged.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Cough Mixture (platycodon ) 8mL PRNQ8H
      • Neurontin (gabapentin 100mg) 1# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Ulstop (famotidine 20mg) 1# BID
      • Durogesic (fentanyl 12ug/h, 2.1mg/patch) 2# Q3D EXT
  • 2023-11-15 SAOP Chest Medicine Wu ZhiWei
    • A/P
      • Plan:
        • refer to ortho/oncology fot spine T8 pathologic fracture (adenoCA with unknown origin)
        • quit smoking
      • smoking: 2 PPD x 50 years, current
      • PHx: COPD s/p anoro [chest Dr. Huang & Wu]; CAD under aspirin
    • Prescription x3
      • Anoro Ellipta (umeclidinium 55ug/dose, vilanterol 22ug/dose; 30 doses/bot) 1# QD INHL

[chemotherapy]

  • 2024-01-02 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-12-12 - pemetrexed 500mg/m2 726mg NS 100mL 10min + cisplatin 75mg/m2 100mg NS 350mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-09

[reconciliation]

A repeat prescription for Anoro Ellipta for the patient’s COPD, issued on 2023-11-15 by our pulmonologist, has been added to the active medication list.

[reduced CEA growth after pemetrexed-cisplatin initiation]

The patient’s CEA level doubled within a month, from 2023-11-14 to 2023-12-15. Notably, this rapid increase seems to have slowed down in the following 21 days (2023-12-15 to 2024-01-05), with only a 12% increase observed. The initiation of pemetrexed + cisplatin therapy on 2023-12-12 may be contributing to this slowdown.

  • 2024-01-05 CEA (NM) 383.080 ng/ml
  • 2023-12-15 CEA (NM) 341.960 ng/ml
  • 2023-11-14 CEA (NM) 176.550 ng/ml
  • 2023-09-15 CEA 49.34 ng/mL
  • 2023-08-23 CEA 20.17 ng/mL

700289323

240108

[MedRec]

==========

2024-01-08

[reconciliation]

The medications prescribed by both your cardiologist and psychosomatic medicine specialist on 2023-10-19 are currently in use without any discrepancies. These repeat prescriptions will expire soon. Please remind the patient to consider scheduling follow-up appointments with both specialists before the prescriptions expire, if clinically necessary.

701111632

240108

[MedRec]

  • 2024-01-04 ~ 2024-01-08 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with multiple bone metastases, stage IV
      • Right lower lung pneumonia, sputum culture: Mixed normal flora Growth:4+
      • Hypokalemia
      • Oral candidas
    • CC
      • for fever without comtrol for 10 days
    • Present illness
      • This 54 year-old woman has invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection on 2016-08-04, Chemotherapy was started on 2016-09-02 and completed on 2017-03-27.
      • Nolvadex since 2017-04-14. Completion of radiotherapy on 2017-06-16.
      • Regular followed up and abdominal echo showed Hepatic tumor, rule out metastatic tumor on 2021/01/19.
      • Followed up ABD CT showed the largest one measuring 1.5 x 0.7 cm at S2, are noted again, stable in size and feature and a hemangioma 0.7 cm in the spleen is suspected on 2021/01/29.
      • Bone scan also was done on 2021/03/16, image showed in comparison with the previous study on 2016/07/21, the lesions in the sternum and lower T-spine are new. Bone metastases should be considerd.
      • 2021/04/20 E2 <15.0 pg/mL, FSH 31.14 mIU/mL. Whole body PET scan on 2021/04/13 showed glucose hypermetabolism in the sternum and T11 spine, compatible with bone metastases.
      • Under the impression of Invasive carcinoma (NST, no special type) of the left breast, stage pT2N1a (2/21)(cM0); pStage: IIB, ER (+, 90 %), PR (+, 70 %), HER-2/Neu (-, score=1+); HER2 Dual ISH: (-, non-amplified), s/p MRM and axillary lymph nodes dissection, chemotherapy, radiotherapy, and status during endocrine therapy, with newly identified recurrence with multiple bone metastases, stage IV, /p RT and Kisqualis permitted in May 2021. but declined in April 2023, /p Aromasin since 2023/11.
      • Follow up chest CT on 2023/08/19 showed left upper lobe tiny nodule, right middle lobe ground glass nodule stationary and bone meta is found.
      • Follow up bone scan on 2023/10/9 showed increased tracer uptake in the sternum and T11 spine come to more evident, indicating metastatic bone disease in progression.
      • She was diagnosed with influenza B on 2023/12/25 and took antiviral drugs at my own expense. But, she still have a fever up to 39.1C at LMD and Tamiflu for 5 days productive cough (yellowish sputum) with sore throat for 7 days, so she was brought to our ED for help on 2024/01/03.
      • CXR showed pneumonia over RLL. Lab data showed WBC 3400/uL, CRP 3.6mg/dL, ALT 71U/L and AST 79U/L, normal renal function.
      • Initial antibiotic as Cravit for infection control. Under the impression of RLL pneumonia, so she was admitted on 2024/01/04.
    • Course of inpatient treatment
      • After admission, she received Cravit for pneumonia control. Throat swab was done for oral candidas and we gave Nystatin treatment. After treatment, her cough with sputum decrease and no fever, so she can be discharged and take oral antibiotic going back home on 2024/01/08. OPD follow up is arranged.
    • Discharge prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • Z-cough (benzonatate 100mg) 1# TID
      • Cravit (levofloxacin 500mg) 1.5# QDAC

700027309

240106

[exam finding]

  • 2025-01-04 Pelvis AP
    • S/P posterior instrumentation of L3-L5 vertebrae.
  • 2024-12-31 Evoked Potential Test
    • Findings:
      • Delayed peak latencies of N9, N20; Normal interpeak intervals of N13-20 following each median nerve stimulaiton.
      • Delayed peak latencies of N22, P40; Normal interpeak intervals of N22-P40 following each tibial nerve stimulaiton.
    • Conclusion
      • This probably abnormal SSEP study suggests Polyneuropahty on both arm & leg.
  • 2024-12-31 Evoked Potential Test
    • Findings
      • Delayed peak latencies and Normal CCTs following cortical and cervical stimulation during each Abductor minimi digiti muscle (ADM) recording.
      • Delayed peak latencies and Normal CCTs following cortical and lumbar stimulation during each Tibialis anterior (TA) recording.
    • Conclusion
      • This probably abnormal MEP study suggests a peripheral motor conduction defect of both of upper & lower limbs,
  • 2024-12-25 Nerve Conduction Velocity, NCV
    • Findings
      • Upper limb MNCV study:
        • Prolonged distal latency, Normal CMAP amplitude & Reduced MNCV in bilateral median nerves & bilateral ulnar nerves.
      • Lower limb MNCV study:
        • Prolonged distal latency, Normal CMAP amplitude & Reduced MNCV in bilateral peroneal nerves & Lt tibial nerve.
        • Normal distal latency, Normal CMAP amplitude & Normal MNCV in Rt tibial nerve.
      • SNCV study:
        • Prolonged distal latency, Normal SNAP amplitude & Reduced SNCV in bilateral median nerves.
        • Prolonged distal latency, Dampened SNAP amplitude & Reduced SNCV in bilateral ulnar nerves.
        • Normal distal latency, Normal SNAP amplitude & Normal SNCV in Rt sural nerve.
        • Absence of signal in Lt sural nerve.
      • F wave study:
        • Prolonged F wave-latency in (Rt / Lt / bilateral) median nerves, ulnar nerves, peroneal nerves & tibial nerves.
      • H reflex study:
        • Prolonged H reflex latency in bilateral tibial nerves.
    • Conclusion
      • The above findings suggest
        • sensorimotor polyneuropathy,
        • bilateral cervical and lumbosacral radiculopathies.
      • Advise clinical correlation.
  • 2024-12-21 CT - brain
    • Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • Focal faint hypodense change over left anterior corona radiata, may be recent ischemic infarct.
      • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. There is no intracranial hemorrhage seen.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
      • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • 2024-12-21 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2024-12-21 ECG
    • Sinus rhythm with 1st degree A-V block
    • Cannot rule out Anterior infarct, age undetermined
    • Nonspecific T wave abnormality
  • 2024-11-27 Bladder Sonography
    • PVR: 63.23 mL
  • 2024-11-26 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 36) / 110 = 67.27%
      • M-mode (Teichholz) = 67
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Dilated RA; normal RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
  • 2024-11-25 Portable 24hr ECG
    • Baseline was sinus rhythm with 1st degree AVB
    • Rare isolated VPCs
    • Rare isolated APCs / APC couplet
    • 1 episode of short-run AT, 5 beats
    • No long pause
  • 2024-11-20 SONO - abdomen
    • Finding
      • Liver
        • Smooth liver surface without definite lesion. Several small anechoic lesions up to 1.5 cm over both lobe of liver. A 0.7 cm hypoechoic mass at rt ant seg.
      • Bile duct and gallbladder:
        • Small stones noted at GB
    • Diagnosis:
      • Gall stones
      • Liver cysts, multiple
      • Hepatic tumor, small
  • 2024-08-07 Bladder Sonography
    • PVR: 195 mL
  • 2024-07-28 CT - brain
    • No definite intracranial hemorrhage
    • Old lacune, brain atrophy, and intracranial atherosclerotic disease

[MedRec]

  • 2025-01-05 Attending Doctor Note on Admission Day
    • An 89-year-old male with a significant medical history, including hypertension, coronary artery disease (status post percutaneous coronary intervention with one stent placement at Cathay Hospital in 2018), atrial fibrillation with rapid ventricular response (managed with amiodarone and dabigatran), chronic kidney disease, degenerative lumbar spondylosis (status post posterior decompression and pedicle screw instrumentation with posterolateral fusion and vertebroplasty), dementia, benign prostatic hyperplasia, and a prosthetic left knee infection previously treated with Curam 625 mg twice daily for four weeks, presented with progressive lethargy.
    • The patient had been experiencing lethargy for three weeks, with worsening symptoms over the past week, including general weakness, easy fatigue, and dysphagia. He sought evaluation at the hematology outpatient clinic on 2025-01-03 but subsequently came to the emergency department on 2025-01-04 due to further symptom progression.
    • On arrival at the emergency department, laboratory findings revealed the following abnormalities: Blood urea nitrogen (BUN): 55 mg/dL, Creatinine: 3.58 mg/dL, Glomerular filtration rate (GFR): 17.16 mL/min, Serum glucose: 125 mg/dL, Calcium: 3.29 mmol/L, Given the significant hypercalcemia of unknown etiology, the patient was admitted for further evaluation and management.
  • 2024-12-31 SOAP Cardiology Ke YuLin
    • Prescription x3
      • Lixiana FC (edoxaban 30mg) 0.5# QD 28D
      • Cordarone (amiodarone 200mg) 1# QD 28D
      • Diovan FC (valsartan 160mg) 0.5# BID 28D
      • Ulstop FC (famotidine 20mg) 0.5# QD 28D
      • Norvasc (amlodipine 5mg) 0.5# QD 28D
      • Atanaal (nifedipine 5mg) 1# ASORDER 28D PRN
      • Nebilet (nebivolol 5mg) 0.5# QD 28D
  • 2024-11-27 SOAP Urology Li MingWei
    • Prescription x3
      • Wecoli (bethanechol 25mg) 1# QDAC 28D
      • MgO 250mg 1# QD 28D
      • Harnalidge OCAS (tamsulosin 0.4mg) 1# QDAC 28D
  • 2024-11-27 SOAP Psychosomatic Medicin Wang ZongXi
    • Alpraline (alprazolam 0.5mg) 2# HS 28D
    • Alpraline (alprazolam 0.5mg) 1# PRNHS 28D
    • Eurodin (estazolam 2mg) 2# HS 28D
    • Seroquel XR (quetiapine 300mg) 0.5# HS 28D
    • Risperdal FC (risperidone 1mg) 0.5# BID 28D
  • 2024-11-26 SOAP Gastroenterology Chen JianHua
    • Prescription x3
      • Nexium (esomeprazole 40mg) 1# QDAC 28D
  • 2024-11-17 ~ 2024-11-21 POMR Gastroenterology Chen JianHua
    • Discharge diagnosis
      • Obscure gastrointestinal bleeding, favor new oral anticoagulants with Pradaxa related.
      • Acute posthemorrhagic anemia
      • Reflux esophagitis LA Classification grade A (minimal)
      • Colon stricture site without obvious mucosa lesion, ascending colon, ststus post biopsy
      • Gall stones
      • Hepatic tumor, small
      • Chronic ischemic heart disease with Pradaxa used.
      • Dementia without behavioral disturbance
      • Enlarged prostate without lower urinary tract symptoms
      • Essential (primary) hypertension
    • CC
      • Tarry and bloody stool for one day.    
    • Present illness history
      • This is a 89-year-old male with a past history of: 1. HTN; 2. CAD in 2018 s/p PCI with one stent at Cathay Hospital, under dabigatran; 3. Af with RVR, under amiodarone; 4. CKD; 5. Degenerative lumbar spondylosis, s/p PDPIPLF and VP; 6. Dementia; 7. BPH.
      • This time, he was admitted due to tarry and bloody stool for one day.
      • According to patient’s himdelf, family and previous medical record, patient’s ADL was partially independent (could walk with a walker). His family noticed that the patient had tarry with bloody stool this morning. Associated symtpoms were abdomimal fullness and poor appetite and general weakness for 2 days. There was no diarrhea, vomiting, dizziness, dyspnea, abdominal pain, fever, URI symptom or body weight loss.
      • Due to above problem, his family brought him to our ER for help. At ER, vital signs were T/P/R 35/92/20/BP: 91/45. PE revealed pale conjunctiva, no abdominal tenderness or rebounding pain. Lab: no leukocytosis (4120) with neutrophil predominant (80.1), no CRP elevation (0.9), decreased Hb (6.1), PT (14.2) and APTT (52.6) prolong.
      • Stool analysis: OB 3+, no pus cell. 2024/11/17 CXR: bil. diffuse infiltration increase. PE: no contributory finding.
      • Under the impression of GI bleeding, the patient was admitted to our ward for further evaluation and treatment.    
    • Course of inpatient treatment
      • After admission, hold Pradaxa first.
      • NPO with IV fluid suppplement and IV form PPI was given to correct GI bleeding. Blood transfution was given to correct anemia.
      • Abdominal sonography, upper GI endoscopy and colonscopy were all performed that showed reflux esophagitis LA Classification grade A (minimal); remnant gastritis on EGD; colonscopy revealed colon stricture site without obvious mucosa lesion, ascending colon, s/p biopsy.
      • Abdominal sonography showed gall stones; liver cysts, multiple and hepatic tumor, small. Explained this condition to his son and himself, they understood. Follow up hemogram that showed Hb stable. Under a stable condition, he was discharged on 2024/11/21 and further GI OPD was arranged later.
  • 2024-10-28 SOAP Dermatology Wang ChunHua
    • Prescription x3
      • Asthan (ketotifen 1mg) 1# BID 28D
      • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
      • Pilian (cyproheptadine 4mg) 1# HS 28D
      • Zalain Cream (sertaconazole nitrate 2%) BID TOPI 28D
      • betamethasone 4mg ST IM
  • 2024-05-12 ~ 2024-05-16 POMR Integrative Medicine Duan WeiLun
    • Discharge diagnosis
      • Calculus of gallbladder without cholecystitis without obstruction
      • Liver function impairment
      • Fever, unspecified
      • Low C3 and C4, cause unknown
      • Unspecified kidney failure
      • Increased lipase
      • Essential (primary) hypertension
      • Chronic ischemic heart disease, unspecified
      • Chronic obstructive pulmonary disease, unspecified
      • Enlarged prostate without lower urinary tract symptoms
      • Lumbar spondylosis i
    • CC
      • fever, headache, eneralized arthralgia, body aches, cough, and sort throat for two days
    • Present illness history
      • A 88-year-old male has a medical history of hypertension, coroanry artery disease post stent, atrial fibrillation, chronic obstructive pulmonary disease, peptic ulcer, benign prostatic hyperplasiam, L1 compression fracture, and dementia; no history of allergy, travel, contact or cluster recently.
      • He sometimes choked when eating before, nasogastric tube placement was recommend, he and his son both refused, and he denied easy choking now. This time, he had fever, headache, eneralized arthralgia, body aches, cough, and sort throat for two days, he was brough to out hospital, the temperature 37.5’C, the pulse 75 beats per minute, the blood pressure 104/54 mmHg, the respiratory rate 18 breaths per minute, and the oxygen saturation 97%, E4V5M6, the physical examination showed no injected throat, pale conjunctiva, symmetrical breath without coarse or wheezing sounds, soft abdomen without tenderness, no edema.
      • A blood serum tests showed leukocytosis, impaired renal function, elevated c reactive protein and alanine aminotransferase. Chest x ray showed increase bilateral lung markings and blunting of left costophrenic angle. Brosym was given, he was hospitalized on 2024-05-12.
    • Course of inpatient treatment
      • In the ward, he received the empirical antibiotic treatment with brosym (2024/05/12 ~ 2024/05/16) plus doxycycline (2024/05/14 ~ 2024/05/16) for infection control, vitamin with phytonadione for coagulation (used brosym), antipyretic and analgesic with acetaminophen for fever and pain relief, expectorant with actein for phlegm, laxatives with bisacodyl suppositorie for constipation, silymarin for liver function impairment, and wound care with neomycin ointment.
      • Previous regular outpatient clinic medications were continued, including amiodarone, pradaxa, famotidin, harnalidge, and diovan; then the actein and diovan were discontinued. The sputum culture showed mixed normal flora.
      • The abdomen echo showed gall bladder stone and common hepatic duct dilatation. The blood serum tests showed low C3 and C4, abnormal antinuclear antibodies and high lipase. He wanted to early discharged, explained the current condition and the risk of early discharged, he was discharged on 2024-05-16, cefixime plus doxycycline were prescribed to him back home.
    • Discharge prescription
      • Ceficin (cefixime 100mg) 1# Q12H 7D
      • doxycycline 100mg 1# Q12H 7D
      • Acetal (acetaminophen 500mg) 1# PRNQ8H 3D
  • 2023-05-19 ~ 2023-05-31 POMR Chest Medicine Chen XinYi
    • Discharge diagnosis
      • Other pneumonia, unspecified organism
      • Chronic obstructive pulmonary disease with (acute) exacerbation
      • Acute on chronic diastolic (congestive) heart failure
      • Essential (primary) hypertension
      • Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris
      • Paroxysmal atrial fibrillation with rapid ventricular rate
      • Chronic corditis
    • CC
      • chest pain and epigastric for 3 days.
    • Present illness history
      • This 87-year-old man has past history of COPD, CAD s/p stent. pulmonary TB, dementia, GU s/p OP years ago.
      • This time, he suffered from chest pain and epigastric for 3 days. He denid tarry stool, but tarry stool was noted 1 month ago.
      • Therefore, he came to our ED for help. At ED, his vital sign was BP 135/62; TPR 37.7/112/18. Con’s E4V5M6; SpO2 97%. Lab data showed leukocytosis with elevated CRP, elevated BUN/Cre, mild normocytic anemia. CXR showed Ground glass opacities in bil. lungs. Normal appearance of trachea and bil. main bronchus. Cardiomegaly. Non-specific small bowel and colon gas pattern. KUB plain film shows Non-specific small bowel and colon gas pattern.
      • Abdominal CT showed Pericardial effusion. Some LNs at mediastinum. Some nodules (up to 2.5cm) in both kidneys. A GGO (1.5cm) at RML. A patchy density (1.3cm) at RUL. Empirical antibiotic with cravit was given.
      • Under the impression of bilateral pneumonia, he was admitted to chest ward for further treatment
    • Course of inpatient treatment
      • After admission, atrial fribillation was noted.
      • Cordarone pump was perscribed on 2023/05/22, and then tappered to Cordarone PO 1#QD since 2023/05/24. However, intermittent atrial fribillation was still noted, thus it was added to 1#BID.
      • Intermittent choking was also noted since admission. We suggested the patient NG tube insertion for many times for preventing choking episode and nutrition support, but the patient and his son refused it.
      • The followed-up CXR on 2023/05/25 showed deteriorated. We suggested the NG tube insertion, but they still refused it.
      • After treatment. the followed-up CXR on 2023/05/30 showed improvement. Under relative stable condition, he was discharged on 2023/05/31.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID 9D
      • Asthan (ketotifen 1mg) 1# BID 9D OPD drug
      • Cordaron (amiodarone 200mg) 1# BID 9D
      • Harnalidge OCAS (tamsulosin 0.4mg) 1# HS 9D self-carried drug
      • Through (sennoside 12mg) 2# PRNHS 9D OPD drug if constipation
      • Mycomb Cream (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI 9D OPD drug
      • Spiriva Respimat (tiotropium 2.5ug/puff) 2puff QD INHL 9D OPD drug
      • Zalain External Gel (sertaconazole 2%) Q3D EXT 9D OPD drug
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if BT > 38’C
      • Alpraline (alprazolam 0.5mg) 2# PRNHS 9D OPD drug
      • Cartil (diltiazem 30mg) 1# TID 9D
      • Eurodin (estazolam 2mg) 2# HS 9D OPD drug
      • Lixiana FC (edoxaban 30mg) 1# QD 9D
      • Sinpharderm Cream (urea) BID TOPI 9D OPD drug
      • Symbicort Rapihaler (budesonide, formoterol) 2puff BID inhl 9D self-carried drug

==========

2025-01-06

[Patient Summary]

This is an 89-year-old male with a complex medical history, including chronic kidney disease (CKD), hypertension, atrial fibrillation (AF) on anticoagulation therapy, coronary artery disease (CAD) post-stenting, degenerative lumbar spondylosis post-instrumentation, dementia, benign prostatic hyperplasia (BPH), and recurrent gastrointestinal (GI) bleeding. He was admitted on 2025-01-04 for progressive lethargy, worsening general weakness, and severe hypercalcemia of unknown etiology (2025-01-04 lab: Ca 3.29 mmol/L).

He has ongoing complications from multiple systems, including probable sensorimotor polyneuropathy and radiculopathy based on nerve conduction studies and evoked potential tests (2024-12-31). Imaging reveals chronic changes, including cortical atrophy, ischemic brain changes, and cardiomegaly with pulmonary congestion. Current treatments focus on managing his chronic atrial fibrillation, hypertension, and renal dysfunction, while addressing recurrent bleeding episodes related to anticoagulation.

[Problem Comments]

Problem 1. Hypercalcemia of Unknown Etiology

  • Objective:
    • Serum Calcium: Persistently elevated at 3.29 mmol/L (2025-01-04), decreased to 2.64 mmol/L by 2025-01-06.
    • Albumin: 3.5 g/dL (2025-01-06); minimal correction needed for calcium.
    • Historical hypercalcemia: No prior significant records of hypercalcemia.
    • Associated symptoms: Lethargy, weakness, dysphagia (2025-01-04).
  • Assessment:
    • Likely primary hyperparathyroidism or malignancy-associated hypercalcemia (e.g., multiple myeloma, metastasis, or PTHrP-related mechanisms).
    • Possible secondary contribution from chronic kidney disease (reduced renal clearance of calcium/phosphorus) and/or immobilization.
    • Recent lab (2024-12-31): PTH 9.19 pg/mL—low normal, inconsistent with primary hyperparathyroidism.
    • Imaging: CT brain (2024-12-21) showed ischemic infarcts but no suspicious mass or metastasis.
    • Serum phosphorus levels and other cancer-related markers pending.
  • Recommendations:
    • Workup:
      • Serum PTHrP, vitamin D, and phosphorus levels to differentiate causes.
      • Skeletal survey or PET-CT to rule out malignancy-related causes (e.g., multiple myeloma, bone metastasis).
    • Acute Management:
      • Continue hydration to enhance calcium excretion.
      • Initiate calcitonin or bisphosphonate therapy if calcium levels remain >3.0 mmol/L.
      • Consider corticosteroids if sarcoidosis or other granulomatous disease is suspected.

Problem 2. Progressive Chronic Kidney Disease

  • Objective:
    • Creatinine: 3.07 mg/dL (2025-01-06); historically worsening from 1.51 mg/dL (2024-11-22).
    • eGFR: Declined to 20.49 mL/min/1.73m² (2025-01-06) from 54.76 mL/min/1.73m² (2024-11-21).
    • Contributing factors: Persistent hypertension, recurrent GI bleeding, and nephrotoxic drugs (e.g., Cordarone (amiodarone)).
    • No prior renal biopsy or nephrology intervention documented.
  • Assessment:
    • Progressive Stage 4 CKD, likely multifactorial (chronic hypertension, ischemic nephropathy, and possibly recurrent acute kidney injuries from GI bleeding or dehydration).
    • Likely suboptimal volume management in the context of diuretics and potential hypoperfusion episodes.
  • Recommendations:
    • Workup:
      • Monitor serum potassium, phosphorus, and bicarbonate for metabolic derangements.
      • Evaluate for possible biopsy or advanced planning for renal replacement therapy.
    • Management:
      • Optimize blood pressure control with ARB or ACE inhibitors (Diovan is in use currently) while avoiding nephrotoxic agents (e.g., NSAIDs).
      • Manage anemia of CKD with erythropoietin-stimulating agents if Hb <10 g/dL persists.
      • Continue renal-friendly diet (low phosphorus, low potassium).

Problem 3. Atrial Fibrillation and Anticoagulation in Context of Recurrent Bleeding

  • Objective:
    • Anticoagulation history: Currently on Lixiana (edoxaban) and previously on Pradaxa (dabigatran).
    • Recurrent bleeding episodes:
      • 2024-11-17: Tarry stool, Hb 6.1 g/dL, PT/APTT prolongation, anticoagulation held.
      • 2024-11-27: Hemoglobin stabilized post-transfusion and supportive measures.
    • Imaging: CT brain (2024-12-21) revealed ischemic changes, no intracranial hemorrhage.
  • Assessment:
    • High risk of recurrent bleeding from GI and age-related vascular fragility.
    • Stroke risk remains high with CHA₂DS₂-VASc score ≥6, necessitating anticoagulation.
    • Current bleeding appears stable with no active symptoms.
  • Recommendations:
    • Risk-Benefit Review:
      • Multidisciplinary discussion (cardiology, hematology, gastroenterology) to determine the safest anticoagulation regimen.
      • Consider Left Atrial Appendage Occlusion (LAAO) if anticoagulation contraindicated.
    • Further Workup:
      • Repeat upper GI endoscopy and colonoscopy to identify treatable sources of bleeding.
      • Evaluate for iron studies and fecal occult blood test to guide long-term anemia management.

Problem 4. Neurodegenerative Progression and Polyneuropathy

  • Objective:
    • Neurological studies (2024-12-31):
      • Abnormal SSEP and MEP studies suggest sensorimotor polyneuropathy and radiculopathy in upper and lower limbs.
    • Clinical symptoms: Generalized weakness, easy fatigue, and history of gait instability (partially ambulatory with walker).
  • Assessment:
    • Likely multifactorial etiology (age-related degeneration, chronic ischemia, and possible vitamin B12 deficiency).
    • Imaging and neurophysiology correlate with cervical and lumbar radiculopathy.
  • Recommendations:
    • Workup:
      • Screen for vitamin B12, folate, and thyroid function.
      • MRI of the cervical/lumbar spine if significant radiculopathy symptoms persist.
    • Management:
      • Continue physiotherapy and occupational therapy to optimize functional status.
      • Address pain management with neuropathic pain medications (e.g., Lyrica (pregabalin)).

700179585

240105

[History]

  • Left iavasive ductal carcinoma of breast (2023/09/21): Femara and Palbociclib
  • Infiltrating tubulolobular carcinoma (2006): chemotherapy, radiotherapy (21 times) and tamoxifen

[exam findings]

  • 2023-12-30 CXR supine
    • S/P PICC catheter insertion via right forearm.
    • Pleura effusion of right and left costal-phrenic angle
    • S/P pigtail catheter implantation at bilateral CP angle.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-12-29 SONO - chest
    • Right massive pleural effusion post pig-tail insertion.
  • 2023-12-22 MRI - brain
    • No evidence of brain metastasis. Cerebral white matter T2-hyperintensities, stationary as compared with scan MRIs.
  • 2023-12-20 SONO - chest
    • Pleural effusion, moderate, left
    • Pleural effusion, moderate, oragnized, right
    • Atelectasis, LLL, RLL
    • Pleural thickening, diffuse
  • 2023-12-15 Tc-99m MDP bone scan
    • Increased activity in the middle and lower T-spines, L3-5 spines and bilateral S-I joints. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-12-14 CXR
    • S/P PICC catheter insertion via right forearm.
    • Pleura effusion of right and left costal-phrenic angle
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2023-12-14 Cardiac Catheter
    • SvO2 was also check, it revealed 76 %.
    • Estimated Fick Cardiac index 2.44 L/min/m2 (normal cardiac index range 2.6~4.2 L/min/m2)
    • Estimated Fick cardiac output 3.88 L/min. (nomral cardiac output range 5~6 L/min)
  • 2023-12-14 SONO - chest
    • Pleural effusion, moderate and organized, right
    • Pleural effusion, moderate, left
    • Atelectasis, RML, RLL and LLL
    • Lung nodule, left
    • Pleural thickening, bilateral
  • 2023-12-12 CXR erect
    • Rt greater than Lt, large volume of bilateral pleural effusions
    • Regression of Rt pleural effusion s/p thoracocentesis
    • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
  • 2023-12-12 CT - chest
    • without contrast enhancement, coronal and sagittal reconstructed images shows:
      • large volume of bilateral pleural effusions.
      • lungs: partial posterior atelectasis of both lower lobes.
        • mild interstitial and alveolar lung edema at nondependent LUL, RML, and RUL r/o lymphangitic infiltration.
      • Mediastinum and hila: no enlarged LN or mass.
      • Thoracic aorta: normal caliber,
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers.
      • Chest wall and visible lower neck: absence of Rt breast,
        • skin thickening over left breast, anterior chest wall.
      • Visible abdominal-pelvic contents: Rt renal stone measuring 0.4cm.
      • Visualized bones: small blastic change in multiple vertebrae, may be bony metastasis
  • 2023-12-12 ECG
    • Sinus tachycardia
    • Cannot rule out Inferior infarct, age undetermined
    • Possible Anterior infarct, age undetermined
  • 2023-12-12 CXR erect
    • Rt greater than Lt, moderate bilateral pleural effusions
    • Consolidation and volume reduce over lower lung zones dependent lung parenchyma.
    • elongated and tortuosity of thoracic aorta
  • 2023-12-12 SONO - chest
    • Right thorax: large amount, septated pleural effusion s/p drainage twice; total 250cc yellowish fluid was drained.

[chemotherapy]

  • 2024-01-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-21 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-12-15 - gemcitabine 800mg/m2 1200mg NS 250mL 30min (Gemzar weekly)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

700712591

240105

[lab data]

2023-12-05 EBV DNA quantative PCR <35 IU/mL
2023-12-04 HCV RNA-PCR quantative Target Not Detected IU/mL

2023-11-28 HBsAg Nonreactive
2023-11-28 HBsAg (Value) 0.35 S/CO
2023-11-28 Anti-HCV Reactive
2023-11-28 Anti-HCV Value 14.16 S/CO
2023-11-28 Anti-HBc Nonreactive
2023-11-28 Anti-HBc-Value 0.21 S/CO
2023-11-28 Anti-HBs 1.51 mIU/mL

[exam findings]

  • 2024-01-03 Pap Smear
    • Moderate dysplasia (CIN2)
  • 2024-01-03 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 39 dB HL; LE 38 dB HL.
    • RE normal to moderate mixed type HL.
    • LE normal to moderately severe mixed type HL.
  • 2023-11-30 PET scan
    • Glucose hypermetabolism involving the nasopharynx, more prominent at the right side. Primary nasopharyngeal malignancy may show this picture.
    • Glucose hypermetabolism in a left retropharyngeal lymph node. Metastatic lymph node may show this picture.
    • Mild Glucose hypermetabolism in some bilateral neck level II and right neck evel Ib lymph nodes. The nature is to be determined (inflammation? metastatic lymph nodes of low FDG uptake?). Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in some focal areas in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG uptake may show this picture.
  • 2023-11-29 MRI - nasopharynx
    • Indication: NPC
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • abnormal thickening of bilateral nasopharyngeal mucosa, especially on right side, compatible with nasopharyngeal carcinoma (NPC). There is no involvement to parapharngeal space, nor pterygoid and prevertebral muscles. T1 disease is favored.
      • enlarged lymph nodes at bilateral retropharyngeal spaces, bilateral level Ib and II, compatible with N2 disease.
    • Impression:
      • NPC, T1N2.
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-11-17 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopahrynx, right, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stain: CK (+).
  • 2023-11-17 Nasopharyngoscopy
    • Findings
      • Some clear mucus content at nasopharynx, right nasopharyngeal Rosenmullar fossa
      • smooth oropharynx, hypopharynx and patent airway.
    • Dx, Conclusion
      • Postnasal dripping.
      • right nasopharyngeal lesion, r/o cyst or tumor

[MedRec]

  • 2023-11-28 ~ 2023-11-30 POMR Ear Nose Throat Huang TongCun
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, cT1N2M0, stage III
    • CC
      • Lumping throat, dry cough, easy choking for 2 months
    • Present illness
      • This 72-year-old woman was a HCV carrier for more than 10 years. Lumping throat, dry cough, and easy choking were noted for 2 months and worsened recently. Hoarseness was noted too. She denied alcohol drinking, smoking and betel nut chewing. Neigher body weight loss nor poor appetite were noted. She went to our ENT OPD for help. Physical exam showed right nasopharyngeal smooth bulging tumor at Rosenmuller fossa and no neck mass. Fiberscopic exam showed smooth oropharynx and hypopharynx.
      • Biopsy of the tumor was done, and the pathology report revealed non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B). Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of nasopharyngeal cancer, the patient was admitted for cancer work-up.        
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up.
      • Nasopharyngeal MRI showed nasopharyngeal carcinoma T1N2M0, stage:III.
      • Abdominal sonography showed gall stones and GB slugde.
      • PET was done and the result was pending.
      • GI man was consulted for HCV, and check a-Fetoprotein and HCV RNA PCR quantative was suggested.
      • Under relative stable condition, the patient was dishcarged with OS/ Dental/ ENT OPD follow up.     

[radiotherapy]

  • 2023-12-07 SOAP Radiation Oncology Huang JingMin
    • S: For CCRT due to nasopharyngeal carcinoma.
      • PI: Incidental finding nasopharyngeal tumor at TuCheng Hospital. nasopharyngeal carcinoma was proved at our hospital. Due to old age, CCRT then C/T was suggested by medical oncologist.
      • Family history: (mother: nasopharyngeal carcinoma)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • A:
      • Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B) of the nasopharynx, stage cT1N2M0.
    • P: CCRT then adjuvant chemotherapy is indicated for this patient with the following indicators: NPC, stage cT1N2M0. The medical oncologist opinion: Due to old age, suggest CCRT then C/T.
      • Goal: curative
      • Treatment target and volume: nasopharyngeal tumor to bilateral neck
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the nasopharyngeal to bilateral neck, and 7000cGy/35 fractions of the nasopharyngeal tumor to involed neck nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2023-12-13.
      • According to the patient and her family statement, the pre-RT dental evaluation: no dental extraction.
  • 2023-11-30 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S
      • Ask for oral examination
      • pre-CCRT dental evaluation
    • O
      • Panoramic findings:
        • Missing: 16,17,2427,3537,46,47
        • Impaction: nil
        • Crown and Bridge: 13,14,42X31-32,43X45
        • Caries: nil
        • retained root:23
        • Periodontal condition: chronic periodontitis
      • multiple questionable teeth were present
    • A/P
      • Take panoramic film for evaluation
      • Explain the findings and treatment plan to the patient (multiple teeth might be extracted for prevention).
      • patient understands but chose to receive CCRT first.

[chemotherapy]

  • 2024-01-05 - cisplatin 40mg/m2 64mg NS 500mL 2hr + NS 1000mL 2hr (Y-sited with cisplatin) (CCRT. Xia HeXiong)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700039857

240104

[exam findings]

  • 2023-11-03 MRI - nasopharynx
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 1(T_value) N: 0(N_value) M: 0(M_value) STAGE: I(Stage_value)
  • 2023-10-30 Patho - larynx biopsy
    • Labeled as “Arytenoid and aryepiglottic fold uneven mucosal surface, left”, LMS biopsy — squamous cell carcinoma in situ (CIS)
    • Section shows squamous cell carcinoma in situ (CIS).
  • 2023-10-27 Bronchodilator Test
    • poor done, difficult interpretation
    • Mild restrictive ventilatory impairment
    • with response to bronchodilator, AHR or learning effect?
  • 2023-10-26 Miniprobe Endoscopic Ultrasound
    • Diagnosis:
      • Esophageal cancer, cT3NxMx, upper to lower esophagus
      • Rule out left dysplastic arytenoid cartilage mucosal lesion
      • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
      • Superficial gastritis and atrophic gastritis
    • Suggestion:
      • Consider to consult ENT for left arytenoid cartilage mucosal lesion biopsy
      • Pursue the pathology report
  • 2023-10-25 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-10-24 PET
    • Glucose hypermetabolism in the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Mild glucose hypermetabolism in three adjacent lymph nodes. Metastatic lymph nodes of low FDG uptake can not be ruled out. Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in a right supraclavicular lymph node. A metastatic lymph node may show this picture.
    • Glucose hypermetabolism in the region about the left posterior aspect of the cricoid cartilage. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumultion in both kidneys. Physiological FDG accumulation may show this picture.
  • 2023-10-23 MRI - brain
    • Old lacunes in bilateral basal ganglia. Cerebral small vessel disease. General brain atrophy. Venous angioma in left cerebellum.
  • 2023-10-21 CT - chest
    • Indication: Esophageal cancer survey
    • Chest CT with and without IV contrast ehnancement shows:
      • Wall thickening at middle third esophagus measuring 5.5cm in largest dimension. Regional lymph nodes (n=4) is found.
      • Some reticulation at right lower lobe is found. Previous aspiration is considered.
      • Bilateral renal cysts are found. Polycystic disease is considered.
    • Imp:
      • Compatible with esophageal cancer with regional lymph nodes. No evidence of distant meta.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-10-16 Patho - stomach biopsy
    • Esophagus, 30 cm to 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells.
  • 2023-10-16 EGD
    • Diagnosis:
      • Esophageal polypoid lesion, 30cm to 33cm below incisors, s/p biopsy (B)
      • Gastric mucosal lesion, upper body, GC, s/p biopsy (A)
      • Mucosal lesion, left arytenoid cartilage.
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis and atrophic gastritis
    • Suggestion:
      • ENT OPD for mucosal lesion, left arytenoid cartilage.
      • Pursue pathology report
  • 2023-10-16 SONO - abdomen
    • R/o polycystic kidney disease

[MedRec]

  • 2023-12-15 SOAP Radiation Oncology Wang YuNong
    • S
      • Diagnosis:
        • Esophageal ca, cT3N2M0
        • Hypopharygneal ca, cT1N0M0.
      • However, the Rt SCF LAP could be counted as from hypopharynx, and the staging won’t be the same.
      • CC: can’t swallow saliva.
    • O
      • Since 2023-12-08 RT to the hypophayrnx and bil. neck: 12 Gy/ 6 fx. The esophagus and adjacent lymphatic drainage area: 10.8 Gy/ 6 fx.
      • Chest CT showed esophageal cancer, middle third, cT2N2M0
      • 2023-10-26) EUS showed:
        • Esophageal cancer, cT3NxMx, upper to lower esophagus
        • Rule out left dysplastic arytenoid cartilage mucosal lesion
        • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
    • Plan:
      • RT to the hypopharynx and bil. neck: 50 Gy/ 25 fx.
      • The hypopharyngeal tumor and Rt SCF LAPs: 70 Gy/ 35 fx.
      • The esophagus and adjacent lymphatic drainage area: 45 Gy/ 25 fx.
      • The esophageal tumor: 50.4 Gy/ 28 fx.
  • 2018-01-12 SOAP Orthopedics Lin KunHui
    • diagnosis
      • Synovitis and tenosynovitis, unspecified [M65.9]
      • Olecranon bursitis [M70.22]

[consultation]

  • 2023-11-02 Oral and Maxillofacial Surgery
    • Q
      • for perpare CCRT evaluation
      • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB & hypophargenal cancer (SCC). We need expertise to evaluate his condition thanks!
    • A
      • This is a 68-year-old male patient recently diagnosed with esophageal cancer and laryngeal cancer and is scheduled for concurrent chemoradiotherapy, and we were consulted for pre-CCRT dental evaluation.
      • O:
        • Full mouth multiple residual roots and severe periodontitis was noted.
        • Poor oral hygiene was noted.
        • Multiple caries was revealed by radiographic examination.
      • P:
        • Explained the findings and treatment plan to the patient and his family.
        • Suggest extraction of tooth 16, 24, 26, 34, 42, 43
        • Patient wanted to consider.
  • 2023-10-26 Radiation Oncology
    • Q
      • This 68-year-old man, had past history of hypertension and a smoker.
      • He had suffered from dysphagia for solid material with sorethorat for 1~2 months, associated with body weight loss 13~14 kg in 2-3 month.
      • He came to GI OPD and done PES and biopsy showed esophageal cancer, SCC.
      • This time, he admission for esophageal cacner staging.
      • Chest CT show esophageal cancer, middle third, cT2N2M0
      • Arrange on port A and jejunostomy on 10/30.
      • We would like to consult for CCRT further treatment. Thank you.
      • Sincerely request your help to evaluate and manage this patient.
    • A
      • 2023-10-26 EUS showed:
        • Esophageal cancer, cT3NxMx, upper to lower esophagus
        • Rule out left dysplastic arytenoid cartilage mucosal lesion
        • Gastric mucosal lesions, rule out gastric cancer, upper body, GC, s/p biopsy
      • In consideration of the possiblity of hypopharyngeal ca. and gastric ca., I will follow up the biopsy result (Lt hypopharynx and stomach) next Monday (10/30) and discuss the treatment plan with medical oncologist Dr. Hsia accordingly. Thank you very much.
  • 2023-10-26 Hemato-Oncology
    • Q
      • This 68 year old man is a case of Squamous cell carcinoma of esophageal cancer, middle third, moderately differentiated, cT2N2M0, stage IIIB. He will received port A insertion and jejunostomy on 2023/10/30. We are consulted for CCRT.
      • Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
      • We will disucss with patient about CCRT with PF. Thanks for your consultation.

[surgical operation]

  • 2023-10-30
    • Surgery: Laryngomicrosurgery    
    • Finding: Left arytenoid and AE fold uneven mucosal surface
  • 2023-10-30
    • Surgery: Feeding jejunostomy + port-A insertion.
    • Finding
      • 8.0 Fr. Polysite, left cephalic vein, cut-down method.
      • 18 Fr. silicon Foley catheter as jejunostomy tube.

[chemotherapy]

  • 2023-12-18 - NS 500mL 2hr (before CDDP) + cisplatin 75mg/m2 110mg NS 500mL 4hr + NS 500mL 2hr (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2024-01-04

The patient is properly hydrated and Cefim (cefepime) has been dose adjusted for the patient’s renal function. G-CSF (filgrastim) is used for neutropenia. No medication discrepancies are found.

2023-12-19

The entirety of the oral medications listed on the active medication list are compatible with enteral feeding administration.

2023-11-06

All of the oral drugs on the list of active medications can be fed by tube.

700175387

240104

[exam findings]

  • 2024-01-01, 2023-12-11 KUB

    • Scoliosis of the L-spine with convex to right side.
    • Wedge deformity at right lateral aspect of L2 vertebral body is noted.
  • 2023-12-12 MRI - brain

    • Old lacuna infarcts over right putamen and inferior capsule.
    • One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study.
  • 2023-10-20 Patho - bone exostosis

    • Labeled as “L4 spine”, CT guided biopsy — diffuse large B cell lymphoma, non-germinal center type.
    • Section shows tissue diffusely infiltrated by diffuse large B cell lymphoma, non-germinal center type.
    • IHC stais: CD3 (focal +), CD20 (-), CD20 repeat stain: (-), CD79a (diffuse +), PAX5 (diffuse +), bcl-2 (+), bcl-6 (+) MUM-1 (+, > 30%), C-myc (-), Ki-67 (90%), CD23 (-), cyclin-D1: (-).
  • 2023-10-18 Nerve Conduction Velocity, NCV

    • Findings
      • Prolonged distal latenies in bilateral medial and ulnar CMAPs. Decreased amplitudesin all sampling CMAPs. Slowed CNVs in right medial, bilatal ulnar, peroneal and tibial CMAPs.
      • Proloned distallatencies and slowed NCVs in bilateral medial, ulnr and sural sNAPs.
      • Prolonged f-wave latencies followed all sampling nerve stimulations.
      • Absence of H-refelx peaks followed bilatral tibial nerve stimulations.
    • Conclusions
      • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy superiposed polyradiculopathy.
  • 2023-10-17 PET

    • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV).
    • In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared. However, more new FDG avild lesions are noted.
  • 2023-10-16 CT - chest

    • Indication: Diffuse large B-cell lymphoma, extranodal and solid organ sites
    • Findings:
      • Lungs: dependent band subsegmental consolidation or atelectasis at Rt lower lobe.
      • Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. enlarged LNs at Rt supraclavicular fossa.
      • Mediastinum and hila: no enlarged LN or mass.
        • mild coronary arterial calcification
      • Thoracic aorta: normal caliber, mild atherosclerotic change of Heart: normal size of cardiac chambers.
      • Pleura: no effusion but Rt posterior pleural thickeing.
      • Visible abdominal-pelvic contents: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles.
        • a 13mm low attenuation in the spleen.
        • mild soft tissue lesion in para-aortic and para-cava spaces stationary
        • unremarkable of the liver, GB, both adrenal glands, pancreas, and both kidneys.
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Diffuse large B-cell lymphoma, in both sites of diaphgram with extranodal and solid organ sites.
  • 2023-10-14 MRI - L-spine

    • Indication: Diffuse large B cell lymphoma, non- GCB, stage III, S/P chemotherapy with R-CHOP
    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
      • Abnormal abundant soft tissue in right low parasinal and psoas muscle regions.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Dilated right ureter, likely due to tumor obstruction.
      • A small focal right L4 body leison.
      • Thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration?
      • Correlation with previous imaging study for comparison is suggested.
  • 2023-10-13 L-spine AP + Lat. (including sacrum)

    • Scoliosis of the L-spine with convex to right side.
    • Wedge deformity at right lateral aspect of L2 vertebral body is noted. Please correlate with clinical symptom and history.
  • 2023-10-12 MRI - brain

    • Imaging finding:
      • Old lacuna infarcts over right putamen and internal capsule.
      • The size of the cerebral ventricles is normal.
      • There is no space occupying lesion in the brain or midline shift of the brain supratentorially or infratentorially.
      • The intracranial vessels are normally signal-void.
      • The paranasal sinuses and mastoid air cells are aerated.
      • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
      • 3D TOF MR angiography of circle of Willis reveals no aneurysm or vascular malformation. The intracranial vessels in the territories of anterior, middle and posterior cerebral arteries and vertebro-basilar arteries are of normal in calibres and flows. No focal stenosis is identified.
    • Impression:
      • Old lacuna infarcts over right putamen and internal capsule.
  • 2023-10-12 CT - brain

    • Mild cortical brain atrophy. Old right putamen-corona radiata infarct. Abnormal abundant soft tissue mass? in left skull base, anterior lateral C1 region, nature?
    • With abnormal soft tissue in left anterior lateral skull base/C1 region, nature?
  • 2023-10-06 Nasopharyngoscopy

    • B cell lymphoma
    • left neck mass, progressive recent weeks
  • 2023-10-06 SONO - ENT head and neck soft tissue

    • Clinical Impression/Intent: LEFT NECK MASS LEVEL II
    • Sonographic Impression: LEFT NECK LEVEL II MULTIPLE LAP, ROUND NO CENTRAL HILUM, R/O MALIGNANCY
  • YYYY-MM-DD many omitted …

  • 2022-09-30 KUB

    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2022-09-19 CXR

    • Blunted bilateral CP angle is found.
  • 2022-09-16 Whole body PET scan

    • The FDG PET findings are compatible with lymphoma involving the huge confluent soft tissue masses in the retroperitoneal space, stomach, multiple focal areas in the abdominal and pelvic cavities and some focal areas in the mediastinum. Please correlate with other clinical findings for further evaluation.
  • 2022-09-09 CT - abdomen

    • Findings:
      • There is huge confluent soft tissue masses in retroperitoneal space with total encasement of celiac trunk, superior mesenteric artery, abdominal aorta, and bilateral renal artery. The largest cranial-caudal dimension of this mass measuring 19 cm in size.
        • In addition, There are multiple enlarged nodes in the omentum, mesentery, gastrohepatic ligament, para-aortic space, bilateral common iliac chain.
        • Malignant lymphoma is highly suspected.
      • There is mild ascites in the pelvis.
      • There are minimal pleura effusion in bilateral posterior basal CP angle.
    • Impression:
      • Malignant lymphoma is highly suspected.
        • CT-guided biopsy is indicated.
  • 2022-09-08 Patho - stomach biopsy

    • Stomach, AW of low body, biopsy — Diffuse large B cell lymphoma, non- GCB
    • Histology type: B-cell neoplasms — Diffuse large B-cell lymphoma (any subtype)
    • Immunohistochemical stain profiles: Ki-67 index: 90%, CK(-), CD20(+), CD3(-, immunoreactive at background T cells), CD10(focal +), MUM-1(+), Bcl-2(+), CD23(-), CD5(focal+), C-myc (-, < 30%), cyclin D1(-).
  • 2022-09-08 Esophagogastroduodenoscopy, EGD

    • Highly suspected gastric cancer, Borrmann type III, AW of low body, s/p biopsy
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, s/p CLO test
    • Pseudodiverticula and deformed bulb
  • 2022-09-08 SONO - abdomen

    • Finding: A huge retroperitoneal lesion measured at least 13 cm was noted.
    • Diagnosis: Retroperitoneal tumor, huge
  • 2022-09-02 ECG

    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2021-10-12, 2020-11-02 SONO - neurology

    • Mild atheromatous lesions in R subclavian artery.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor temporal windows for transcranial insonation.
  • 2019-12-02 Carotid phonoangiograph, CPA

    • Sonographic diagnosis:
      • Mild atheromatous lesions in R distal CCA.
      • Normal extracranial carotid, vertebral, and L intracranial basal cerebral arterial flows.
      • Poor R temporal windows for transcranial insonation.

[MedRec]

  • 2017-03-22 SOAP Neurology Xiao ZhenLun
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.511]
      • Essential hypertention, unspecified [I10]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription x3
      • Romicon-A (dextromethorphan, cresolsulfonate, lysozyme) 1# TID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mefno (mephenoxalone 200mg) 1# BID
      • Tonec (aceclofenac 100mg) 1# BID
      • Pentop (pentoxifylline 400mg) 1# BID
      • Robestar (rosuvastatin 10mg) 1# QD
      • Uformin (metformin 500mg) 0.5# BIDCC
      • Bokey (aspirin 100mg) 1# QD

[consultation]

  • 2023-12-14 Rehabilitation
    • A
      • P
        • Rehabilitation programs: arrange bedside PT and OT rehabilitation programs.
        • Goal: recondition; maintain ROM; improve endurance and muscle strength.
  • 2023-12-12 Radiation Oncology
    • Q
      • for radiotherapy evaluation
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints edema at left eye, and Diplopia noted for 2 days, follow-up brain MRI (2023/12/12) revealed 1. Old lacuna infarcts over right putamen and inferior capsule. 2. One lobulated mass lesion (40.8mm) over left carotid space, encasement of ICA and ECA. R/O neurogenic tumor or enlarged nodes or metastatic lesion. Suggest check enhanced study, so we need your help for radiotherapy evaluation, thanks a lot!!
    • A
      • Diagnosis: Diffuse large B cell lymphoma, non-GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low paraspinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
      • Plan: R/T to left retro-pharyngeal tumor for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Dec 13 15:30 and possible RT toxicity is told. Diet education.
  • 2023-10-26 Rehabilitation
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs
      • Premorbid status
        • Walk ID / BADL ID
      • Physical examination
        • 2023/10/26 20:05 T/P/R: 36.2’C / 119bpm / 18bpm BP:154/79mmHg
        • Body weight: 42.5
          • Consciousness: E4V5M6
          • Cognition: grossly intact
          • Sphincter: urinary and stool incontinence with diaper
          • Muscle power:
            • RUE/RLE 2/2
            • LUE/LLE 4/3
          • Functional status: roll ID; sit up under modA with poor to fair balance
          • BADL: light hygiene modA / heavy hygiene: maxA
      • Assessment
        • Diffuse large B cell lymphoma, non- GCB, involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as right psoas muscle, lower lumbar spines, sacrum and possible adjacent nerve roots (stage IV), status post chemotherapy with R-CHOP
        • Old lacuna infarcts over right putamen and internal capsule about 7 years ago with mild left hemiparesis
        • Mix-type sensorimotor polyneuropathy superiposed polyradiculopathy
      • Plan
        • Rehabilitation programs: arrange bedside PT rehabilitation programs.
        • Goal: recondition; maintain ROM; improve endurance and muscle strength.
  • 2023-10-18 Radiation Oncology
    • Q
      • for radiotherapy evaluation
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB, stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for radiotherapy evaluation, thanks a lot!!
    • A
      • Subjective:
        • History: This is a 64 years-old female who has the history of diffuse large B cell lymphoma, non- GCB , stage III s/p 7th R-CHOP on 2023/4/28 and regular follow-up at our OPD. The patient complaints bilateral lower limbs numbness, and right side weakness. Her T-L spine MRI on 10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration. Neck-chest CT showed large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis. PET scan showed increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71); but no FDG uptake over C spines.
          • Previous RT: denied.
          • Other disease: Old CVA at right cerebral artery; hypertension; type II DM; hyperlipidemia with medication control.
          • Family history: denied.
            • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
            • Married. Caregiver: her husband (survivor of buccal cancer s/p OP, R/T > 10 years ago). Job: housewife. Mild or no economic stress at least.
            • Language: Mandarin. Taiwanese.
            • Religion: Buddhism.
      • Objective:
        • General Condition-ECOG: 3.
        • PE, 2023/10/18: Multiple LAPs over bilateral necks and SCFs. Rt upper and lower limb muscle power: only 2/5.
        • Pathology, 2022/9/08, Stomach, AW of low body, biopsy— Diffuse large B cell lymphoma, non- GCB.
        • Images:
          • Brain MRI, 2023/10/12: Old lacuna infarcts over right putamen and internal capsule.
          • T-L spine MRI, 2023/10/14 revealed abnormal abundant soft tissue in right low parasinal and psoas muscle regions; dilated right ureter, likely due to tumor obstruction; a small focal right L4 body lesion; thick and well enhanced nerve roots in low lumbar spine due to tumor infiltration.
          • CT, 2023/10/16: Chest wall and lower neck: extensive lymphadenopathies in left neck from the level of the nasopharynx to the supraclavicular fossa. Enlarged LNs at Rt supraclavicular fossa. Pleura: no effusion but Rt posterior pleural thickening. Large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles. A 13mm low attenuation in the spleen. Mild soft tissue lesion in para-aortic and para-cava spaces, stationary. Imp: Diffuse large B-cell lymphoma, in both sites of diaphragm with extranodal and solid organ sites.
          • PET scan, 2023/10/17: There was increased FDG uptake in the left neck and left supraclavicular lymph nodes (SUVmax early: 23.30, delay: 31.55), right lower neck and right supraclavicular lymph nodes (SUVmax early: 16.33, delay: 24.67), bilateral axillary lymph nodes (SUVmax early: 17.01, delay: 26.20), some mediastinal lymph nodes (SUVmax early: 13.49, delay: 23.66), multiple right abdominal and pelvic lymph nodes (SUVmax early: 19.24, delay: 25.43), right inguinal lymph nodes (SUVmax early: 11.61, delay: 16.12) and possible lymph nodes in bilateral thighs (SUVmax early: 19.01, delay: 31.93).
            • Besides, there was increased FDG uptake in the right psoas muscle (SUVmax early: 14.12, delay: 17.59), in the lower lumbar spines, sacrum and possible adjacent nerve roots (SUVmax early: 13.30, delay: 18.71). IMP: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm and extralymphatic organ involvement as mentioned above (stage IV). In comparison with the previous study on 2022/09/16, the previous FDG avid lesions in the lower mediastinum and upper abdomen are less evident or disappeared.
          • Shoulder X-ray, 2023/10/13: No significant abnormality is seen in this study.
      • Diagnosis: Diffuse large B cell lymphoma, non- GCB, origin from stomach, stage III s/p 7th R-CHOP on 2023/04/28 with relapse and involvement of right low parasinal and psoas muscle & nerve roots in low lumbar spine, r stage IV; ECOG 3.
      • Plan: C spine MRI may be considered to R/O tumor involvement of C spinal cord and nerve root or intramedullary lesion. R/T to L spines, nerve roots and psoas muscle for 2500cGy/10 fx is suggested for symptom control & neurological sequela. CT simulation is arranged on Oct 19 08:30 and possible RT toxicity is told. Diet education and psychological support.
  • 2023-10-17 Neurology
    • Q
      • for bilateral lower limbs numbness, and right side weakness.
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non-GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The patient complaints bilateral lower limbs numbness, and right side weakness, T-L spine MRI revealed A small focal right L4 body leison, neck-chest CT: large soft-tissue mass in Rt lower posterior retroperitoneum involving the psoas muscles, marginal spurs of multiple vertebrae due to spondylosis, so we need your help for evaluation, thanks a lot!!
    • A
      • This 64 y/o female p’t is a case of olf right hemisphere infarction, HTN, DM, and hyperlipidemia with regular F/U at our OPD. He is also a caw of B-cell lymphoma with regular F/U at Hema OPD.
      • Since 2023/08/24, easy chocking and bulatral leg numbness was noted. She visited our ER on 8/29 and I arranged brain CT for excluded recurrent stroke in left hemisphere but no no newly lesion was noted.
      • This time, she admitted at Hema ward. Due to right leg weakness became worse, brain MRI and L-spine MRI was performed. So, we were consulted for further evaluation .
        • E4V5M6
        • Pupil: 3+/3+
        • EOM: Full
        • dysarthria:-
        • Dysphagia:+/- (no obvious chnage when compared to 8/29)
        • sensory:Bilateral leg numbness (smilar to 8/29)
        • MP:Rl: 2, RU:4Left limbs: all 4
        • DTR: bilateral knee:+, left ankle:+, right ankle: -
      • Imp:
        • right lumbosacral radiculopathy, highly suscepted tumor related
        • old Left henmisphere infarction
        • B-cell lymphoma
        • DM
        • HTN
        • Hyperlipidemia
      • Suggestion:
        • We agreed your treatment plan for tumor biopsy
        • may consider arrange lower limb NCV study (motor, sensory, F-wave, H-reflex), but this study only for pre-treatment baseline data collection.
        • Due to complainted right leg radiation pain, may increase neurontin to 2# tid, may titrate to 3# tid if necessary
        • Consider tramacet 1# prnHS
        • F/U consultation prn.
  • 2023-10-16 Radiation Oncology
    • Q
      • for biopsy at L4
      • This is a 64 years-old female who has the history of Old CVA at right cerebral artery, hypertension, type II DM, hyperlipidemia with medication control, Diffuse large B cell lymphoma, non- GCB , stage III s/p R-CHOP and regular follow-up at our OPD.
      • The T-L spine MRI revealed A small focal right L4 body leison, so we need your help for biopsy, thanks a lot!!
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2022-10-24 Infectious Disease
    • Q
      • This time, PortA blood culture yeild Candida albicans. Blood cultrure yield yeast-like, Pending culture result. WBC:18.26 *10^3/uL . we need your help, thank you a lot!
    • A
      • Consultatiaon for anti-fungal Mycamine
        • There was MRSA and Enterococcus bacteremia on 2022-10-14, followed by Candida albicans candidemia on 2022-10-20.
        • Peripheral blood and Port-A blood culture all shows Candida albicans isolate.
        • Use of Candin drug acceptable.
        • Since there is no GNB isolate, further use of Mepem can be stopped.
        • For MRSA bacteremia, Targocid can be shifted to oral Avelox or Cipro as sequential therapy to complete 3-week treatment course.
      • Suggestion:
        • DC Mepem and fluconazole
        • Add oral Avelox or Cipro
        • Add Mycamine 100mg iv qd for one week first
        • Repeat Port-A and peripheral blood culture 3 days later, to see if there is sterile blood.
  • 2022-10-15 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • Covid-19 related right lung pneumonia and post-chemotherapy neutropic fever with severe sepsis case.
        • Now Mepem and Targocid use.
        • Preliminary blood culture shows GPC isolate.
      • Suggestion:
        • Continue Mepem and Targocid for 3 days first.
        • Check blood and sputum culture report for further antibiotic adjustment.

[immunochemotherapy]

  • 2024-01-04 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-12-11 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-11-16 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 2000mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-10-24 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 30min D1-4 + etoposide 40mg/m2 50mg NS 150mL 1hr D1-4 + cisplatin 25mg/m2 30mg NS 500mL 18hr D1-4 + cytarabine 2000mg/m2 1500mg NS 500mL 2hr D5 (R-ESHAP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug D1,4 + NS 250mL D1,4
  • 2023-04-28 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-02-24 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-02-01 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2023-01-17 - rituximab 375mg/m2 540mg NS 500mL 4hr + cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (R-CHOP Q3W)
    • [diphenhydramine 30mg + acetaminophen 500mg PO + methylprednisolone 40mg + NS 250mL] (before Mabthera) + dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + NS 250mL
  • 2022-12-22 - (R-CHOP Q3W)
  • 2022-12-01 - (R-CHOP Q3W)
  • 2022-10-03 - (R-CHOP Q3W)

R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) - from 2023-11-17 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-patients-who-are-medically-fit

  • Administration - R-ESHAP refers to
    • rituximab 375 mg/m2 on day 1,
    • etoposide 40 mg/m2/day as a one-hour infusion on days 1 to 4,
    • methylprednisolone 250 to 500 mg/day as a 15-minute infusion on days 1 to 5,
    • cisplatin 25 mg/m2/day as a continuous infusion from day 1 to 4, and
    • cytarabine 2 g/m2 as a two-hour infusion on day 5,
    • every three or four weeks.
  • Adverse effects
    • Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used.
    • Other AEs (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
  • Outcomes
    • A retrospective study of 163 patients reported that R-ESHAP for relapsed DLBCL was associated with a 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2024-01-04

The latest lab results, drawn on 2024-01-03, show that the patient’s neutropenia has resolved.

  • 2024-01-04 WBC 11.05 x10^3/uL
  • 2023-12-27 WBC 11.88 x10^3/uL
  • 2023-12-25 WBC 0.33 x10^3/uL ***
  • 2023-12-18 WBC 1.21 x10^3/uL **
  • 2023-12-07 WBC 28.29 x10^3/uL

The sputum aerobic culture, drawn on 2023-12-22, grew S. aureus (MRSA). The patient was started on Targocid (teicoplanin) on 2023-12-12 and continued on this medication until 2024-01-02. Avelox (moxifloxacin) was started on 2023-12-27 and is still being used.

Both CRP and PCT levels on 2024-01-04 were undetectable. Given this, kindly reassess whether the patient still exhibits any potential signs of infection.

2023-11-17

Leukopenia was observed in early Nov, approximately 1 to 2 weeks after the patient first started the R-ESHAP regimen on 2023-10-24. The WBC reading has since returned to almost normal, and no further treatment is currently required.

  • 2023-11-16 WBC 3.29 x10^3/uL
  • 2023-11-08 WBC 1.28 x10^3/uL ** Granocyte (lenograstim 250ug administered)
  • 2023-11-02 WBC 1.83 x10^3/uL **
  • 2023-10-30 WBC 4.47 x10^3/uL
  • 2023-10-22 WBC 5.52 x10^3/uL
  • 2023-10-19 WBC 6.69 x10^3/uL

2022-10-14

  • Tube feeding is possible with all oral medications included in the active prescription.

  • The CNS depressant estazolam might enhance the CNS depressant effect of tramadol, so please monitor any adverse effects as always.

2022-10-03

  • In the case of this patient, who has recently been diagnosed with DLBCL, RCHOP might be an option for treatment.
  • Under prescribed medications, blood pressure and blood sugar levels were in acceptable ranges.
  • Serum electrolyte imbalances (lab data 2022-10-03) are treated with corresponding supplements currently.
  • Hypoalbuminemia (2.6 g/dL 2022-10-03), could it be due to albumin loss in the urine in the nephrotic syndrome? due to decreased hepatic albumin synthesis?
  • There is no issue with the active prescription.

700532258

240104

[exam findings]

  • 2023-12-26 CXR erect
    • Solitary pulmonary nodule at RUL.
  • 2023-12-26 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2023-10-11 CT - chest
    • Indication: breast cancer with lung metastasis
    • With and without contrast enhancement CT of chest shows:
      • s/p mastectomy.
      • Mild regression of left axillary lymph nodes.
      • Small nodules in both lung fields, mild in regression.
      • Hyperdense gallstones.
    • Impression
      • Brease CA, s/p operation
      • Lung and left axillary lymph node metastasis, mild in regression
  • 2023-10-05 SONO - abdomen
    • Sonography of hepatobiliary system revealed:
      • Left liver cysts (0.66x0.95cm, 0.73x0.91cm).
      • Gallbladder stones (up to 0.86cm).
    • IMP:
      • Left liver cysts (0.66x0.95cm, 0.73x0.91cm). Gallbladder stones (up to 0.86cm).
  • 2023-04-10 CT - chest
    • Indication: left breast cancer s/p MRM with lung and LN mets
    • Findings: comparison was made with previous CT dated on 2022/07/07
      • Lungs:
        • multiple nodules as miliary and small nodular patterns in bilateral lungs consistent with lung metastases, seem stationary as compared with CT on 2022/07/07
      • Mediastinum and hila no enlarged LN or mass.
        • old tiny calcified LNs in both hila.
      • Chest wall and lower neck: stastionary of small left axillary LAP as compared with CT on 2022/7/7. s/p Lt MRM.
      • Visible abdominal contents: tiny gall bladder stones.
      • Visualized bones: marginal spurs of vertebrae and no lytic or blastic change.
    • Impression:
      • left breast ca s/p MRM with stationary of lung metastass as compared with CT on 2022/07/07
  • 2022-12-27 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2022-11-03 CT - abdomen
    • S/P left MRM.
    • Left liver cysts (up to 7.6mm).
    • Hyperplasia of left adrenal gland.
    • Gallbladder stones (2-4mm).
  • 2022-10-04 SONO - abdomen
    • Two hepatic cyst measuring 1 cm and 0.8 cm at S3.
    • Multiple gallstones (< 1 cm) are noted.
  • 2022-07-07 CT - chest
    • Hx
      • Lt breast ca biopsied at Far Eastern Hospital.
      • Lt breast ca s/p MRM at our hospital on 2013-03-29
      • Adjuvant C/T (FEC) since 2013-04-15
    • Chest CT with and without IV contrast ehnancement shows:
      • Mild atelectatic change at bilateral basal lungs is found.
      • Non-specific lymph nodes are found at left axillary region. In comparison with CT dated on 202-01-20, the lesion is stationary.
      • One calcified dot at right upper lobe up to 0.43cm in largest dimension.
      • There is stone at dependent portion of GB. GB stone(s) are noted.
    • Imp:
      • S/P mastectomy at left side.
      • Non-specific lymph nodes at left axillary region. Stable.
      • Right upper lobe calcified dot. Old granulation is favored.
  • 2022-01-20 CT - chest
    • Hx
      • Lt breast ca biopsied at Far Eastern Hospital.
      • Lt breast ca s/p MRM at our hospital on 2013-03-29
      • Adjuvant C/T (FEC) since 2013-04-15
      • AI since 2013-08-26 and extension therapy or E/T 5 yrs
    • Chest CT with and without IV contrast ehnancement shows:
      • Calcified dot at right upper lobe up to 0.3cm in largest dimension is found. (Se9 IM22).
      • Several tiny nodular lesions scattered at both lungs are found. LUng meta is considered. In comparison with CT dated on 2021-08-03, the lesions are stationary.
      • S/P mastectomy at left side.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • S/P mastectomy at left side.
      • Diffuse lung meta. Stationary.
  • 2021-09-23 Tc-99m MDP bone scan
    • In comparison with the previous study on 2020/9/29, the lesions in the lower C-spine, lower T-spine and L4-5 spines are either stationary or a little less evident. Degenerative change may show this picture.
    • The previous faint hot spots in bilateral rib cage and the lesion in the distal portion of the sternal body are less evident, possibly more benign in nature.
    • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2021-08-03 CT - chest
    • Impression: left breast ca s/p MRM with stationary of lung and left axillary LN metastass as compared with CT on 2021/02/16
  • 2021-02-16 CT - chest
    • Impression: left breast ca s/p MRM with stationary of lung metastases and regression of left axillary LN metastass as compared with CT on 2020/09/08.
  • 2020-09-29 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental prolbem may show this picture.
    • Some faint hot spots in bilateral rib cage and mildly increased activity in the distal portion of the sternal body. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.

[MedRec]

  • 2023-11-13 SOAP Neurology
    • S
      • 2023/11/13: neurological condition stable
      • 2023/08/21: more cramp, try requip bid
      • 2023/05/29: more cramp, add trental –> improved
      • 2022/12/07: keep plavix qw1357 prevention (self-pay)
      • 2022/09/19: clinical stable, keep current dose, 3m
      • 2022/06/27: clinical stable, 3m
      • 2022/03/30: f/u carotid sono: mild P, right SCA, bil BIF, little progression, f/u carotid sono every year, keep low dose plavix prevention
      • 2022/01/05: less cramp with current dose, 3m
      • 2021/10/13: vital signs stable, 3m
      • 2021/07/19: clinical stable, taper plavix, 3m
      • 2021/04/26: clinical stable, 3m
      • 2021/02/01: less cramp, keep current dose, 3m
      • 2020/12/07: easy cramp, less effect with rivotril, try rivotril +requip, 2m
      • 2020/10/14: NCV: WNL, electrolyte: WNL, easy cramp at night, increase rivotril dose
      • 2020/09/07: left leg soreness and weakness, 1 month, check NCs and ABI
      • 2020/06/15: clinical stable, 3m
      • 2020/03/23: f/u carotid sono: mild P, left BIF, improved, keep current dose, 3m
      • 2020/02/24: no discomfort with plavix, f/u carotid sono for medication adjustment
      • 2020/02/17: gemfibrozil was added at LMD, severe HA with pletaal, try plavix(self-pay)
      • 2020/02/03: epigastric pain with licodin, try pletaal, TG 250, diet control, f/u
      • 2019/11/04: stable, 3m
      • 2019/09/16: less pain but numbness, increase licodin dose
      • 2019/07/22: WBC 4200, Cr 0.7, stable with current dose
      • 2019/06/24: stable with current dose, f/u CBC and renal function
      • 2019/06/17: little effect, no sleepy, increase dose, carotid sono: mod P, RSCA, mild P, bil BIF, epigastric pain with ASA, try licodin
      • 2019/06/03: more fullness and tingling discomfort over bil feet, less effect with neurontin this time, try lyrica; neck stiffness and pain and limited motion, try celebrex PRN
      • 2019/05/06: HA with cerenin, less tingling pain and numbness, consider to taper neurontin next time
      • 2019/04/08: no discomfort with cerenin, keep current dose, increase neurontin dose
      • 2019/03/25: HA with trental, try cerenin, check electrolyte & vit B12, Hb
      • 2019/02/25: s/s recurred, related to weather change, re-add rivotril, trental & neurontin
      • 2018/07/02: improved, more cramp recently, increase rivotril dose, 2m
      • 2018/06/04: no response to neurontin 2# bid, try cymbalta
      • 2018/05/07: sometimes more pain and sleepy, DC TCa, increase neurontin
      • 2018/03/12: sometimes more tingling discomfort, increase neurontin
      • 2018/01/15: sometimes more tingling discomfort, related to weather change
      • 2017/12/18: still numbness, no severe pain, try neurontin
      • 2017/11/20: blood exam: WNL, less tingling pain, still numbness, increase trental, keep TCA
      • 2017/11/06: still bil feet numbness, try TCA, check metabolic condition
      • 2017/10/9: HA with TCA, clinical improved with rivotril & trental, increase dose
      • 2017/09/25: NCV: right C4 radiculopathy and left L45 radiculopathy; less cramp and tingling pain still numbness, try TCA
        • bil feet numbness and tingling pain, easy cramp, years, more severe after op
      • Hx
        • Lt breast ca biopsied at Far Eastern Hospital.
        • Lt breast ca s/p MRM at our hospital on 2013-03-29
        • Adjuvant C/T (FEC) since 2013-04-15
        • AI since 2013-08-26 and extension therapy
    • Diagnosis
      • Cerebral atherosclerosis [I67.2]
      • Polyneuropathy [G62.9]
      • Cramp [R25.2]
    • Prescription x3
      • Lyrica (pregabalin 75mg) 1# Q12H
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Pentop (pentoxifylline 400mg) 0.5# HS
      • Mirapex (pramipexole 0.375mg) 1# HS

[chemotherapy]

  • 2024-01-03 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-12-06 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-11-10 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-10-11 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-09-14 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-08-17 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-07-19 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-06-21 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-05-25 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-04-26 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-03-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-03-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2023-02-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-12-28 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-11-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-11-02 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-10-05 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-09-07 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-08-10 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-07-13 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-06-15 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2022-05-18 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2022-04-20 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-03-23 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-02-23 - fulvestrant 500mg IM - Zhang YaoRen
  • 2022-01-26 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-12-29 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-12-01 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-11-03 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-10-06 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-09-08 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-08-11 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-06-16 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2021-05-19 - fulvestrant 500mg IM - Zhang YaoRen OPD
  • 2021-04-21 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-03-24 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-02-24 - fulvestrant 500mg IM - Zhang YaoRen
  • 2021-01-27 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-12-30 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-12-02 - fulvestrant 500mg IM - Zhang YaoRen
  • 2020-10-07 - fulvestrant 500mg IM - Zhang YaoRen

Ibrance (palbociclib 125mg -> 100mg since 2024) 1# QDCC - 2022-09-07 ~ 2024-01-24 ongoing (21 days of 28 days) Kisqali (ribociclib 200mg) 3# QD - 2020-10-07 ~ 2022-08-03 (21 days of 28 days)

Femara (letrozole 2.5mg) 1# QD - 2017-02-20 ~ 2018-10-01 (repeat prescription)

==========

2024-01-04

[neutropenia]

The patient’s WBC count has been gradually declining for a long time. In late 2023, the count dropped to less than 2K/uL, which is considered grade 3 neutropenia.

  • 2023-12-26 WBC 1.83 x10^3/uL ** Neutrophil 45.5% => ANC 833/uL, grade 3
  • 2023-10-05 WBC 2.92 x10^3/uL *
  • 2023-07-05 WBC 2.16 x10^3/uL *
  • 2023-04-10 WBC 2.91 x10^3/uL *
  • 2023-03-01 WBC 2.32 x10^3/uL *
  • 2022-12-27 WBC 2.75 10^3/uL
  • 2022-11-30 WBC 2.55 10^3/uL
  • 2022-11-02 WBC 2.14 10^3/uL
  • 2022-10-30 WBC 2.89 10^3/uL
  • 2022-10-05 WBC 2.47 10^3/uL
  • 2022-09-19 WBC 2.22 10^3/uL
  • 2022-09-07 WBC 3.36 *10^3/uL
  • 2022-07-07 WBC 2.61 10^3/uL
  • 2022-04-12 WBC 2.47 10^3/uL
  • 2022-01-20 WBC 2.61 10^3/uL
  • 2021-11-03 WBC 3.79 *10^3/uL
  • 2021-09-07 WBC 3.15 *10^3/uL
  • 2021-06-16 WBC 2.77 10^3/uL
  • 2021-05-19 WBC 2.15 10^3/uL
  • 2021-04-21 WBC 3.62 *10^3/uL
  • 2021-02-16 WBC 3.49 *10^3/uL
  • 2020-12-30 WBC 3.12 *10^3/uL
  • 2020-12-02 WBC 3.73 *10^3/uL
  • 2020-11-04 WBC 3.03 *10^3/uL
  • 2020-10-21 WBC 3.12 *10^3/uL
  • 2020-10-05 WBC 5.40 *10^3/uL
  • 2020-08-31 WBC 5.06 *10^3/uL

The patient is currently taking fulvestrant and palbociclib as the main treatment medications. Fulvestrant was started on 2020-10-07, and palbociclib was started on 2020-09-07, to replace ribociclib.

The incidence of neutropenia for fulvestrant is 2%, with 1% grade 3 and <1% grade 4. The incidence of neutropenia for palbociclib is 80-83%, with 55-56% grade 3 and 10-11% grade 4. Therefore, neutropenia is more likely to be attributed to palbociclib.

It is recommended considering a palbociclib dose reduction in future cycles if recovery from grade 3 neutropenia is prolonged (>1 week) or if grade 3 neutropenia recurs on day 1 of subsequent cycles.

There is no evidence of prolonged neutropenia yet, but the dose of palbociclib has been reduced from 125mg daily to 100mg daily since 2024. This is a conservative approach.

700524385

240102

[MedRec]

  • 2023-12-12 SOAP NeuroSurgery Xi XianDa
    • Prescription x3
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
      • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
  • 2023-11-07 SOAP Nephrology Wu ZheXiong
    • Diagnosis
      • HCVD, unspecified, without CHF [I11.9].
      • Mixed hyperlipidemia [E78.2].
      • Coronary atherosclerosis of native coronary artery [I25.10].
      • With unspecified pathological lesion in kidney [N05.9].
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 0.5# BID
      • Euricon (benzbromarone 50mg) 0.5# QD
  • 2023-10-31 ~ 2023-11-04 POMR NeuroSurgery Xu XianDa
    • Discharge diagnosis
      • Cervical spinal stenosis and compression of cervical cord with myelopathy at C3-4-5-6-7.
      • Retention of urine
      • Fracture of right 4th, 5th, 7th, 9th, 10th ribs, and left 4th, 5th, 8th, 9th, 10th ribs.
      • Poor healing wound of scalp with tissue necrosis and defect.
      • Anemia post blood transfusions
      • Atherosclerotic heart disease of native coronary artery without angina pectoris
      • Rheumatic aortic stenosis
      • Hypertensive heart disease without heart failure
      • Mixed hyperlipidemia
      • Chronic kidney disease, stage 3 (moderate)
    • CC
      • Less urine output for one day.
    • Present illness
      • This 90-year-old female patient had several underlying health conditions, including:
        • Hypertensive heart disease
        • Atherosclerotic heart disease of the native coronary artery without angina pectoris
        • Chronic kidney disease, stage 3 (moderate)
      • According to medical records and her daughter’s account, she suffered a head injury from a fall down the stairs on 2023-10-18. Subsequently, she was admitted due to COVID-19 virus infection from 2023-10-18 to 2023-10-25. However, on 2023-10-31, decreased urine output was observed, prompting her visit to our emergency room for assistance. A Foley catheter was inserted for urine retention. The patient displayed weakness in motor function, with the right-side extremities graded as 1, the left upper limb as grade 3, and the left lower limb as grade 2.
      • A cervical spine MRI revealed severe spinal stenosis at the C3-4-5-6-7 levels, along with compression of the cervical cord leading to myelopathy. After consultation with a Neurosurgeon, she was admitted for further management.
      • No cervical surgery
      • No cancer histroy
    • Course of inpatient treatment
      • Following admission, a neck collar was applied for protective purposes. The patient experienced severe pain when changing positions. A bilateral rib X-ray revealed injuries to the right 4th, 5th, 7th, 9th, and 10th ribs, as well as the left 4th, 5th, 8th, 9th, and 10th ribs. Consultation with Thoracic Surgery specialists confirmed the absence of hemopneumothorax. To manage the pain, analgesics were prescribed, and the use of a ThoraxBelt for stabilizing the chest wall was recommended.
      • Anemia was also identified, with a hemoglobin level of 7.5 mg/dL, leading to a prescription for a blood transfusion. Once the patient’s neurological condition had improved to an acceptable level, she was discharged home with plans for outpatient follow-up care.
    • Discharge prescription
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Siliverzine (silver sulfadiazine 10mg/g) QD EXT for head wound
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# Q6H
      • Nexium (esomeprazole 40mg) 1# QDAC stool OB 3+
      • Sindine (povidone iodine Aq Soln) ASORDER EXT for wound dressing change
  • 2023-10-11 SOAP Cardiology Zhang HengJia
    • Prescription x3
      • Concor (bisoprolol 5mg) 0.5# QD
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Doxaben (doxazosin 4mg) 1# QN
      • Crestor (rosuvastatin 10mg) 1# QD

==========

2024-01-02

Upon comparing the refilled repeat prescription with patient records in PharmaCloud and HIS5, all medications were successfully integrated into the active medication list without any discrepancies.

701496796

240102

[exam findings]

  • 2023-12-19 Bronchodilator Test
    • mild to moderate restrictive ventilatory impairment with partial bronchodilator ressposne
  • 2023-12-14 CT - chest
    • Indication: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02. PET on 2023/9/25 showed cervical esophagus recurrence. s/p cervical esophgeal tumor palliative RT in Oct 2023.
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p esophagectomy and gastric tube reconstruction
      • Diffuse soft tissue change at superior mediastinum is found. In comparison with CT dated on 2023-09-13, the lesion is slightly progressed.
      • s/p jejunalstomy.
      • The GB is well distended without soft tissue lesion
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
    • Imp:
      • s/p esophagectomy and gastric tube reconstruction
      • Mediastinal lymphadenopathy s/p C/T, in slightly progression.
  • 2023-11-22 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-11-10 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • s/p gastric tube reconstruction at chest region.
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
      • s/p jejunostomy.
      • Normal heart size. Mild pericardial effusion is found.
      • Elevation of right hemidiaphragm is found.
    • Imp:
      • s/p gastric tube reconstruction at chest region.
      • Gallstones.
      • No evidence of free air is noted at the subphrenic region.
  • 2023-11-10 KUB
    • Scoliotic alignment of the lumbar spine is found.
    • The psoas shadow is clear.
    • s/p drainage tube placement.
    • Increased intestinal gas is found.
  • 2023-09-26 PET
    • A glucose hypermetabolic lesion in the retrotracheal and prevertebral space, extending from the level of the cricoid carlage to the upper mediastinun at the level of aortic arch, compatible with recurrent esophageal maliangncy. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in a left paratracheal lymph node, in a lymph node in the right paravertebral region at the level of T4 spine and in three right precarinal lymph nodes. Metastatic lymph nodes may show this picture.
  • 2023-09-25 Patho - stomach/small bowel polyp
    • Soft tissue, jejunostomy outlet, left upper, excisison — Granulation tissue
  • 2023-09-22 Standing KUB
    • S/P feeding jejunostomy at left upper abdomen.
  • 2023-09-18, -09-11 CXR
    • surgical clips over left apical hemithorax
    • Rt superior mediastinal widening with thickening of paratracheal stripes and Rt shift of trachea s/p reconstructed esophagus, may be recurrent tumor
  • 2023-09-11 Nasopharyngoscopy
    • Bilateral vocal cord paralysis.
  • 2023-09-07 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Possible Right ventricular hypertrophy
  • 2023-09-07 CXR
    • Rt-sided convexity of the azygoesophageal recess interface

[MedRec]

  • 2023-10-20 SOAP Radiation Oncology Wang YuNong
    • Diagnosis: esophageal cancer, clinical stage II, status post operation in 2022/12 and due to N(+), s/p CCRT (25 fx) in 2023/02 and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07and s/p 5 times of esophageal dilatation procedures but failed. PET on 2023/9/25 showed cervical esopahgus recurrence.
    • S: less blood in saliva, r/o esophageal tumor oozing. no melena this week. numbness over the chin.
    • O: 2023/9/28~ RT to the cervical esophagus and adjacent lymphatic drainage area: 28 Gy/ 14 fx.
    • Plan to deliver 20 Gy/ 10 fx to the esophgeal tumor below the superior border of the manubrium. The above esophageal tumor and lymphatic drainage area: at least 50 Gy/ 25 fx.
  • 2023-09-07 ~ 2023-10-17 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Eesophageal cancer, squamous cell carcioima, cT2N1M0, stage II, s/p single-port minimally ivasive tri-incision esophagectomy and reconstruction with gastric tube via posterior mediastinum on 2022/12/02 at NTUH s/p CCRT in 2023/02 s/p balloon dilatation on 2023/07/05, 2023/08/11, 2023/08/15, 2023/08/23, post Jejunostomy in 2023/07/21, recurrent esophageal cancer at neck and upper mediastinum lymph node metastases, s/p left Port-A implantation on 2023/09/18,
      • Eesophageal cancer, squamous cell carcioima, s/p radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~ and Concurrent chemotherapy with Q2W PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs) on 2023/10/06(C1D1)
      • Insomnia, unspecified
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Fever, unspecified
      • Anemia due to antineoplastic chemotherapy
    • CC
      • Difficult swallowing of fluid since 2023-07.
    • Present illness
      • A 55-year-old man had underlying diseases of esophageal cancer status post operation in 2022/12 and post CCRT in 2023/02 at NTUH, and dysphagia post esophageal balloon dilatation procedure 5 times between 2023/07 to 2023/08 at NTUH, Jejunostomy at NTUH in 2023-07, and hepatitis B infection under Baraclude and insomnia.
      • According to his statement, esophageal cancer stage II was diagnosed in 2022-11 and he received esophagestomy with gastric tube recontruction at NTUH in 2022-12. Due to lymph nodes metastasis, he received CCRT in 2023-02 at NTUH. Then he was admitted to NTUH due to pancreatitis in 2023-06. He started to feel difficult swallowing of fluid in 2023-07, and admitted to NTUH for Jejunostomy and esophageal dilatation procedure. After 5 times of esophageal dilatation procedure, he still couldn’t drink water and re-contruction of esophageal was suggested but he wanted to try dilatation procedure again, thus he came to this hospital chest surgery department on 2023-09-05. After well discussed with the doctor about the successful rate, benifit and complication, he decided to undergo endoscopic esophageal dilatation. At ward he couldn’t take anything by mouth and hoarseness was noticed since yesterday.
    • Course of inpatient treatment
      • After admitted, Follow-up suspected GI bleeding condition with Panzolec 1pc iv Q12H from 2023/09/19~2023/09/25.
      • Esophageal obstruction status post endoscopic inspection on 2023-09-11 and image showed recurrence of esophageal cancer on 2023-09-13.
      • Chest CT on 2023/09/13 showed recurrent esophageal cancer at neck and upper mediastinum with metastatic mediastinal LAP s/p esophagectomy and gastric tube reonstruction.
      • Port-A catheter insertion on 2023/09/18.
      • Ultracet 1# po Q6H and Tramadol 100mg iv PRNQ6H for pain control.
      • Sodicon 1# po QID, Shitan 1# po TID and NS 3ml I/H QID for cough with sputum.
      • Whole body PET on 2023/09/26 showed esophageal cancer with left paratracheal, right paravertebral lymph node and upper mediastinun lymph node metastatic.
      • Radiotherapy 30 Gy/ 15 fractions for the esophageal tumor from 2023/09/28~.
      • Concurrent chemotherapy with PF(CDDP 50mg/m2, 5FU 2000mg/m2 IVF 48hrs)(C1D1) on 2023/10/06~2023/10/09 -> 2023/10/08 Hold chemotherapy for fever, R/O spesis.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • NS 500ml Q8H IVF hydration.
      • Double lower teeth shake with consult Dentistry on 2023/10/02 IMP: #27, 313235, 414245: suggest ext at os.
      • Consult OS on 2023/10/03 IMP:Tooth #27, #31, #32, #35, #41, #42, #45 chronic periodontitis A:1.Tooth 35 45 extracted under local anestheia 2.We will arrange stitches removal on 2023/10/10.
      • Cough Mixture 5ml po QID for cough. Allegra 1# po BID for runny nose.
      • Comfflam spray (self pay) 1 puff MOSP PRNQ4H for sore throat.
      • Insomnia with Mirtapine 1# po HS, Zolon F.C 1# po HS and Xanax 1# po HS.
      • Constipation with MgO 2# po Q6H -> DC for diarrhea and Sennoside 2# po HS -> DC for diarrhea.
      • Chronic viral hepatitis B without delta-agent (Anti-HBc(+)) with Baraclude 0.5mg 1# po QDAC.
      • Fever with Antibiotic therapy with Rocephin 2000mg iv QD from 2023/09/23~2023/10/05 and Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/10/08~2023/10/16 and Panadol 1# po PRNQ6H for BT >38^C.
      • Anemia(Hb:9.1 -> 8.5 -> 9.7g/dL) with BT P-RBC 2u on 2023/09/26, 2023/10/02. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/17 and OPD followed up later.
    • Discharge prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Lysozyme (lysozyme 90mg) 1# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Sodicon (dextromethorphan 15mg) 1# QID
      • Zolon (zopiclone 7.5mg) 1# HS
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Cough Mixture (platycodon) 5mL QID
      • Mirtapine (mirtazapine 30mg) 1# HS
      • Shitan (bromhexine 8mg) 1# TID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
  • 2023-09-05 SOAP Thoracic Surgery Xie MinXiao
    • S
      • Esophageal ca. s/p op + adjuvant CCRT.
      • complicated with eso. stricture.
    • P
      • arrange admission 9/7
      • 9/8 endoscopic eso. dilatation.

[chemotherapy]

  • 2023-12-26 - docetaxel 75mg/m2 114mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-11-03 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-10-06 - cisplatin 50mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) D2 + furosemide 20mg NS 30mL 10min (after CDDP) D2 + fluorouracil 2000mg/m2 3100mg NS 500mL 48hr D2 (PF CCRT Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2024-01-02

[tube feeding]

All medications currently listed on the active drug list for oral administration are suitable for enteral tube feeding.

[reconciliation]

The PhamaCloud database did not contain any records of the patient’s medical history from other healthcare facilities. No medication discrepancies were identified.

2023-12-22

[tube feeding]

All medications currently listed for oral administration on the active medication list are suitable for enteral feeding via tube.

2023-11-06

The patient has been a long-term patient at NTUH before seeking treatment at our institution. Currently, there are no valid repeat prescriptions issued by NTUH. No discrepancies with medication reconciliation have been identified.

701510054

240102

[exam findings]

  • 2023-12-29 SONO - abdomen
    • Diagnosis:
      • Liver tumor, left
      • Left pleural effusion, moderate
      • Suspected GB polyp
    • Suggestion:
      • Please correlate with other image
      • Check AFP, CA-199, CEA, HBV, HCV
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-12-25 CT - brain
    • Brain atrophy.

[MedRec]

  • 2023-12-30 MultiTeam - Multidisciplinary Team Recommendations - Palliative Care
    • Consultation Date: 2023-12-29
    • Response Content:
      • During the visit, the patient was conscious and reported no pain or difficulty breathing, feeling more fatigued.
      • The palliative care team established a relationship and explained the concept of shared palliative care.
      • The patient was somewhat guarded but nodded in agreement to shared care.
      • The patient’s ex-husband, who was caring for her, mentioned that the patient verbally expressed not wanting resuscitation but had not yet completed the advance directive for palliative care.
      • The patient’s father and younger brother lean towards not resuscitating, letting the patient pass naturally and comfortably.
      • Diagnosed with breast cancer at the end of last year at another hospital, the first phase of chemotherapy (May and June 2023) was very effective, with the tumor disappearing. Radiation therapy was recommended, but the patient did not proceed.
      • The tumor grew again around August-September with a wound, and subsequent chemotherapy was ineffective, leading to the current large wound.
      • The patient is still struggling to accept the disease’s progression.
      • The ex-husband left with the shared care consent form to be signed by the family later. Follow-up is planned.
    • Conclusion and Recommendations: Shared palliative care and follow-up on the advance directive for palliative care.
    • Responder: Chen Hui
    • Response Date: 2023-12-29 18:35
    • Doctor’s Response: 12/30 02:16 Response by Zhang JiaYu: Noted
  • 2023-12-28 MultiTeam - Multidisciplinary Team Recommendations - Psycho-Oncology
    • Consultation Date: 2023-12-26
    • Reason for Consultation: Stress events due to illness: Psychological stress response due to physical illness or deciding on treatment options, Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
    • Conclusion:
      • S
        • Visit on 12/27, accompanied by the ex-husband.
        • The patient reported severe mouth pain, painful to talk and swallow, unsure of the next steps or what to ask.
        • The ex-husband mentioned they are applying for medical records from TPEVGH, using spray powder for mouth sores, and glutamine for temporary relief, expecting slow recovery.
        • The patient was unprepared and needed time to think, sleeping a lot these past two days, and will see how it goes in the next few days.
      • O
        • Breast cancer diagnosed in 11/12, radiation therapy in November, last chemotherapy on 12/19, wound on the left breast, self-dressing; lost consciousness at home for 5 minutes on 12/25 and recovered, fever started three days ago, admitted on 12/26, inpatient doctor referred for psychosomatic stress response.
      • I
        • Care for the family’s care expectations.
      • AP
        • The ex-husband and patient appeared worried but did not express it explicitly, still hoping to discuss palliative treatment plans, should consider overall treatment tolerance, enhance prognosis awareness and preparedness, and timing for shared palliative care. Counseling psychologist Huang XiaoFang
    • Responder: Huang XiaoFang
    • Response Date: 2023-12-27 17:53
    • Doctor’s Response: 12/28 08:06 Response by Zhang JiaYu: Noted
  • 2023-12-27 ProgressNote
    • Problem #1: Left breast cancer
      • Assessment:
        • under chemotherpy at TPEVGH
        • R/T done in 2023/11
        • Hb 5.1 -> 6.4 -> 8.1 g/dL, WBC 240 -> 130 uL, PLT 58000 -> 86000 -> 52000 uL
        • CRP 26.4 mg/dL
        • blood transfusion with LPRBC 2u on 12/25, 2u on 12/26, LRP 1u on 12/25
        • 12/25 CXR: Left pleural effusion
        • stool OB 3+
      • Plan:
        • keep OPD medications:
          • Xeloda 2# Q12H,
          • Cartil 1# Q8H,
          • Jardiance 1# QD,
          • Eltroxin 1# QDAC,
          • Zcough 1# TID,
          • Trand 1# BID -> shift to IV form,
          • Tramacet PRN for pain,
          • Megest 5ml QD
        • fungus infection told at TPEVGH:
          • keep FLU-D 2# QD,
          • Avelox 1# QDAC,
          • Nystatin 1# TID
        • wound care (consult wound nurse)
        • check finger sugar QDAC, HS
        • fluid supplement with normal saline BID
        • empirical antibiotic with Cefim 2mg Q8H since 12/26
        • Filgrastim (G-CSF) 300 mcg QD
        • Loperamide PRN for diarrhea
        • Hemoclot 500mg Q12H
  • 2023-12-26 MultiTeam - Multidisciplinary Team Recommendations - Wound Care
    • Consultation Date: 2023-12-26
    • Reason for Consultation: Malignant fungating ulcer wound care, Other: Cancer wound
    • Response Content:
      • The left breast has a malignant fungating tumor wound, with 100% yellow necrotic tissue in the wound bed, moderate exudate (yellow-green in color), and a strong foul odor (++).
      • The wound was cleaned with saline solution using cotton swabs, and some necrotic tissue was locally debrided.
      • It is recommended to apply Aq-BI + N/S 1:1 wet dressing BID.
      • The skin under the left armpit and the inner side of the upper arm is damaged due to friction, showing red granulation tissue. After cleaning, a foam silver ion dressing was applied (to be changed during the visit on 12/29).
    • Responder: Chen ShuRong
    • Response Date: 2023-12-26 16:09
    • Doctor’s Response: 12/26 16:33 Response by Zhang JiaYu: Noted, will proceed as recommended.

==========

2024-01-02

[tube feeding]

This hospital offers Const-K 750mg, the only oral potassium supplement available. Each extended-release tablet delivers 10 mEq of potassium, equivalent to about 4.5 medium bananas. While a single banana can provide some potassium (2.2 mEq per inch, 0.9 mEq per cm), Const-K offers a concentrated and stable dose for easier dietary supplementation. For easier swallowing, the tablet can be crushed into fine particles and mixed with water.

700784315

231228

[exam findings]

  • 2023-12-18, -12-14, -12-11, -12-07, -12-05, -11-30, -11-28, -11-27 CXR
    • Normal heart size and contour.
    • Increased bilateral parahilar peribronchial /interstitial and low lungs infiltration.
  • 2023-11-29 Patho - brain biopsy
    • Brain, right FT lobe, stereotactice biopsy — astrocytic glioma, IDH wild type, in favor of high grade
    • Microscopically, sections shows astrocytic glioma characterized by hypercellular astrocytic neoplasm with hyperchromatic, elongated nuclei and irregular nuclear membranes. It shows microvascular proliferation with multilayered, small caliber vessels with glomeruloid appearance. Mitotic activity is not frequent and no geographic-like necrosis is identified in current specimen. A small piece of non-tumor choroid plexus tissue is also noted.
    • Immunohistochemical stains reveals IDH-1 (-), GFAP (+), CK (+ at glial filaments), p53: wild-type (scanty, weak, <1%), EMA (-), SOX10 (focal+), LCA (-).
  • 2023-11-24 CT - chest
    • chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images shows:
      • lungs: a small thin-walled cyst at RUL.
        • mild centrilobular nodules at RML..
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine. normal appearance of left lung.
      • Mediastinum and hila: no enlarged LN or mass.
        • moderate coronary arterial calcification
      • Thoracic aorta: dilated ascending aorta (4cm). extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Visible abdominal-pelvic contents: a 5mm Lt hepatic cyst.
        • enlarged prostate with tiny calcifications indenting the bladder base.
        • questionable wall thickening the urinary bladder.
        • mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • no lung tumor. no abnormal mass in abdomen.
      • BPH
      • Mild RML bronchiolitis.
  • 2023-11-23 MRI - brain
    • Past History: Azihemier disease.
    • Surgical history: s/p cata
    • Pre- and post-contrast multiplanar cerebral MRI (including axial and coronal T1W, axial and sagittal T2W, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) and cerebral TOF MRA reveal:
      • A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base.
      • An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
      • Elevation of bilateral A1 segments due to mass effect from frontal base tumor. Otherwise, no remarkable finding at major intracranial arteries in MRA study (including bilateral ICAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP:
      • Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement.
      • D/D: meningioma or/and lymphoma, metastases.
  • 2023-11-23 CT - brain
    • Imp: Brain atrophy. A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.

[consultation]

  • 2023-12-11 Infectious Disease
    • Q
      • This is a 79-year-old male patient with medical history of Alzheimer’s disease. This time, he had drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
      • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
      • Neuro-surgeon was consulted and further survey was done.
      • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases.
      • After he received brain tumor biopsy on 11/18.
      • The frozen section revealed No evidence of lymphoma or metastasis, pending pathology data.
      • During SICU, under keppra and Hemotastic use.
      • The GCS around E3VTM6, try weaning ventilator and extubation on 11/29.
      • The respiratory pattern smooth, under the general condition became stable, he was transferred to NS ward on 11/30.
      • During ward, solwly taper mannitol.
      • Rehabiliation therapy were undertaken.
      • Brain biopsy report show astrocytic glioma, consultation radiation oncology suggest radiotherapy to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
      • We give applying Temodal for NHI.
      • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin.
      • Current problem:
        • Fever was noted on 12/17, and brosym was give for pneumonia.
        • Suputum culture showed pseudomonas aeruginosa, we shift antibiotic to Ciprofloxacin since 12/8.
      • We need your expertise for further management. Thank you for your reply.
    • A
      • Serial CxR films has shown marked pneumonia regression and patient has received antibiotic more than 2 weeks.
        • Sputum culture grew P.aeruginosa.
        • IV Cipro can be shifted to oral Ciproxin.
      • Suggestion:
        • Continue inhaled Colimycin for one more week
        • DC IV ciprofloxacin
        • Add oral ciprofloxacin as sequential therapy.
  • 2023-12-04 Radiation Oncology
    • Q
      • This is a 79-year-old male patient with medical history of
        • Alzheimer’s disease
        • Bilateral cataract, status post operation
      • According to his sons’ statement, he was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, drolling, slurred speech, impaired response and muscle weakness at left extremities were noticed for 2 days. He was then brought to our emergent department for evaluation.
      • Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Neuro-surgeon was consulted and further survey was done.
      • Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma,lymphoma or metastases. Tumor markers was collected and the result was pending. As a result, admission for close monitoring and possible intervention was suggested and accpeted after explanation of pros and cons.
      • Chest CT revealed no lung tumor. no abnormal mass in abdomen. BPH. Mild RML bronchiolitis. Tumor marker was arranged.
      • He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade. Thus we need your expertise for further CCRT. Temodal applying in advance. Thanks very much!
    • A
      • Subjective:
        • History: This is a 79-year-old male patient was ADL/iADL partially dependent within his usual status. Conversation was intact but mild delayed. However, saliva drooling, slurred speech, impaired response and muscle weakness at left extremities were noted for 2 days. He was brought to our emergent department for evaluation. Brain CT showed a large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma. Brain MRI revealed tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement, r/o meningioma, lymphoma or metastases. Chest CT revealed no lung tumor; no abnormal mass in abdomen; BPH; mild RML bronchiolitis. He received brain tumor biopsy on 11/18. The pathology reported astrocytic glioma, IDH wild type, in favor of high grade.
          • Previous RT: denied.
          • Other disease: Alzheimer’s disease noted since 2023/01 (CDR?); bilateral cataract, status post operation.
          • Family history: denied.
            • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
            • Married. Caregiver: special nurse (his wife, 3 sons). Job: retired cloth merchant. No or mild economic stress at least.
            • Language: Mandarin. Taiwanese.
        • Objective:
          • General Condition-ECOG: 3.
          • PE, 2023/12/05: no SCF LNs; muscle weakness at left extremities. NG feeding.
          • Pathology, 2023/12/04: Brain, right FT lobe, stereotactic biopsy—astrocytic glioma, microvascular proliferation, few mitosis & no necrosis; IDH wild type, in favor of high grade. IHC: IDH-1(-), GFAP(+), CK(+at glial filaments), p53: wild-type (scanty, weak, < 1%), EMA(-), SOX10(focal+), LCA (- ).
          • Images:
            • Brain MRI, 2023/11/23: A well-defined extra-axial enhancing tumor, about 39 mm at the largest dimension, with diffusion restriction at midline of anterior frontal base. An intra-axial well-enhancing tumor, about 24 mm at the largest dimension, with central necrosis and diffusion restriction in tumor bulk involving right mesial temporal lobe, associating with extensive perifocal white matter edema and diffuse infiltrative parenchymal enhancement and irregular thick enhancement along cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns).
            • Chest CT, 2023/11/24: no lung tumor; no abnormal mass in abdomen; BPH; Mild RML bronchiolitis.
            • Tumor marker, 2023/11/24: SCC, CEA, PSA (negative); aFP 21.0, CA199 106.53.
        • Diagnosis: Astrocytic glioma, IDH wild type, in favor of high grade, involving anterior frontal base, right mesial temporal lobe, cistern spaces (including interhemispheric fissure, right hippocampal sulcus, right Sylvian fissure, basal cistern and walls of bilateral frontal horns), s/p stereotactic brain tumor biopsy on 2023/11/18; ECOG =3.
        • Plan:
          • I suggest RT to brain tumor for 5000cGy/20 fx for tumor control with concurrent temozolamide if feasible.
          • I informed him & his family possible radiation toxicity (radiation dermatitis & IICP). I will arranged CT simulation on 2023-12-07 09:30. RT will be initiated 2-3 days later.
  • 2023-11-23 Neurosurgery
    • A
      • A case of 79 y/o male, Alzheimer disease under treatment at TSGH.
      • BWL for > 6 months. Progressive left side weakness for days.
      • A brain CT showed A large isodense frontal base and right parasellar, medial temporal mass, favor a meningioma.
      • A brain MRI showed Tumors at frontal base and right mesial temporal lobe associating with white matter edema, parenchymal and leptomeningeal enhancement. D/D: meningioma or/and lymphoma, metastases.
      • P: check tumor markers; Chest CT for staging; Brain stereotactic biopsy if needed.

[radiotherapy]

[chemotherapy]

  • 2023-12-13 ~ undergoing - temozolomide 100mg QW12345 (1 hr before CCRT)

==========

2023-12-28

[body weight loss]

According to the weight records revealed by the TPR panel, the patient’s weight was 48kg on 2023-11-23, 37.6kg on 2023-12-13, and 37.2kg on 2023-12-27. CCRT with temozolomide QW12345 began on 2023-12-13. It can be found that the patient’s weight loss mainly occurred before temozolomide initialization. Therefore, temozolomide is less likely to be the main cause of the patient’s weight loss.

It is worth noting that the incidence of anorexia with temozolomide is 27%, nausea (49% to 53%; grades >= 3: 1% to 10%), vomiting (29% to 42%; grades >= 3: 2% to 6%), and lymphocytopenia (grades 3/4: 55%). The patient is currently receiving tube feeding. It is important to monitor the patient’s nutritional intake, observe for nausea and vomiting, and monitor CBC and WBC counts.

[lymphopenia]

The patient’s lymphocyte percentage in WBC DC consistently falls below the normal range of 20% to 45% across all available data points, both pre- and post-CCRT. This persistent lymphopenia might suggest a potential impairment in the patient’s capacity for orchestrated and specific immune responses, which could impact their ability to fight the cancer.

  • 2023-12-28 Lymphocyte 5.7 %
  • 2023-12-25 Lymphocyte 9.5 %
  • 2023-12-18 Lymphocyte 10.0 %
  • 2023-12-14 Lymphocyte 5.9 %
  • 2023-12-11 Lymphocyte 7.7 %
  • 2023-12-07 Lymphocyte 8.7 %
  • 2023-12-05 Lymphocyte 10.7 %
  • 2023-11-30 Lymphocyte 1.9 %
  • 2023-11-28 Lymphocyte 4.8 %
  • 2023-11-27 Lymphocyte 9.6 %
  • 2023-11-23 Lymphocyte 12.4 %

701233507

231227

[MedRec]

  • 2023-12-26 Multi-team consultation - Psycho-oncology
    • Consultation date: 2023-12-25
    • Consultation reason: Others: Cancer in-hospital patient simplified health scale >=10 points
    • Conclusion:
      • S
        • On 2023-12-25, the patient’s wife said that she filled in the score for him because she was right next to him and knew his mood best.
        • The patient said that when he first started chemotherapy, the numbness would slowly go away after 3-4 days, but it didn’t go away after that. He would feel pain when he touched something cold, and his feet would also hurt. He couldn’t walk for long distances.
        • “If this is how it’s going to be for the rest of my life, then what’s the point of living?” The patient’s wife said that she was afraid that he would be disabled.
        • The patient said that if he wanted to create a work of art, the ability to control the fine details was very important. Even a small difference could make a big difference. Now, he didn’t even know if he was tying his shoelaces too tightly.
        • The patient’s wife said that she would discuss with the doctor whether the last two rounds of chemotherapy could omit the drug that caused numbness in the hands and feet. The patient said that he had to complete the treatment plan. He would go to see a Chinese medicine doctor after that to see if it would help. If the case manager had any methods, that would be great.
      • O
        • The patient was diagnosed with colon cancer (stage II) in 2012/06. He is undergoing post-operative chemotherapy. He was admitted to the hospital on 2023-12-25 for his 11th round of chemotherapy. His BSRS score was 15 (severe), and his suicidal ideation score was 1 (mild).
      • I
        • Care for the impact of side effects on life. Affirm the patient’s positive attitude towards recovery.
      • AP
        • The patient is actively cooperating with the treatment plan, but is concerned about the impact of the side effect (numbness in the hands and feet) on his life and work. This part is transferred to the case manager for educational care.
    • Responder: Huang Xiaofang
    • Response date: 2023-12-25 17:56
    • Doctor’s response: 2023-12-26 08:06 Lu Zongru Response: Acknowledged
  • 2023-06-05 ~ 2023-06-10 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Sigmoid tumor post tattooed status post 3 dimensions single-incision laparoscopic (SILS) sigmoidectomy on 2023/06/07
    • CC
      • bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
    • Present illness
      • This 59 years old man patient has the history of
        • Calculus of gallbladder for 20-30 years
        • Hyperlipidemia without medication
        • Superficial gastritis without medication
        • Mitral valve prolapse
        • Appendicitis s/p traditional open appendectomy for 30+ years at JingMei Hospital
        • Puckering of macula, right eye, status post 25G pars plana vitrectomy and epiretinal membrane peeling on 2022/08/17.
      • He suffered from bright red blood on toilet paper since last year and epigastric dull discomfort in recent weeks.
      • He came to GI OPD for help and colonoscopy revealed
        • One sessile polyp was noted in the transverse colon Size 0.8 cm. (90 cm from anal verge)
        • One large polypoid tumor lesion was noted in the sigmoid colon Size 3.0 cm. (20 cm from anal verge).
      • Upper gastrointestinal endoscopy showed superficial gastritis.
      • Abdominal CT revealed focal wall thickening of S-colon.
      • Therefore he was referred ro CRS OPD for further evaluation. After fully explained of the condition, the surgical intervention was indicated and the patient understood and agreed.
      • This time, he is admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage.
      • Operation of 3D SILS sigmoid colectomy under general anesthesia were performed on 2023-06-07.
      • NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat.
      • Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day.
      • The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better.
      • In stable condition, he was discharged on 2023-06-10 and will receive OPD follow up next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H

[chemotherapy]

  • 2023-12-25 - leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5045mg NS 1000mL 46hr (Lv ZongRu)
    • betamethasone 4mg + metoclopramide 10mg + NS 250mL
  • 2023-11-27 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-07 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4900mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-19 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4933mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-02 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4914mg NS 1000mL 46hr (FOLFOX Q2W. Lv ZongRu)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-14 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 715mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-28 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-14 - oxaliplatin 85mg/m2 149mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 4920mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-01 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-17 - oxaliplatin 85mg/m2 148mg D5W 250mL 2hr + leucovorin 400mg/m2 698mg NS 250mL 2hr + fluorouracil 2800mg/m2 4891mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-07-03 - oxaliplatin 85mg/m2 147mg D5W 250mL 2hr + leucovorin 400mg/m2 694mg NS 250mL 2hr + fluorouracil 2800mg/m2 4858mg NS 1000mL 46hr (FOLFOX Q2W. Xiao GuangHong)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-27

[chemotherapy-induced peripheral neuropathy]

Due to concerns about the developed peripheral neuropathy, oxaliplatin was not included in the FOLFOX protocol administered during this hospital stay.

Recent guidelines support the use of duloxetine for managing chemotherapy-induced peripheral neuropathy (CIPN). Both the 2020 ASCO guideline and the joint ESMO/EONS/EANO guideline recommend duloxetine as a treatment option for neuropathic pain in this setting. (Reference: Loprinzi CL, et al. J Clin Oncol 2020; 38:3325)

For adult patients with CIPN, duloxetine is typically started at 30mg orally once daily for the first week, then increased to 60mg once daily thereafter. This dosing recommendation is based on a large, randomized clinical trial by Smith et al. (Reference: Smith EM, et al. JAMA 2013;309(13):1359-67)

There is Cymbalta (duloxetine 30mg capsules) readily available within our stock to be prescribed.

700147427

231226

[exam findings]

  • 2023-12-25 CT - brain
    • Indication: dyspnea with much sputum for 2 days
    • Past history: hx of NSTEMI, duodenal ulcer, gastric ulcer s/p op, HTN
    • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
      • moderate dilated intraventricular and extraventricular CSF spaces
      • moderate bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia
      • unremarkable change in the skull base
    • IMP:
      • no acute intracranial hemorrhage
  • 2023-12-24 CXR (erect)
    • cardiomegaly
    • Lung markings: focal increased desity in the left upper and left retrocardiac lung fields.
    • blunting left costophrenic angle

[MedRec]

  • 2023-12-07 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Norvasc (amlodipine 5mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QOD
      • Eurodin (estazolam 2mg) 1# HS
  • 2020-04-09 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Concor (bisoprolol 1.25mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD

==========

2023-12-26

Based on the findings of the upright CXR performed on 2023-12-24, which showed cardiomegaly, focal consolidation in the left upper and retrocardiac lung fields, and blunted left costophrenic angle, empirical Sintrix (ceftriaxone) was initiated while culture results are pending.

The patient’s persistent hypertension (170/75 mmHg since admission) could suggest exploring a target systolic blood pressure (SPB) of 150 mmHg. Amlodipine 5mg QD and hydralazine 50mg PRNBID have been prescribed for blood pressure control.

701114210

231225

[MedRec]

  • 2023-10-24 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Decone (dexamethasone 0.5mg) 1# QD
      • Florinef (fludrocortisone 0.1mg) 1# QD
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • MgO 250mg 1# BID
      • Ezetrol (ezetimibe 10mg) 1# QD
      • cortisone acetate 25mg 2# PRNBID if headache or fever
  • 2023-07-25 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • Docone (dexamethasone 0.5mg) 1# QD
      • Florinef (fludrocortisone 0.1mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • cortisone acetate 25mg 2# PRNBID if headache or fever
  • 2023-06-21 ~ 2023-06-29 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • K-RAS wild type Rectum cancer, pT3N0M0 post neoadjuvant with concurrent chemoradiotherapy, status post low anterior resection in 2018-08 WITH recurrence post palliative chemotherapy. Multiple LNs, lung and liver metastases in 2023-04.
      • Secondary malignant neoplasm of right adrenal gland
      • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
    • CC
      • for further management
    • Present illness
      • This 68-year-old male, a pt of rectal adeno CA, cT3N0M0 s/p neoadjuvant CCRT, s/p LAR in Aug 2018 by Dr Xiao GuangHong, s/p post-Op adjuvant Xeloda & R adrenal mets s/p bil adrenectomy in 2020-01 by Dr Cai YaoZhou, s/p post-Op palliative C/T with FOLFIRI / Avastin from April to July 2020 by Dr Liu JunHuang & recurrenec at para-aortic LN mets in 2021-01.
      • KRAS: wild type., s/p 2nd line palliative C/T wt CapeOx x 12 from Feb to Nov 2021 wt Dz in progress at new hepatic tumor, s/p 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 since 12/7 21.
      • L adrenal tumor with rapid increase in size after surgery, Adrenal gland, R, lap.
      • Adrenalectomy (2/21 20) proved mets adenoCA, favoring colorectal origin. Adrenal MRI (1/20 20) showed mets in right adrenal gland is highly suspected. Right adrenaltumor enlargment suspect adrenal mets, suggest LPS adrenalecotmy. Lt adrenalectomyin 06/2019 & Rt adrenalectomy on 2020/02/21.
      • A left para-aortic glucose-hypermetabolic soft tissue lesion, metastasis in a leftpara-aortic lymph node was noted.He was referred to our clinic on 5/25 20 for continuous C/T by Dr Liu JunHuang. #5 chemotherapy with Avastin / FOLFIRI IV Q2W x 8 on 6/8 20, #6 on 6/22 20. #7 on7/6 20. #8 on 7/20 20 (finished).
      • Follow-up abd CT (7/15 20) showed s/p LAR with autosuture retention at the rectum.No evidence of tumor recurrence. CEA: 1.4 (7/15 20), CEA: 1.0 (12/28 20).FCXR & abd sono (9/28 20): negative. Abd CT (1/228 20) revealed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets. Newly developed para-aortic LNs;biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w lcolorectal recurrence.
      • We explain to pt about the indication & risk / benefit of 2nd line palliative C/T wt mFOLFOX IV Q2W x 12.
      • Follow-up abd CT (12/28 20) showed rectal CA s/p Op. A LN (1.8cm) at paraaortic region r/o tumor mets.newly developed para-aortic LNs; biopsy (1/12 21) proved adenocarcinoma. IHC stain: CK20(+), c/w colorectal recurrence.
      • 2nd line palliative C/T wt mFOLFOX IV Q2W x 1 on 2/1 21. (DC it due to SE & pt declined it). Due to SE, may shift to CapeOx.will shift to CAPEOX ( Capecitabine 1000mg/m2 PO BID D1~14 Q3W + Oxaliplatin 130mg/m2 ) IV Q3W .
      • 2nd line palliative C/T wt CapeOx ( Capecitabine 700mg/m2 ( 2# ) PO BID D1~14 Q3W + Oxaliplatin 60mg/m2 IV Q3W ) x 6 on 2/23 21, #2 CapeOx ( Capecitabine 1000mg/m2 (3#) + Oxaliplatin 70mg/m2 IV Q3W x 6 on 3/16 21, #3 on 4/6 21, #4 on 4/27 21. #5 on 5/18 21. #6 on 6/30 21. #7 ( Oxalip 100mg/m2 ) on 7/13 21. #8 ( Oxalip 110mg/m2 ) on 8/3 21. #9 ( Oxalip 120mg/m2 ) on 8/24 21. #10 on 9/14 21. #11 ( Oxalip 130mg/m2 ) on 10/5 21. #12 on 11/2 21. ( portable ).Abd CT (5/4 21) (8/4 21) showed s/p R hemicolectomy, post-op at rectum with left paraaortic recurrence, stationary.
      • Abd CT (11/16 21) revealed s/p RAR. L perirenal space metastatic lymphadenopathy, stable. New hepatic tumor at dome. r/o meta.#1A 3rd line palliative C/T wt FOLFIRI / Erbitux IV Q2W x 12 on 12/7 21.Erbitux 400mg/m2 (give 600mg) IVF 2 hr then 250mg/m2 ( give 400mg ) IVF 1 hr QW x8, plus FOLFIRI as 3rd line palliative C/T.
      • RTC 1 wk later on 5/10 22 for #3 4th palliative C/T wt FOLFIRINOX / Erbitux IV Q2W x 12 (the last biochemotherapy on 2022/7/5).
      • Followed CT of abdominal on 2023/5/16 revealed S/P colon operation. Multiple LNs, lung and liver metastases. He was admitted for further management
    • Course of inpatient treatment
      • After admission,CT guide biopsy was administered on 2023/6/23 revealed Metastatic adenocarcinoma, consistent with colorectal primary.
      • Chemotherapy with C1D1 FOLFIRI (dose adjusted to 20% off) was administered on 2023/6/26-28 after fully explaination.
      • Adequate hydration. selfpaid of Emend and PRN Dexamethasone for chemotherapy related emesis.
      • With the relatively stable condition, he was discharged on 2023/06/29 and will OPD follow up later
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H as painkiller
      • loperamide 2mg 1# PRNQ6H if diarrhea
      • Limeson (dexamethasone 4mg) 1# PRNBID as antiemetic
  • 2019-08-07 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • Corticoadrenal insufficiency [E89.6]
      • Malignant neoplasm of rectum [C20]
      • Goiter, unspecified [E04.9]
      • Malignant adrenal gland neoplasm [C74.02]
      • Anemia [D64.9]
    • Prescription x3
      • cortisone acetate 25mg 2# PRNBID
      • Compesolon (prednisolone 5mg) 0.5# BID
  • 2018-03-29 SOAP Colorectal Surgery Xiao GuangHong
    • S: A case of newly diagnosed rectal cancer at 8cm from AV

[chemotherapy]

  • 2023-12-05 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-21 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-11-07 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-24 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-10-03 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2900mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-09-19 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-08-17 - irinotecan 180mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 400mg NS 250mL 2h4 + fluorouracil 2800mg/m2 2860mg NS 500mL 46hr (FOLFIRI Q2W. Iri 25% off, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-07-12 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-06-26 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 430mg NS 250mL 2h4 + fluorouracil 2800mg/m2 3000mg NS 500mL 46hr (FOLFIRI Q2W. Iri, Lv and Fu 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-07-05 - (FOLFOXIRI)

  • 2022-06-21 - (FOLFOXIRI)

  • 2022-06-07 - (FOLFOXIRI)

  • 2022-05-24 - (FOLFOXIRI)

  • 2022-05-10 - (FOLFOXIRI)

  • 2022-04-12 - (FOLFOXIRI)

  • 2022-03-22 - (FOLFOXIRI)

  • 2022-03-08 - (cetuximab + FOLFOXIRI)

  • 2022-02-22 - (cetuximab + FOLFOXIRI)

  • 2022-02-08 - (cetuximab + FOLFOXIRI)

  • 2022-01-18 - (cetuximab + FOLFOXIRI)

  • 2022-04-04 - (cetuximab + FOLFOXIRI)

  • 2021-12-07 - (cetuximab + FOLFOXIRI)

  • 2021-11-02 - (Oxa)

  • 2021-10-05 - (Oxa)

  • 2021-09-14 - (Oxa)

  • 2021-08-24 - (Oxa)

  • 2021-08-03 - (Oxa)

  • 2021-07-13 - (Oxa)

  • 2021-06-09 - (Oxa)

  • 2021-05-18 - (Oxa)

  • 2021-04-27 - (Oxa)

  • 2021-04-06 - (Oxa)

  • 2021-03-16 - (Oxa)

  • 2021-02-23 - (Oxa)

  • 2021-02-01 - (FOLFOX)

  • 2020-07-20 - (Avastin + FOLFIRI)

  • 2020-07-06 - (Avastin + FOLFIRI)

  • 2020-06-22 - (Avastin + FOLFIRI)

  • 2020-06-08 - (Avastin + FOLFIRI)

  • 2020-05-25 - (Avastin + FOLFIRI)

  • 2020-05-06 - (Avastin + FOLFIRI)

  • 2020-04-15 - (Avastin + FOLFIRI)

  • 2020-04-01 - (Avastin + FOLFIRI)

  • 2020-03-20 - (Avastin + FOLFIRI)

==========

2023-12-25

[reconciliation]

It is noted that not all of the drugs prescribed on 2023-10-24 by our endocrinologistare currently reflected on the active medication list. To prevent any potential misunderstandings and to ensure timely access to necessary medications, it might be beneficial to double-check and update the list if needed.

2023-08-18

Our endocrinologist issued a repeat prescription for Docone (dexamethasone), Florinef (fludrocortisone), Crestor (rosuvastatin), and Lipanthyl Supra (fenofibrate), all of which are currently in use, with no medication reconciliation problems found.

700039896

231222

[chemotherapy]

  • 2023-12-20 - bortezomib 1.3mg/m2 2mg SC (VTd QW)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-21 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
    • Pregnancy warning
      • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, renal function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the dose of bortezomib on days 1, 8, 15, and 22.
    • Monitor for signs of neuropathy. Many clinicians provide a prophylactic bowel regimen for patients taking thalidomide.
    • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
    • Monitor for signs of rash, infection, or thrombotic event periodically.
  • Suggested dose modifications for toxicity:

    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available.
      • Thalidomide should be discontinued or dose reduced if a patient develops paresthesias accompanied by pain, motor deficit, or interference with activities of daily living.
    • Rash
      • Thalidomide has been associated with rashes including SJS and TEN. If a rash develops, thalidomide should be discontinued and the rash further evaluated. Thalidomide should not be administered again if the rash is exfoliative, purpuric, or bullous, or if SJS or TEN is suspected.
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[3] If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2, or from 1 mg/m2 to 0.7 mg/m2).

==========

2023-12-22

[hyperuricemia]

Hyperuricemia was detected on 2023-12-22 with a serum uric acid level of 11.7 mg/dL. Two potential treatment options for this elevated uric acid level might be considered:

  • Fasturtec (rasburicase 1.5mg/mL/vial is available): This is a medication that directly breaks down uric acid in the blood, offering a rapid and effective way to lower its levels. It may be an appropriate choice for patients with severe hyperuricemia or those who require a quick reduction in uric acid levels.
  • Urinary alkalinization: This approach aims to make the urine more alkaline, which can help uric acid dissolve and be excreted more easily through the kidneys. This can be achieved through various medications, including acetazolamide and sodium bicarbonate. However, the specific choice and effectiveness of these medications for controlling hyperuricemia remain an area of ongoing research and debate.

2023-12-21

[anemia]

The patient’s HGB level has been consistently below normal since admission. The lowest level was observed on 2023-12-21. Bortezomib was administered on 2023-12-20 and is associated with anemia in 12-23% of patients (grades 3-6). It is possible that bortezomib exacerbated the existing anemia.

  • 2023-12-21 HGB 7.2 g/dL *
  • 2023-12-18 HGB 9.2 g/dL
  • 2023-12-14 HGB 9.6 g/dL
  • 2023-12-11 HGB 8.1 g/dL
  • 2023-12-09 HGB 8.4 g/dL
  • 2023-12-09 HGB 8.5 g/dL
  • 2023-12-07 HGB 8.0 g/dL
  • 2023-12-05 HGB 8.7 g/dL
  • 2023-12-04 HGB 7.7 g/dL
  • 2023-12-02 HGB 9.7 g/dL
  • 2023-12-01 HGB 9.7 g/dL
  • 2023-11-27 HGB 9.8 g/dL

The patient should receive red blood cell transfusions as clinically indicated.

[VTd regimen administration schedule]

VTd regimen is supposed to be administered as following:

  • Bortezomib
    • 1.3 mg/m2 SC
    • Given as a single SC injection.
    • Days 1, 8, 15, and 22
  • Thalidomide
    • 100 mg for first 14 days then 200 mg per day thereafter by mouth
    • Take with water on an empty stomach at least one hour after the evening meal.
    • Daily, days 1 through 21
  • Dexamethasone
    • 40 mg by mouth
    • Take with food (after meals or with food or milk) in the morning.
    • Days 1, 8, 15, and 22

Bortezomib and dexamethasone were administered on 2023-12-20 (C1D1). However, thalidomide 100 mg daily was started ahead of schedule on 2023-12-14. To align with the administration cycle (28 days) and discontinue thalidomide on C1D22, it should be stopped on 2024-01-10.

[CMV viral load detected]

As of 2023-12-18, the CMV viral load was measured at 190 IU/mL. Depending on the clinical context and your concerns about this level, valganciclovir 900mg BID could be a potential treatment option.

700971109

231222

[exam findings]

  • 2023-11-14 CT - chest
    • Indication: Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype, CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-). Bone marrow involvement. Lugano stage IV, IPI 4.
    • Without & with contrast enhancement, coronal and sagittal reconstructed images shows: comparison made with CT on 2023/07/04
      • Lungs: patchy ground-glass opacities and septal thickening at nondependent LUL and medial RUL.
        • subpleural reticulation at both lower lungs, associated scattered patchy ground-glass opacities.
        • residual enlarged LN at left anterior perivascular space of the mediastinum.
        • resolution of lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, splenic hilum, paraaortic and left inguinal region as well as at left anterior chest wall.
      • Visible abdomen:
        • hyperplasia of left adrenal gland, stable.
        • interval significant decrease in size of low density at right lobe liver measuring 1cm and Lt renal tumor based on this F/U exam.
        • extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA, s/p MVR.
      • Pleura: no effusion
    • Impression:
      • resolution of the diffuse B-cell lymphoma in both sides of diaphgram and in extra-nodular locations, as compared with previous CT on 2023/07/04. post treatment related change in lungs.
  • 2023-07-26 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — lymphoma involvement
    • Section shows piece(s) of bone marrow with one nodule of lymphoma involvement.
  • 2023-07-25 CXR (erect)
    • S/P median sternotomy with metalic wires fixation. Please correlate with clinical history.
    • S/P mitral valve replacement.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2023-07-24 PET scan
    • Glucose hypermetabolism lesions in bilateral neck regions, SCF, ICF, axillae, mediastinum, abdomen, pelvis, left upper thigh and left inguinal regions, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the right lobe of the liver, and in C2 spine, right rib cage, bilateral pelvic bones and femurs, highly suspected lymphoma with involvement of liver, bones and/or bone marrow.
    • B-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-07-11 Patho - lymph node region resection
    • Lymph node, inguinal, left, excision — Diffuse large B-cell lymphoma, NOS, non-germinal center B-cell subtype
    • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(-), BCL6(+), MUM1(+) and MYC(-)
  • 2023-07-04 CT - chest
    • Generalized enlarged lymph nodesHe was informed to have abnormal LN enlargement over Rt axillary and Rt lower neck and Lt inguinal region
    • Chest CT with and without IV contrast ehnancement shows:
      • Lymphadenopathy at bilateral lower neck involving bilateral thoracic inlet, bilateral axillary, mediastinum, splenic hilum, paraaortic and left inguinal region.
      • One enlarged soft tisuse at left anterior chest wall, r/o meta.
      • s/p sternotomy with metalic wire fixation of the sternum.
      • s/p thymectomy.
      • Enlarged left adrenal gland is found.
      • Low density at right lobe liver is found with target appearance measuring 2.3cm in largest dimension. Liver meta is considered.
      • Soft tissue mass at left renal cortex measuring 3.58cm in largest dimension. r/o renal meta
    • Imp:
      • Extensive lymphadenopathy from lower neck to mediastinum and abdominal cavity as well as left inguinal region.
      • Liver, left adrenal and left renal soft tissue mass, meta is favored.
      • r/o thymoma with recurrence
  • 2023-06-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 37) / 93 = 60.22%
      • M-mode (Teichholz) = 59
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy
      • Trivial MR, mild AR and mild TR
      • Preserved RV systolic function

[MedRec]

  • 2023-08-18 SOAP Cardiology Xie JianAn
    • Prescription x3
      • Caduet (amlodipine 5mg, atorvastatin 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • carvedilol 6.25mg 0.5# QD (hold if HR < 60)

[immunochemotherapy]

  • 2023-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 50mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-10-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-09-19 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-08-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 48mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2
  • 2023-07-26 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 47mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-2

==========

2023-12-22

Serum uric acid levels sometimes exceed the normal range, and Feburic (febuxostat) has been prescribed for treatment. No medication discrepancies have been identified.

2023-10-06

[reconciliation]

The patient’s PharmaCloud records are not currently available. However, after reviewing HIS5, no medication discrepancies were found.

[leukopenia]

Leukopenia was noted in early Oct, approximately 2 weeks after his last R-CHOP treatment (3rd dose) on 2023-09-19. On 2023-10-04, the patient was started on G-CSF (filgrastim) 300mg SC QD. A slight improvement in WBC count was observed on 2023-10-06. There is no problem with the treatment.

2023-10-06 WBC 0.85 x10^3/uL
2023-10-04 WBC 0.65 x10^3/uL
2023-09-26 WBC 3.37 x10^3/uL
2023-09-18 WBC 4.63 x10^3/uL

2023-09-19

  • On 2023-08-18, our cardiologist provided a repeat prescription for Caduet (amlodipine, atorvastatin), Plavix (clopidogrel), and carvedilol, each with a 3x28-day supply. These medications are currently being taken as prescribed without any reconciliation issues detected.

700021401

231219

[lab data]

  • 2023-11-26 Aerobic Culture - Wound/Pus
    • Proteus mirabilis Growth:3+
      • Doripenem(S), Amilkacin(S =2), Flomoxef(S =2), Gentamicin(S =1), Imipenem(S), Ceftriaxone(S =1), Ampicillin(R >=32), Cefazolin(other)(R 8), Cefoperazone/Sulbactam(S =8), Ciprofloxacin(S =0.25), Amoxicillin/Clavulanic Acid(R), Cefazolin(Urine)(S 8), Piperacillin/tazobactam(S =4), Levofloxacin(S =0.12)
    • Escherichia coli Growth:3+
      • Gentamicin(S =1), Flomoxef(S =2), Cefazolin(Urine)(R >=64), Ceftriaxone(R >=64), Ciprofloxacin(S =0.25), Levofloxacin(S =0.12), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S =4), Ampicillin(R >=32), Doripenem(S =0.12), Imipenem(S =0.25), Cefoperazone/Sulbactam(S 16), Amilkacin(S =2), Amoxicillin/Clavulanic Acid(R)
    • VREfm(E.faecium) Growth:3+
      • Teicoplanin(R >=32), Vancomycin(R >=32), Gentamicin High Level Resistance(S SYN-S), Penicillin(R >=64), Linezolid(S), Erythromycin(R >=8)
  • 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
    • Pseudomonas aeruginosa
      • Piperacillin/tazobactam(S 8), Amilkacin(S =2), Cefepime(S =1), Levofloxacin(S 1), Ceftazidime(S 4), Imipenem(S 1), Ciprofloxacin(S =0.25), Colistin(S =0.5), Gentamicin(S =1)
  • 2023-11-25 Blood Culture - Whole Blood - Gram Strain: GNB
    • Pseudomonas aeruginosa
  • 2023-10-10 Aerobic Culture - Wound/Pus
    • Escherichia coli Growth:3+
      • Flomoxef(S =2), Ciprofloxacin(S =0.25), Cefoperazone/Sulbactam(S 16), Amoxicillin/Clavulanic Acid(R), Doripenem(S =0.12), Cefazolin(Urine)(R >=64), Gentamicin(S =1), Cefazolin(other)(R >=64), Piperacillin/tazobactam(S 8), Ceftriaxone(R >=64), Ampicillin(R >=32), Levofloxacin(S =0.12), Imipenem(S =0.25), Amilkacin(S =2)
  • 2023-10-10 Anaerobic Culture - Wound/Pus
    • Bacteroides fragilis Growth:2+
      • Clindamycin(S), Tetracycline(R), Metrenidazole(S), Ampicillin/Sulbactam(I), Penicillin(R), Cefoperazone(R)
  • 2023-10-03 Aerobic Culture - Sputum
    • Mixed normal flora Growth:4+
    • Staphylococcus aureus Growth:4+
      • Rifampin(S =0.5), Vancomycin(S 1), Erythromycin(R >=8), Linezolid(S 2), Trimethoprim/Sulfamethoxazole(S =10), moxifloxacin(S =0.25), Daptomycin(S 0.25), Fusidic Acid(S =0.5), Penicillin(R >=0.5), Teicoplanin(S =0.5), Tetracycline(R >=16), Tigecycline(S =0.12), Oxacillin MIC(S), Clindamycin(S =0.25)

[exam findings]

  • 2023-12-06 ENT Hearing Test
    • Reliabilty Poor
    • PTA
      • R’t : 55 dB HL, moderate to severe mixed type HL
      • L’t : 63 dB HL, moderateto profound mixed type HL
    • Tymp
      • Bil Type C
    • ART
      • Bil absent.
  • 2023-12-05 ECG
    • Atrial fibrillation with premature ventricular or aberrantly conducted complexes
    • Right bundle branch block
    • T wave abnormality, consider inferolateral ischemia
  • 2023-12-05 CXR
    • S/P Port-A infusion catheter insertion.
    • Patch density at RUL.
    • Atherosclerosis of the aorta.
  • 2023-11-25 CXR
    • S/P port-A implantation.
    • Patchy consolidation projecting at right upper lung is noted. Please correlate with clinical condition to rule out Bronchopneumonia.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-11-07 Patho - brain biopsy
    • PATHOLOGIC DIAGNOSIS
      • Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: stereotactic biopsy
      • Topology: left hippocampus
      • Specimen size and number: multiple fragments, up to 0.4 x 0.2 x 0.1 cm
      • All embedded for section [Reference: frozen, F2023-00496 one tiny piece measured 0.2 x 0.1 x 0.1 cm]
    • MICROSCOPIC EXAMINATION
      • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli, frequent mitoses and starry-sky feature
      • Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells. Clinical correlation is advised.
  • 2023-11-07 CXR
    • Supine chest film shows:
      • Presence of borderline cardiomegaly by cardiac/thoracic ratio.
      • Presence of calcification of the intima at the aortic knob.
      • No obvious lung patchy density or nodule.
  • 2023-11-07 Frozen Section
    • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis.
  • 2023-11-06 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-11-06 ECG
    • Atrial fibrillation
    • Right bundle branch block
    • Abnormal ECG
  • 2023-11-02 CT - brain for navigator
    • Clinical information: R/O secondary CNS lymphoma
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • One lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe.
      • The size of the lateral and third ventricles appears normal.
      • Prominent peritumoral edema.
  • 2023-10-31 MRA - brain
    • Clinical information: R/O secondary CNS lymphoma
    • Findings:
      • Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2023-10-31 EEG
    • The back ground activity were composed by alpha rhythm with 8-12 Hz, 20-50 uv in bilateral occipito-temporal area.
    • There were diffuse beta waves with 15-25 Hz, 1-5 uV in bilateral hemisphere.
    • No epileptiform discharge was noted. Intermittent muscle artifact may interference with interpretation.
    • The above findings may suggest normal EEG study. Advice clinical correlation
  • 2023-09-29 CT - abdomen
    • History and indication: Two weeks ago, the patient had chemotherapy. Now he feel unwell all over his body, and his bowel movements are not smooth.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some small LNs at retroperitoneum and right axillary region.
      • Splenomegaly.
      • Renal cysts (up to 2.4cm).
      • Mild enlargement of prostate.
      • Hyperplasia of right adrenal gland.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Focal GGO at bilateral lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Some small LNs at retroperitoneum and right axillary region.
      • Splenomegaly.
  • 2023-09-08 PET
    • In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared.
    • Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely.
    • Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-09-07 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right upper lung and left middle lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-08-25 CT - abdomen
    • History and indication: reccurent DLBCL involving right lung, liver, spleen and multiple bone marrow, Lugano stage IV
    • Findings:
      • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
      • Prior CT identified some LNs (up to 1.2cm) at para-aortic space and para-cava space are noted again, decreasing in size to 0.6 cm.
      • Prior CT identified enlarged node at right axillary region is noted again, stationary.
      • Prior CT identified some low attenuations in the spleen are noted again, stationary that may be old infarction.
      • Renal cysts (up to 2.4cm).
      • Hyperplasia of right adrenal gland.
      • There is mild bilateral Pleura effusion and pericardial effusion.
      • There is a poor enhancing lesion 7 mm in S4 of the liver that may be cyst. Please correlate with sonography.
    • Impression:
      • There are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected. please correlate with clinical condition.
  • 2023-08-16 SONO - abdomen
    • Diagnosis:
      • cholecystopathy, unknown etiology
      • GB polyp
      • Renal cyst, left
      • pancreatic neck cystic lesion, suspicious, IPMN
      • splenomegaly, mild
      • Pleural effusion, left
      • Enteropathy, uknown etiology.
    • Suggestion:
      • correlate with other image
  • 2023-08-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 29) / 78 = 62.82%
      • LVEF(%) = 63
      • M-mode(Teichholz) = 63
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; atrial fibrillation (elevated average E/e’).
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS and AR; mild MR; mild to moderate TR.
      • Minimal pericardial effusion without tamponade and constriction sign.
  • 2023-08-02 24hr portable ECG
    • Atrial fibrillation thoughout the holter recording period
    • HR:47-165 bpm, AVE:85 bpm
    • Intraventricular conduction delay
    • Longest R-R interval 2.01 secs at 04:40
  • 2023-05-25 CT - abdomen
    • History and indication: reccurent DLBCL involving right lung,liver,spleen and multiple bone marrow, Lugano stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
      • Some low attenuations in spleen.
      • Renal cysts (up to 2.4cm).
      • Hyperplasia of right adrenal gland.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Some LNs (up to 1.2cm) at retroperitoneum and right axillary region.
      • Some low attenuations in spleen.
  • 2023-03-13 Peropheral Vascular Test - AV fistula
    • Result: adequate size of RIJV
  • 2023-03-10 PET
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
    • In comparison wih the previous study on 2022/05/05, more new FDG avid lesions are noted, suggesting lymphoma in progression.
  • 2023-01-31 Spirometry
    • DLCO 48 -> 66 -> 73%
    • TLC: 88%
  • 2022-11-08 CXR
    • RRt paratracheal stripe thickening
    • reticular opacities and hazy areas of increased opacities over both lungs scatteredly
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • mild enlarged cardiac silhoutte
  • 2022-11-02 Spirometry
    • TLC: 82%.
    • DLCO 66% improved
    • FEV1/FVC<75%.
  • 2022-08-16 Spirometry
    • TLC: 68%.
    • DLCO 48%.
  • 2022-05-05 PET
    • The FDG PET findings are compatible with recurrent lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above and involving the bone marrow of left femoral shaft (stage IV).
    • Glucose hypermetabolism in a a focal area in the left humeral shaft. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in multiple focal areas in bilateral lung fields. Inflammation is more likely.
  • 2022-04-26 CT - chest
    • History of relapsed lymphoma over neck and mediastinum post autoPBSCT
    • Comparison made with previous CT dated on 2022/01/11
      • Lungs:
        • extensive centrilobular micronodular and branching opacities associated scattered lobular areas of ground-glass opacity
        • focal minimal paraspinal fibrosis in RLL, related to osteophytes of spine.
        • a subpleural paraseptal emphysema at medial right apical lung region.
      • Pleura:
        • minimal bilateral pleural effusions.
        • small pericardial effuion.
      • Mild atherosclerotic change of the aortic arch and descending thoracic aorta. mild coronary arterial calcification.
      • An irregular soft-tissue lesion at Rt axilla (19 mm in longest axial dimension), stationary in size as compared with CT on 2022/1/11
      • Neck, mediastinum and hila: multiple enlarged LNs in visceral space of the mediastinum.
      • Visible abdomen and pelvis:
        • unremarkable of the liver, Rt kidney, spleen, adrenal glands, and pancreas. Several left renal cysts up to 25 mm.no enlarged LNs. mild enlarged prostate.
    • Impression:
      • post treatment change in Rt axillary region, stationary.
      • lung infection, infectious bronchiolitis.
      • new neoplastic LAP in the mediastinum.
  • 2022-02-15 SONO - chest
    • Echo diagnosis:
      • pleural effusion, trivial amounts located over left CP angle.
      • Favor arrhythmia, heart failure related pleural effusion and history of pneumonia before.
  • 2022-02-14 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-01-18 ECG
    • Sinus rhythm with Premature atrial complexes
    • Possible Left atrial enlargement
    • Right bundle branch block

[MedRec]

  • 2023-10-02 ~ 2023-12-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/03, 11/04. Recurrent brain metastsis on 2023/11/07 S/P Left navigation assisted biopsy for temporal hippocampus lesion
      • neutropenia with Sepsis blood culture: GNB -> Pseudomonas aeruginosa
      • Aspiration pneumonia progression sputum culture; Staphylococcus aureus Growth:4+ on 2023/10/03 and the CXR film revealed LUL cavitation, despite broad spectrum antibiotic, S/P receiving high-flow nasal cannula
      • nystagmus due to brain metastasis and brainstem compression
      • anal perianal abscess S/P fistulotomy + debridement + drainage on 2023/11/29 pus culture: Escherichia coli Growth:3+
      • Hypomagnesemia
      • Anemia due to Myelosuppression
      • Thrombocytopenia due to Myelosuppression
      • Hypokalemia
      • memory loss due to brain metastasis related
    • CC
      • fever without chills and dyspnea for 4 days
    • Present illness
      • This 71-year-old man was relatively well until June 2019. He first noticed a mass lesion at right side axillary when June 2019. He went to the ZhengXing Hospital for workups and splenic lesion was demonstrated as well. The axillary LN biopsy confirmed the diagnosis of diffuse large B cell lymphoma.
      • The PET examination also disclosed dissimentated involvement of the disease, including multiple LNs, spleen, skull, spine and bone marrow, Lugano stage IV. The Bone marrow biopsy from the iliac bone (2019-08-22) also had bone marrow involvement of lymphoma with IHC characteristics of the following: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-).
      • After the above staging workups, he had chemotherapy with R-DA-EPOPCH regimens for 6 cycles (from 2019/08/23 to 2020/01/03) without special events for his diffuse large B cell lymphoma with bone marrow involvement, Lugano stage IV with R-DA-EPOPCH with recurrence, he was admitted to hematology ward (from 2021/04/18 to 05/03) for restaging workups.
      • Bone marrow biopsy was done on 2021/04/19, and the pathology report no lymphoma involvement in the bone marrow. The left side neck LN’s pathology confirmed the DLBCL in nature.
      • Chemotherapy with R-DHAP (C1) on 2021/4/29 to 2021/5/2 but he tolerated it poorly.
      • He received C1 Pola-BR (Polatuzumab 1.8mg/kg on D1, Mabthera 375mg/m2 on 2021/5/28 D1, self paid of Bendamustine 90mg/m2 on D2-D3) on 2021/5/28-30.
      • C2 P-BR on 6/28-30 and received autologus stem cell transplantation on 2022/10/29-11/3.
      • PET was performed on 2023/3/10 revealed lymphoma involving multiple lymph nodes on both sides of the diaphragm and involving right lung, liver, spleen and multiple bones/bone marrow as mentioned above (stage IV).
      • Under the impression of Recurrent Diffuse large B-cell lymphoma involving right lung, liver, spleen and multiple bones/bone marrow, Lugano stage IV, status post autoPBSCT on 2021/11/3, 11/4, PS 1, post C1 selfpaid of P-BR on 2023/03/15 - 03/16.
      • C2 selfpaid of P-BR on 2023/4/25-4/26. C3 selfpaid of P-BR on 2023/05/24-25. Neulasta was given after the chemotherapy. C4 P-BR on 2023/07/17 - 07/18, C5 P-BR on 2023/09/15 - 09/16.
      • Follow-up abdominal CT (2023/08/25) showed there are several newly developed patchy ground-glass opacities with air-bronchogram at both lungs. Bronchopneumonia is highly suspected.
      • PET scan (2023/09/08) revealed lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture.
      • This time, general malasie for 2-3 days and mild dyspnea were noted on 09/29 23 and visited to ER for aid and antibiotic with Cefim was given then shifted to Ceficin 2# po q12h x 3 days for take home. Fever (37.1 degree C) without chills and mild cough without sputum and dyspnea were also developed on 9/30 23 and came to our infection OPD for aid and laboratory shwoed leukopenia (WBC = 1.46 x10^3/uL) and Lenograstim 250mcg sc x 2 days was given. The Laboratory shwoed WBC = 0.46 x10^3/uL, seg:6.2% ANC: 28.5, Monocyte = 47.5 %, Creatinine = 1.36 mg/dL.
      • Under the impression of neutropenia fever. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, hydration, antibiotic with Cefim/Targocid/G-CSF 300mg sc were given for neutropenia fever. The White blood cells rise slowly was noted. Blood transfusion with LPRBC 2U & LRP 2PH was given on 10/5 23 for anemia & thrombocytopenia.
      • Sudden onset of dysuria & bladder distension and residual urine volume about 400cc by ICP were noted and we consulted uro for difficulty intubating and advisted to I have successfully inserted a 22Fr three-way Foley catheter. Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
      • Intravenous KCL/Const-K and MgSo4 were administered for hypokalemia & hypomagnesemia. He complained of tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge for days and rectal surgical Dr was consulted for evaluation and advisted to empyric antibiotic drugs treatment/Biomycin onitment for topic use/if s/s got worse then call us again for I&D.
      • Blood transfusion with LRP 2PH was given on 10/9 23 and anal absecss I & D was done and collected pus culture.
      • Blood transfusion with LPRBC 2U 10/11 & LRP 2PH was given on 10/13 & 10/16 23 for anemia & thrombocytopenia. The pus culture Aerobic/Anaerobic yeilded Escherichia coli Growth:3+/Bacteroides fragilis Growth:2+ and antibiotic shifted to Tapimycin 4.5mg ivd q6h since 10/17 23 by infection Dr suggested. Sudden onest of hematuria & blood colt obstruction via foley cather was developed on 10/17 23 at 3:00 AM and foley irrgation with normal saline 2000cc qd and Transamin 1# po bid were given and contact uro Dr for evaluation again.
      • Blood transfusion with LPRBC 2U 10/16 & LRP 2PH was given on 10/23 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 23 for anal infection.
      • Blood transfusion with LRP 2PH was given on 10/26 23 & LPRBC 2U on 10/28 23 for anemia & thrombocytopenia. Tapimycin 4.5mg ivd q6h qas given since 10/17 to 10/30 23 for anal infection. He complained of memory loss in recent 3 days and we consulted neuro for further evaluation.
      • Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia. CT Brain for Navigator (11/2 23) showed one lobulated enhancing lesion (3.5cm in size) over left medial temporal lobe. The size of the lateral and third ventricles appears normal. Prominent peritumoral edema.  We consulted neurosurgery for biopsy evaluation and will arrange biopsy on 11/7 23. Intravenous Dexa 4mg ivd q6h + Mannitol 100ml IVD q8h were added for peritumoral edema & IICP sign. Keppra 500mg ivd q12h was added. Anti-fungus infection was suspected by brain MRA exam and anti-fungus drugs was added by Dr 李啟誠 suggested.
      • Brain MRA (10/31 23) showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Brain biopsy was done on 11/7 23 and he was transferred to SICU for further treatment on 11/7 23.
      • G-CSF 300mg sc was given for neutropenia. Blood transfusion with LRP 2PH was given on 10/31, 11/3, 11/5 23 for thrombocytopenia.
      • Left hippocampus tumor, frozen + stereotactic biopsy (11/10 23) proved Diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells.  
      • Keppra shifted to oral form since 11/14 23. We consulted radiologist for radiotherapy evaluation and advisted to preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor. Radiotherapy started since 11/14 23 and Dexa 4mg ivd was added.
      • Right face reddish, swelling and pain was noted cellulitis was suspected and septic work-up was performed and antibiotic with Augmentin was given since 11/14 23. He complained of severe anal pain and pus yellowish dischage in recent days and constact rectal surgical again for evaluation and suggested to Fistulotomy or fistulectomy,compliitated subcutaneous on next week. Ultracet 1# po q6h was added for pain control.
      • Fistulotomy or fistulectomy,compliitated subcutaneous on 11/27 23. Owing to abnormal liver function was noted and Ultracet change to prn used. Sudden onest of fever with chills was developed on 11/25 23 night and septic work-up was performed and G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed GNB. Sudden onest of fall down (the patient walked out of the bathroom and fell forward without knowing how it happened) was found on 11/26 23 and without any discomfort or trauma wound. He complained of his jaw had been always clenched for days and neuro was consulted for evaluation.
      • G-CSF 300mcg sc qd + antibiotic with Cefim 2mg ivd q8h were administered for neutropenia fever with sepsis. The blood culture (port-A & peripheral )showed Pseudomonas aeruginosa. Consulted Neuro for evaluation and advisted to arranged EEG. Anal culture revealed E coli & VRE to sensitive anti treatment. blood transfusion with LRP 2PH was given on 12/3 23. Repeat blood culture x 2 on 11/30 23.
      • Blood transfusion with LRP 2PH was given on 12/7 23. Repeat blood culture x 2 showed negative. Romiplate 250mcg was given on 12/8 23.
      • Hold Radiotherapy on 12/11 23 due to poor condition. G-CSF 300mcg sc qd .Blood transfusion with LRP 2PH & LPRBC 2U were given on 12/12-12/14 23. Sudden onest of fever with chills and dyspnea were noted on 12/11 23 and CXR showed ARDS, bilateral pneumonia and pulmonary edema and septic work-up was performed and antibiotic with antibiotic with Bestnem 500mg ivd q6h since 12/11, Targocid 600mg ivd qd since 12/12, Mycamine 100mg ivd qd since 12/11 for R/O fungus infection hydration/ Albumin 50mg (self-paid)+ Lasix 1amp ivd q12h on 12/12-12/14 23 & Sevatrim 10mg in N/S 250ml IVD q8h and Norepinephrine 8mg + D5W 250ml were given and O2 therapy with HFNC total flow:60L, O2 flow:40L/74%/Medason 40mg ivd q8h were added for sepsis with septic shock , ARDS, pulmonary edema and bilateral pneumonia. Intravenous KCL 10cc in N/S 250ml IVF 2hrs was given for hypokalemia. Follow-up CXR showed pulmonary edema improving and bilateral pneumonia remain.
      • There is pneumonia progression and the lastest yeterday CXR film revealed LUL cavitation, despite broad spectrum antibiotic, including Tienam, Targocid, iv Baktar, and Mycamine combination therapy.Suspect seizure with hand tremor noted yesterday, which may be related to Tienam use.Since there is cavitation and high PCT level one week ago, that PJP possibility is not hight.Patient is receiving high-flow nasal cannula now, that intubation indicated for him.But patient refused intubation and DNR consent already been signed. antibiotic shifted to DC Tienam, Targocid, Mycamine and PJP/Add Mepem, Zyvox, and Cresemba. Follow up serum Aspergillus antigen titer again by infection De suggested.
      • Owing to nystagmus was happened on 12/16 afternoon and Keppar shifted to IV from 750mg q12h for symptom relief. Neurologist revisits patient again on 12/18 23 and explained his poor condition to his family and suggested add Morphine 3mg ivd prnq6h for symptom relief.
      • Consciousness coma & dyspnea were noted and EKG monitor showed asystole, no respiratory movement, pupil size dilated and he was expired at 04:24 AM on 11/19 23.
      • skin: right upper lip black scab & left 2nd hand reddsih scab, Pseudomonas aeruginosa infection related by infection Dr said, if wound pus will collect pus culture and wating blood culture report.
      • The patient reported shortness of breath but refused intubation. The patient’s wife was informed of the current condition and that not intubating would lead to respiratory failure. The patient and the wife expressed they could understand clearly. Infection specialist Dr. Peng MingYe visited the patient and explained the current condition and medication treatment to the family. Oxygen can be changed to high flow used. The patient still refused to put in a nasogastric tube.
  • 2023-09-18 SOAP Cardiology Ye GuanHong
    • Prescription x3
      • Urief (silodosin 8mg) 1# HS
      • spironolactone 25mg 0.5# QD
      • Multaq (dronedarone 400mg) 1# BID
      • Lixiana (edoxaban 30mg) 1# QD
      • Atozet (ezetimibe 10mg, atorvastatin 20mg) 1# QN
      • Wecoli (bethanechol 25mg) 1# BID
      • Nirandil (nicorandil 5mg) 1# BID

[consultation]

  • 2023-11-10 Radiation Oncology
    • Q
      • For radiotherapy evaluation
      • This 71 year old man is a retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-03, disease recurrent on 2023-03, s/p Pola-BR with image complete remission (2023-09 PET).
      • This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days. Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
      • The Left hippocampus tumor, frozen + stereotactic biopsy (11/9 23) proved diffuse large B-cell lymphoma, Immunohistochemistry: CK(-), GFAP(-), CD3(-), CD20(+), Bcl-2(+), CD10(-), Bcl-6(+), C-MYC(+, 30%), MUM-1(+) and Ki-67(>90%) for tumor cells.
      • We need your expertise for further evaluation thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to brain metastasis with memory loss.
        • PI: The patient suffered from memory loss for about 2 weeks. MRI of brain (2023-10-31) showed focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
      • O: ECOG: 1
        • PE: poor memory function.
        • PET (2019-8-16): 1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, spleen and multiple bones or bone marrow as mentioned above. Please correlate with other clinical findings for further evaluation. 2. A mild glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined (lymphoma? inflammatory process? other nature?).
        • Pathology (S2019-14043, 108-8-26): Bone marrow, iliac, clinical history of diffuse large B cell lymphoma dignosed inJune 2019, biopsy — Lymphoma involvement, B cell type, IHC stains: CD3 (-), CD20 (+). bcl-2 (+), bcl-6 (equivocal, -/+), CD10 (-). The pattern is compatible with large B cell lymphoma.
        • CT scan of lung (2019-11-27): normal appearance of lungs based on this follow up CT study. Rt axillary tumor lesion.
        • CT scan of lung (2020-3-17): Minimal nonspecific inflammation in RLL, paravertebral region. Rt axillary mass lesion, in regression.
        • PET (2020-3-25): 1. Almost all glucose-hypermetabolic lesions disappear including multiple lymph node regions on both sides of the diaphragm, spleen, and skeleton compared with the previous study on 2019-08-16, indicating lymphoma with good response to current therapy. 2. Glucose hypermetabolism involving vocal cord and post. wall of pharynx, probably inflammation process. 3. Glucose hypermetabolism in the myocardium of the right ventricle, suggesting pulmonary dysfunction.
        • Pathology (s2020-05124, 2020-4-28): Bone marrow, iliac, history of lymphoma in 2019, biopsy — Negative for malignancy. IHC stains: LCA (15% of the nucleated cells). CD and CD20 no monoclonality. Bcl-2 (-), bcl-6 (-).
        • CT scan of lung (2020-6-16): Minimal nonspecific inflammation or fibrosis in RLL related to aging, paravertebral region. Rt axillary mass lesion, stationary based on CT exam.
        • RT (2020-7-3 ~ 2020-7-31): 3600cGy/20 fractions of the right axillary area.
        • CT: Lung/Mediastinum/Pleura (2020-9-17): Right axillary lesion. Mildly decreased in size. Splenic lesion, r/o hemangioma. Suggest MRI, if necessary. Enlarged prostate, please correlate with PSA.
        • PET (2023-9-8): 1. In comparison with the previous study on 2023/03/10, the previous FDG avid lesions in multiple lymph nodes on both sides of the diaphragm and in the right lung, liver, spleen and multiple bones/bone marrow disappeared. 2. Increased FDG uptake in some focal areas in bilateral lungs and in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation/infection may show this picture. 3. Increased FDG uptake in a focal area in the left aspect of the maxilla. Dental problem is more likely. 4. Increased FDG uptake in a focal area in the left lobe of the liver, in a focal area in the region about the spinal cord of T12 level and in the region about the lower portion of the rectum. The nature is to be determined (inflammation/infection? other nature?).
        • MRI of brain (2023-10-31): 1. Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis. Suggest clinical correlation. 2. Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation. 3. MR angiography of the brain shows normal intracranial vessel including circle of willis.
        • Pathology (S2023-22180, 2023-11-9): Left hippocampus tumor, frozen + stereotactic biopsy — Diffuse large B-cell lymphoma
      • A: Large B cell lymphoma, stage IV, s/p chemotherapy, with residual tumor over right axillary area, s/p radiotherapy, with recurrence s/p autologous stem cell transplantation, with brain metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 2340cGy/13 fractions of the whole brain, and 3600cGy/20 fractions of the metastatic brain tumor
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, the treatment planning of radiotherapy will be started at 1330, 2023-11-13.
  • 2023-11-01 Neurosurgery
    • Q
      • For tissue biopsy?
      • This 71 year old man, retired Oral and Maxillofacial Surgery Chief of the Tri-Service General Hospital (underline CAD, HTN and PAf), is a case of Diffuse large B cell lymphoma, diagnosis on 2019-08, Lugano stage IV with R-DA-EPOPCH with recurrence s/p Pola-BR and then autologoud stem cell transplantation on 2022-11-3, disease recurrent on 2023-3, s/p Pola-BR with image complete remission (2023-09 PET). This time, he was admiited due to neutropenia fever after chemotherapy. During this time, he suffered from memory loss in recent 3 days.
      • Brain MRA showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size). Also presence of peritumoral subcortical edema. Highly suspect lymphoma or other metastasis.
      • We need your expertise for further evaluation (tissue biopsy?). Thanks a lot.
    • A
      • A case of 71 y/o male, Diffuse large B cell lymphoma s/p C/T. Fever?
        • Memory impairment noted for days; NS is consulted for left temporal intraaxial lesion. Biopsy evalaution.
        • A brain MRI showed Focal area of water-restriction over left medial temporal lobe with one lobulated enhancing lesion (3.5cm in size).
      • P: please arrange brain CT with contrast for NAVIGATION; Brain biopsy will be performed after well explanation of surgical benefits and risks to him.
  • 2023-10-30 Neurology
    • Q
      • for memory loss in recent 3 days
      • The 71 y/o man has DLBCL s/p auto-PBSCT. This time, he was admitted for neutropenia fever stage. He complained of memory loss in recent 3 days. We need expertise to his condition thanks!
    • A
      • O
        • CN: intact
        • MP: full
        • Gait: intact
      • Suggestion:
        • Arrange EEG
        • Arrange brain MRA with contrast in case of secondary CNS lymphoma
        • Check free T4, TSH, vit B12, folic acide, homocysteine, and RPR
      • I will F/U this case
        • Thanks for consultation
        • Feel free to contact me if you have any problem
  • 2023-10-03 Urology
    • Q
      • for dysuria and feeling like he can’t finish urinating
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
    • A
      • I have successfully inserted a 22Fr three-way Foley catheter.
      • Please keep the catheter in place for at least one week and prescribe Harnalidge to increase the success rate of catheter removal.
      • Arrange Dr. Hsu’s OPD’s follow up after discharge. Thank you for your consultation!
  • 2023-10-03 Colorectal Surgery
    • Q
      • for anal pain progression
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for with neutropenia fever stage. Due to anal pain progression noted for days. We need expertise to his condition thanks!
    • A
      • This is a 71-yr old man with anal pain for days
        • hx: DLBCL /p auto-PBSCT
        • DRE: tenderness perianal and anal canal about 6o’clock region, no fluctuation, no pus discharge
      • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
      • P: empyric antibiotic drugs treatment
        • Biomycin onitment for topic use
        • if s/s got worse then call us again for I&D
        • we will also closely follow up this case
    • A 2023-10-09 17:50:49
      • CC: much anal pain was told
      • PE: fluctuation was found
      • A/P: perianal abscess
        • I&D with epineprhine gaunze wet dressing was done
        • explaint the possilbe of anal fistula
    • A 2023-11-11 08:18:16
      • CC: bloody discharge was told 2 days ago
      • PE: one 0.2cm pin hole over 6 o’clock region with clear fluild discharge when compression
      • A: R/I anal fistula over 6 o’clock region
      • P: wound cd and biomycin local treatment
  • 2023-08-21 Colorectal Surgery
    • Q
      • The 71 y/o man has DLBCL /p auto-PBSCT. This time, he was admitted for sepsis with neutropenia stage. Due to anal pain, so we need your help for management. Thanks!
    • A
      • This is a 71-yr old man with anal pain for 2 days
        • hx: DLBCL /p auto-PBSCT
        • DRE: tenderness perianal and anal canal about 6 o’clock region,no fluctuation, no pus discharge, mild tenderness over 12 o’clock region
      • A: anal pain, R/I perianal abscess, R/I DLBCL induce anal pain
      • P: empyric antibiotic drugs treatment add alcos anal onitment topic treatment
        • if s/s got worse then call us again for I&D
  • YYYY-MM-DD xxxxxxxxxx
  • YYYY-MM-DD xxxxxxxxxx
  • YYYY-MM-DD xxxxxxxxxx

[surgical operation]

  • 2023-11-29 - Op Method: fistulotomy + debridement + drainage
    • Finding:
      • one anal fistula over 6o’clock region (extra-sphincter type)
    • Procedure:
      • Under IVG anesthesia ,the outer and internal opening was wide opening and curretage and irrigation with large amount of H2O.
      • The internal opening was closed with 3-0 vicryl and outer opening was layed opened.
      • Check bleeding and pack the wound with gaunze.
  • 2023-11-07   - Op Method: Left navigation assisted biopsy for temporal hippocampus lesion
    • Finding:
      • Four pieces of soft yellowish brain tissue obtained by stereotactic biopsy from left temporal lobe.
    • FROZEN SECTION REPORT
      • Left hippocampus tumor, frozen — Atypical lymphoid hyperplasia. Please pending for followed IHC for final diagnosis
    • Procedure:
      • Under ETGA, Mayfield clamp was appied and Metronic NAVIGATION was set for target plans. After proper disinfection and draping, A 3 cm-long scalp incision was made in left temporofrontal region. A burr hole was made and the dura was tented to the pericranium. The dura was incised in the cruciate fashion. The side-cutting type biopsy needle was inserted. The obtained specimens were sent to pathology for diagnosis. Frozen section, cultures and permient section were harvested. Hemostasis with bipolar coagulation and FLOSEL. The wound was closed in layers. 

[chemoimmunotherapy]

  • 2023-09-15 - polatuzumab vedotin 1.8mg/kg 90mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 142mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-07-17 - polatuzumab vedotin 1.8mg/kg 105mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-05-24 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-04-25 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2023-03-15 - polatuzumab vedotin 1.8mg/kg 112mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 8hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D1-2 + NS 250mL D1-2 + acetaminophen 500mg PO D1
  • 2021-10-27 - busulfan 3.2mg/kg 210mg NS 300mL 3hr D1-3 + etoposide 400mg/m2 690mg NS 250mL 6hr D3-4 + cyclophosphamide 50mg/kg 3300mg NS 500mL 4hr D5-6
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1-3 + granisetron D4-6 + NS 250mL D1-2
  • 2021-09-03 - etoposide 500mg/m2 400mg NS 1000mL 4hr D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-3
  • 2021-06-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
  • 2021-05-28 - polatuzumab vedotin 1.8mg/kg 113mg NS 50mL 90min D1 + rituximab 375mg/m2 600mg NS 500mL 6hr D1 + bendamustine 90mg/m2 150mg NS 250mL D1-2 (BR, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D2-3 + NS 250mL D1-3 + acetaminophen 500mg PO D1
  • 2021-04-29 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cisplatin 100mg/m2 170mg NS 500mL 24hr D2 + cytarabine 2000mg/m2 3400mg Q12H D2-3 + dexamethasone 20mg BID PO D1-5
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-4 + NS D1-3
  • 2020-01-30 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D1-4 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D5 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO
  • 2020-01-03 - rituximab 375mg/m2 600mg NS 500mL 6hr D1 + [etoposide 50mg/m2 84mg doxorubicin 10mg/m2 16mg vincristine 0.4mg/m2 0.5mg NS 1000mL] 24hr D2-5 + prednisolone 60mg/m2 50mg PO BID D1-5 + cyclophosphamide 750mg/m2 1200mg NS 100mL 30min D6 (R-DA-EPOCH Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + acetaminophen 500mg PO

Romiplate (romiplostim 250ug) ST SC

  • 2023-11-17 IPD
  • 2023-10-31 IPD
  • 2023-10-24 IPD
  • 2023-09-07 OPD
  • 2023-08-31 OPD
  • 2023-08-26 IPD
  • 2023-08-08 OPD
  • 2023-07-27 OPD
  • 2023-07-20 OPD

==========

2023-11-23

[atrial fibrillation]

Multaq (dronedarone) and Lixiana (edoxaban) were prescribed for the patient’s atrial fibrillation (AF) in a repeat prescription issued by our cardiologist on 2023-09-18. These medications are not currently being used. Please confirm whether there is a contraindicated condition or if the medications are no longer necessary.

2023-07-17

Our cardiologist prescribed Urief (silodosin), spironolactone, Multaq (dronedarone), Lixiana (edoxaban), Atozet (ezetimibe, atorvastatin), Wecoli (bethanechol), and Nirandil (nicorandil) on 2023-06-28, and these drugs are correctly included in the active formulary, so no reconciliation issues were found.

700843887

231219

[exam findings]

  • 2023-11-02 SONO - abdomen
    • Diagnosis:
      • Propable liver cyst, left
      • Suspected fatty infiltration of pancreas
      • S/p cholecystectomy
      • Suboptimal examination of liver,especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
    • Suggestion:
      • OPD f/u
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-10-27 Patho - lymphnode biopsy
    • Neck mass, right, sono-guide biopsy — Squamous cell carcinoma
    • Microscopically, the section shows a picture of squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltrating in desmoplastic stroma.
  • 2023-10-13 MRI - nasopharynx
    • Findings
      • a nodular lesion in the right thyroid gland
      • a heterogeneous enhancing nodular lesion, about 29.7mm, in the right upper neck, just anterior to the right SCM with tumor attachment to it. THe other heterogeneous enhancing nodular, about 9.8mm in the right carptod spaces.
      • unremarkable change in the nasopharynx, oropharynx and hypopharynx.
      • post-OP change in the right oral cavity.
    • IMP:
      • heterogeneous enhancing nodules in the right neck.
  • 2023-04-10 Patho - oral cancer (wide excision without lymph node)
    • Diagnosis:
      • Oral mucosa, right floor of mouth, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVA, pT4aNx (if cM0)
      • Mandible, right side, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
      • Mandible, right side, alveolar bone, large, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
      • Mandible, right side, alveolar bone, small, marginal mandibulectomy —- Squamous cell carcinoma, by direct invasion
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma,
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) bone (main specimen), alveolar bone large, and alveolar bone small.
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: not recived
      • F2023-00154:
        • Sections of specimens A, B, C, and D show fibrous tissue without malignancy.
        • Section os specimen E ulcerated tissue with granulation tissue and acute and chronic inflammation. No malignancy is seen.
  • 2023-04-06 MRI - nasopharynx
    • Findings:
      • The current study was compared to the prior one obtained on 2022/09/09.
      • Known a case of right buccal cancer and right mouth floor cancer S/P operation. Newly-developed enhancing lesion (1.7cm) over right mouth floor. May be recurrent tumor. Suggest tissue proof.
      • Normal appearance of both mastoid air-cells.
      • Mild paranasal sinusitis.
  • 2023-03-29 Patho - gingival/oral mucosa biopsy
    • Labeled as “right lower gingiva”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2022-09-09 MRI - nasopharynx
    • Findings
      • post-OP change at the right buccogingical region
      • a heterogeneous enhancing lesion, abour 23mm, in the left lower buccogingival mucosa.
      • no neck LAP
    • IMP:
      • r/o a tumor in the left lower buccogingical mucosa.
  • 2021-08-23 MRI - nasopharynx
    • Findings
      • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
      • Post-operation change with right neck for lymph node dissection.
      • Post resection of right submandibular gland.
    • IMP:
      • Post OP for right oral CA with neck LNs dissection. No local recurrence. No neck LAP.
  • 2020-10-26 CT - brain
    • Indication: R/O hydrocephalus
    • Without-contrast CT of brain shows:
      • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
      • s/p right F-T craniotomy.
      • Atherosclerosis of intracranial ICAs, cavernous portion, and vertebral arteries.
    • IMP:
      • Brain atrophy, ventriculomegaly, and intracranial atherosclerotic disease
  • 2020-10-22 MRI - nasopharynx
    • Findings
      • Post-operation change with flap reconstruction at right part of oral tongue and cheek.
      • Post-operation change with right neck for lymph node dissection.
      • General brain atrophy.
      • Partial opacification of bilateral ethmoid sinuses and mucosal thickening in bilateral maxillary sinuses.
      • Scoliosis of C-spine.
    • IMP:
      • C/W oral cancer s/p operation, without evidence of recurrence.
  • 2020-05-12 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Right mouth floor and mandibular gingiva, wide excision — mderaterly differentiated squamous cell carcinoma
      • Sulingual gland, right, wide excision — involved by tumor
      • Margin, right mouth floor and mandibular gingiva, wide excision — free (1 mm away from anterior margin)
      • Tissue, labeled “Sublingual gland”, wide excision — no evidence of tumor
      • Pathology stage: pT2NX
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: Right mouth floor and mandibular gingiva
        • Other part(s) included: right sulingual gland
        • Lymph node dissection: no
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: A, main tumor: 3.5 x 2.8 x 2.2 cm; B:sublingual gland: 1.3x 0.8x 0.7 cm
      • Tumor Site: Right mouth floor
      • Tumor Focality : single focus
      • Tumor Size: Greatest dimension: 2 cm
      • Depth of Invasion (for pT1 to pT3 tumors only): 10 mm of DOI
      • Mucosal Surface : ulcerated
      • Gross Tumor Extension : extenstion to sublingual gland
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: extenstion to sublingual gland
      • Margins: Margins free, Distance from closest margin: 0.1 cm away from anterior margin
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: Not included
        • Ipsilateral: N/A
        • Number examined: N/A
        • Number involved: N/A
        • Contralateral: N/A
        • Number examined: N/A
        • Number involved: N/A
        • Size (greatest dimension) of the largest metastatic deposit: N/A
        • Extranodal extension (not identified / present / indeterminate): N/A
  • 2020-04-30 MRI - nasopharynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:2(T_value) N:0(N_value) M:x(M_value) STAGE:II(Stage_value)
  • 2020-04-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 42) / 120 = 65.00%
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, possible LV diastolic dysfunction, Gr II
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2018-06-22 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Lower gingiva, right, wide excision — Squamous cell carcinoma
      • Pathology stage: rT1Nx(cMx), stage I at least
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure: Wide excision
      • Specimen Type:
        • Main location: Right lower gingiva
        • Lymph node dissection: No
      • Specimen Integrity: Intact
      • Specimen Size: 3.0 x 2.4 x 1.2 cm
      • Tumor Site: Lower gingiva, Laterality : Right
      • Tumor Focality: Single focus
      • Tumor Size: Greatest dimension: 1.5 cm
      • Additional dimensions (if available): 1.1 cm
      • Depth of Invasion (for pT1 to pT3 tumors only): 2 mm
      • Mucosal Surface : Ulcerated
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (Moderately differentiated)
      • Microscopic Tumor Extension: To subepitheliall connective tissue
      • Margins: Free, Distance from closest margin: 0.3 cm (deep margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes: Not submitted
      • IHC for p16: Negative (Reference: path 2018-09723)
  • 2018-06-21 Tc-99m MDP bone scan
    • Mildly increased activity in the middle and lower T-spines. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
  • 2018-06-20 MRI - nasopharynx
    • Indication: SCC of right lower gingiva
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
      • Post fat-containing flap reconstruction surgery at right anterior buccal region with heterogeneous enhancement in the right lower buccogingival region. .
      • Post LNs dissection, right.
      • No evident abnormal enlarged lymph node in the visible neck.
      • unremarkable change in the skull base.
    • Impression:
      • Post-OP of right buccal CA with suspicious recurrent right buccogingival tumor.
  • 2018-06-11 Surgical pathlogy Level IV
    • RIGHT LOWER GINGIVA, biopsy — Squamous cell carcinoma.
    • IHC stain: p16 (-).

[immunochemotherapy]

  • 2023-12-13 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • ………………. diphenhydramine 30mg
  • 2023-12-04 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • ………………. diphenhydramine 30mg + metoclopramide 10mg
  • 2023-11-27 - cetuximab 250mg/m2 400mg 1hr + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-11-16 - cetuximab 250mg/m2 450mg 1hr - He ChengHan
    • ………………. diphenhydramine 30mg
  • 2023-11-07 - cetuximab 400mg/m2 700mg 30mg + carboplatin AUC 2 150mg NS 300mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-10-31 - …………………………. carboplatin AUC 2 150mg NS 500mL 3hr - He ChengHan
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-09-16 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-09-08 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-08-27 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carboplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-08-04 - docetaxel 40mg/m2 70mg NS 150mL 2hr + carboplatin AUC 2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1700mg NS 1000mL24hr + leucovorin 100mg/m2 170mg 24hr (TPFL: docetaxel, carpoplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-07-23 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-07-06 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-06-15 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2020-06-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 3hr + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr + leucovorin 100mg/m2 170mg 22hr (TPFL: docetaxel, cisplatin, 5FU, LV) - Xu BoZhi
    • ………………. diphenhydramine 30mg + granisetron 1mg

==========

2023-12-19

[mucositis]

Combining the suggestions from both the MASCC/ISOO 2020 guidelines and the JCO Oncology Practice, here’s a pointwise summary of the recommendations:

Preventive Measures

  • Benzydamine mouthwash for head and neck cancer patients undergoing moderate-dose radiotherapy (MASCC/ISOO).
  • Photobiomodulation therapy with low-level laser for prevention in adult patients undergoing hematopoietic stem cell transplantation (MASCC/ISOO).
  • Oral cryotherapy for preventing mucositis in patients receiving high-dose melphalan during autologous HSCT (MASCC/ISOO).

General Management

  • Recognize the risk of infections and increased mortality associated with mucositis (JCO).
  • Consider the financial implications of mucositis management (JCO).

Pain Management and Symptom Relief

  • Avoid alcohol and tobacco use until symptom resolution (JCO).
  • Use 2% morphine mouthwash swish and spit for head and neck cancer patients (JCO).
  • Dexamethasone mouthwash for mTOR inhibitor-induced mucositis; in severe cases, high-dose systemic steroids (JCO).
  • 2% viscous lidocaine swish and spit (JCO).
  • Doxepin-containing mouthwashes and systemic opiates (JCO).
  • Transdermal formulations of morphine or fentanyl for long-lasting background pain control (JCO).

Hospital Admission Considerations

  • Severe cases with intractable pain, dehydration, inability to tolerate oral intake, end-organ damage, neutropenia or neutropenic fever, systemic infection (JCO).
  • Patient-controlled analgesia with morphine for severe pain (JCO).

Diet and Oral Care

  • Bland rinses (normal saline or salt and soda) for mild to moderate cases (JCO).
  • Diet modification to manage symptoms (JCO).

Use of Specific Agents

  • Avoiding sucralfate and glutamine for certain patient groups (MASCC/ISOO).

Ref:

  • Management of Cancer Therapy - Associated Oral Mucositis. JCO Oncology Practice. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

  • MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer. 2020;126(19):4423-4431. doi:10.1002/cncr.33100

700898653

231218

[lab data]

2023-08-04 HBV DNA-PCR (quantative) Target Not Detected IU/mL
2023-08-04 Anti-HCV (NM) Negative
2023-08-04 Anti-HCV Value (NM) 0.044
2023-08-04 Anti-HBc (NM) Negative
2023-08-04 Anti-HBc Value (NM) 1.110
2023-08-04 Anti-HBs (NM) Positive
2023-08-04 Anti-HBs Value (NM) 45.800 mIU/mL
2023-08-04 HBsAg (NM) Negative
2023-08-04 HBsAg Value (NM) 0.362
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HBs 45.52 mIU/mL
2023-08-04 Anti-HBc Nonreactive
2023-08-04 Anti-HBc Value 0.48 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.22 S/CO

[exam findings]

  • 2023-12-14 2D transthoracic echocardiography
    • Clinical diagnosis: ARDS s/p V-V ECMO
    • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 23) / 52 = 55.77%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, moderate AR, trivial TR
      • Mild pulmonary hypertension
      • Possible LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-12-13 CT - chest
    • Indication: SOB, Bil. pneumonia, ARDS S/P ETTI decrease SpO2 down to 70% since 4 days ago
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 1.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest without contrast enhancement, coronal and sagittal reconstructed images shows:
      • dependent moderate bilateral pleural effusions and large volume of right pneumothorax.
      • lungs: diffuse consolidation in both lower lobes and diffuse ground glass opacity with interlobular septal thickening at both upper lobes and RML.
      • Mediastinum and hila: extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal size of cardiac chambers. minimal pericardial effusion.
      • Visible abdominal contents: Rt renal cyst measuring 1.9cm.
    • Impression:
      • moderate bilateral pleural effusions and large volume of right pneumothorax and ARDS and/or diffuse pneumonia d/d AIP
  • 2023-12-13 SONO - chest
    • Echo diagnosis: Right side pneumohydrothorax. Although small volume, 14 Fr. pig-tail catheter was still needed to insert under echo-guidance since the patient was a victim of ARDS on ECMO treatment. Due to emergent, picture was not captured.
  • 2023-08-04 CXR (erect)
    • S/P Port-A infusion catheter insertion.
    • Presence of scoliosis of the lumbar spine.
    • Ground glass opacity in RLL.
  • 2023-08-01 PD-L1 (22C3)
    • Block No. S2023-14496 A4
    • RESULTS:
      • Combined Positive Score(CPS) assessment: CPS<1
      • Combined Positive Score(CPS): 0
  • 2023-07-21 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, simple mastectomy —- Invasive carcinoma of no special type
      • Resection margin: free
      • Lymph node, right axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/6)
      • Soft tissue, right axilla, excision —- Negative for malignancy (0/0)
      • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IIA, pT2N0(sn)(if cM0); Prognostic stage: IIA
    • Gross Description
      • Breast: Size: S2023-14496: 18.5 x 15.5 x 3.0 cm
      • Skin: Size: S2023-14496: 17.3 x 6.0 cm.
      • Nipple: S2023-14496: Not retracted
      • Tumor: Size: S2023-14496: 2.2 x 2.0 x 1.1 cm.
      • Resection Margin: S2023-14496: Free, 0.5 cm from the deep margin
      • Lymph node: F2023-00329: sentinel; S2023-14496: axilla soft tissue
      • Sections are taken and labeled as:
        • F2023-00329: All lymph nodes are dissected and labeled as: FsA1: a bisected sentinel lymph node; FsA2: lymph node, sentinel, for frozen examination.
        • S2023-14496: Representative sections are taken and labeled as: A1: nipple; A2: skin; A3: breast; A4-8: tumor; B: right axillary soft tissue.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma (mm): 22 x 20 x 11 mm
        • Histologic grade (Nottingham histologic score): grade II (score 6)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ
        • Tumor size (mm): 12 x 18 mm (mixed with invasive carcinoma)
        • Nuclear grade: 2
        • Architectural pattern: Non-comedo (cribriform)
        • Tumor necrosis: Present
      • Margins: Negative, Closest margin (5 mm from deep margin)
      • Nodal status: Negative, sentinel
        • No. examined: sentinel: 6; axilla soft tissue: 0
        • No. macrometastases (>2 mm): sentinel: 0; axilla soft tissue: 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): sentinel: 0; axilla soft tissue: 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): sentinel: 0; axilla soft tissue: 0
      • Treatment Effect: patient not received
      • Lymphovascular invasion: present
      • Perineural invasion: present
      • Immunohistochemical Study: S2023-13126
      • Tumor infiltrating lymphocytes (TILs): < 10%
  • 2023-07-20 SONO - abdomen
    • Diagnosis:
      • Fatty liver, mild
      • Liver lesions, left. Suspected focal fat-spared area or true liver lesion (?)
      • Suspected right renal cyst
      • Pancreas not shown
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window
    • Suggestion:
      • OPD f/u
      • Because of poor echo window, please follow sono abd 3-6 months later or correlate with other image
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (68 - 21) / 68 = 69.12%
      • M-mode (Teichholz) = 67
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy; impaired LV relexation
      • Trivial MR, trivial AR and mild TR
      • Preserved RV systolic function
  • 2023-07-10 Tc-99m MDP bone scan
    • Faint hot spots in the sternum and both rib cages, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral shoulders, and knees.
  • 2023-07-03 Her-2/neu DISH
    • RESULT OF HER2 IN SITU HYBRIDIZATION:
      • HER-2 (by in situ hybridization) — Negative (NOT amplified)
    • METHOD AND DETAILS:
      • Number of observers: 1
      • Number of invasive tumor cells counted: 20
      • Average number of HER2 signals per cell: 2.55
      • Average number of CEP17 signals per cell: 2.15
      • HER2/CEP17 ratio: 1.19
      • Heterogeneous signals: Absent
      • Origin slide and block number: S2023-13126
      • Specimen: Formalin-fixed paraffin embedded tissue
      • Adequacy of sample for evaluation: Yes
      • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • APPENDIX:
      • ASCO/CAP scoring criteria (2018):
        • Group 1 = HER2/CEP17 ratio >=2.0; >=4.0 HER2 signals/cell
        • Group 2 = HER2/CEP17 ratio >=2.0; <4.0 HER2 signals/cell
        • Group 3 = HER2/CEP17 ratio <2.0; >=6.0 HER2 signals/cell
        • Group 4 = HER2/CEP17 ratio <2.0; >=4.0 and <6.0 HER2 signals/cell
        • Group 5 = HER2/CEP17 ratio <2.0; <4.0 HER2 signals/cell
      • Negative:
        • Group 5
        • Group 2 and concurrent IHC 0-1+ or 2+
        • Group 3 and concurrent IHC 0-1+
        • Group 4 and concurrent IHC 0-1+ or 2+
      • Positive:
        • Group 2 and concurrent IHC 3+
        • Group 3 and concurrent IHC 2+ or 3+
        • Group 4 and concurrent IHC 3+
        • Group 1
  • 2023-07-03 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • Breast, right, core biopsy — Invasive carcinoma of no special type
    • GROSS DESCRIPTION:
      • The specimen submitted consisted of three strips of tan irregular tissue measuring up to 0.8 x 0.1 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Section shows cores of breast tissue with irregular neoplastic glands infiltration. The immunohistochemical stain of E-cadherin is positive.
    • IMMUNOHISTOCHEMICAL STUDY
      • ER (Ab): Negative (Internal control: positive)
      • PR (Ab): Negative (Internal control: positive)
      • Her-2/neu (Ab): Equivocal (2+)
      • Ki-67: 10%

[MedRec]

  • 2023-10-27 ~ 2023-10-28 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma. pT2N0M0, stage IIA. Triple negative. ECOG:0
      • Encounter for antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • for chemotherapy
    • Present illness
      • Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles. Add keytruda since 2023/08/25 by family reguest.
      • Under the impression of right breast invasive carcinoma, she was admitted for 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W.
    • Course of inpatient treatment
      • After admission, 5th adjuvant chemotherapy with weekly Taxol 80mg/m2 + Keytruda 200mg Q3W were given. No discomfort after chemotherapy.
      • Under the stable condition, she was discharged today, arrange next admission three weeks later.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-08-03 ~ 2023-08-05 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast cancer status post port A insertion on 2023/08/04. pT2N0M0, stage IIA. Triple negative, ECOG:0
      • Encounter for antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • for chemotherapy
    • Present illness
      • This 78-year-old female patient has past history of hypertension over 30 years with regular medicine control. Type II diabetes mellitus for 5 years with regular medicine control. She went to United States on 2023/05.
      • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Surgery of right breast simple mastectomy + SLNB on 2023/07/21. pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 4 cycles.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 on 2023-08-05.
    • Course of inpatient treatment
      • After admission, port A insertion was performed on 2023/08/04. 1st adjuvant chemotherapy with Lipo dox 30mg/m2 + Endoxan 600mg/m2 were given. The wound is clean and dry. No discomfort after chemotherapy.
      • Under the stable condition, she was discharged today, wound will be follow up on 8/9. And arrange next admission three weeks later.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Emend (aprepitant 125mg) 1# QD 2D for 8/6 and 8/7
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 3D for 8/8, 8/9, 8/10
      • loperamide 2mg 2# PRNQ6H if diarrhea > 2 per day
  • 2023-07-20 ~ 2023-07-22 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy on 2023/07/21. cT2N0M0, stage IIA. Triple negative. ECOG 0
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • noted a palpable mass at right breast over 6 months.
    • Present illness
      • This 79-year-old female patient has past history of hypertension over 30 years with regular medicine control. TypeII diabetes mellitus for 5 years with regular medicine control. She wnet to United States on 2023/05.
      • She noted a palpable mass at right breast over 6 months. She came to our OPD for help. Breast sono showed a lesion, Right 9/1.7 cm , size: 1.4x1.38 cm, r/o malignancy suggest biopsy. Core needle biopsy revealed invasive carcinoma, ER(-), PR(-), Her2/neu(2+) but FISH negative, Ki-67 10%. CA-153 22.384 U/ml, CEA 1.670 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulitis change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.    
    • Course of inpatient treatment
      • After admission, right breast simple mastectomy + SLNB was performed on 2023/07/21. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescripton
      • Acetal (acetaminophen 500mg) 1# QD

[surgical operation]

  • 2023-12-13
    • Surgery
      • VV ECMO
    • Finding
      • 15Fr A cannula at right IJV, fixed 15cm.
      • 19Fr V cannula at right CFV, fixed 45cm.
  • 2023-08-04
    • Surgery
      • Port-A insertion, L’t after L’t cephalic vein exploration        
    • Finding
      • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.  
  • 2023-07-21
    • Surgery
      • Simple mastectomy and sentinel lymph node biopsy        
    • Finding
      • a 2.5 x 2 x 1.5 cm slight firm mass in rt breast
      • SLN 0/6 

[immunochemotherapy]

  • 2023-12-04 - paclitaxel 80mg/m2 115mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-27 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-20 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-13 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-06 - paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-27 - pembrolizumab 200mg NS 100mL 30min + paclitaxel 80mg/m2 117mg D5W 250mL 90min
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-06 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 880mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-09-15 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-25 - pembrolizumab 200mg NS 100mL 30min + cyclophosphamide 600mg/m2 875mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-04 - cyclophosphamide 600mg/m2 898mg NS 500mL 1hr + liposome doxorubicin 30mg/m2 45mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

[acute respiratory distress syndrome, ARDS]

Treatment course

  • 2023-08-04: AC(lipo) initiated Q3W for 4 cycles after the patient recovered from mastectomy on 2023-07-21.
  • 2023-10-27 onward: weekly paclitaxel.
  • 2023-08-25, 2023-09-15, 2023-10-06, 2023-10-27, 2023-11-17: pembrolizumab 200mg administered Q3W as per patient’s family request (noted in discharge document).

ARDS and pembrolizumab considerations

  • Recent: ARDS developed.
  • Pembrolizumab association: Pneumonitis is a known risk associated with anti-PD-1 monoclonal antibodies like pembrolizumab, with documented cases of grade 3, 4, and fatal severity. The incidence is higher compared to anti-PD-L1 agents. Recurrence is possible after symptom resolution, regardless of re-challenge with immune checkpoint inhibitors. Chronic courses can also occur. The mechanism is non-dose-related and immunologic, with a median onset of approximately 3 months. Treatment-naive patients are at higher risk.

Current status and recommendation

  • Patient currently on VV-ECMO.
  • Recommendation: Due to ARDS and pembrolizumab’s association with pneumonitis, further re-challenge with pembrolizumab is not advisable.

Ref:

700938533

231218

[exam findings]

  • 2023-12-14 20:46 ECG
    • Sinus tachycardia
    • Left axis deviation
  • 2023-12-14 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • R/O right pleural effusion.
    • Degenerative joint disease of T-spine with marginal osteophytes.
    • S/P port-A catheter insertion.
  • 2023-12-14 18:08 ECG
    • Sinus tachycardia
    • Right superior axis deviation
  • 2023-12-11 MRI - brain
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • Favor bilateral cerebral and cerebellar metastases in leptomeninges, cortex and subcortical region, also a deep lesion in right basal ganglia.
      • Patchy or nodular abnormal enhancement after contrast administration of those lesions were found.
    • Imp:
      • Mild cortical brain atrophy. Bilateral cerebral and cerebellar metastases.
  • 2023-11-07 Patho - stomach biopsy (Y1)
    • Labeled as “upper abdominal tumor”, CT guided biopsy — adenocarcinoma. IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-). An addendum report of the result of IHC stain of TTF-1 will be followed.
    • Section shows adenocarcinoma in papillary and cribriform patterns.
    • IHC stains: CK19 (+), CA19-9 (-), CK7 (-), CK20 (-), CDX-2 (-).
    • Additional IHC stains: amylase-A (-), TTF-1 (-).
  • 2023-11-07 Patho - colon biopsy
    • Colorectum, ascending colon. Cold snaring polypectomy (A) — Hyperplastic polyp
    • Colorectum, transverse colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon. Cold snaring polypectomy (C) — Hyperplastic polyp
    • Colorectum, rectum. Polypectomy (D) — Tubulovillous adenoma with low grade dysplasia.
  • 2023-11-07 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Chronic gastritis, H pylori NOT present
  • 2023-11-06 EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric ulcer, multiple, antrum, s/p biopsy
  • 2023-11-06 Colonoscopy
    • Findings
      • The scope had been inserted up to cecum.
      • A 0.6 cm IIa polyp was noted at ascending colon. Cold snaring polypectomy was done (A).
      • A 0.6 cm IIa polyp was noted at transverse colon. Cold snaring polypectomy was done (B).
      • A 0.6 cm IIa polyp was noted at descending colon. Cold snaring polypectomy was done (C).
      • Active oozing from wound was noted. Clip was applied on wound with hemostasis.
      • An about 2 cm Ip polyp was noted at rectum. Polypectomy was done after submucosal injection (D).
      • Active oozing from wound was noted. Clips were applied on wound with hemostasis.
      • Several smaller polyps less then 0.5 cm were noted from transverse colon to sigmoid colon.
      • Several diverticulum were noted at ascending colon.
      • Internal hemorrhoid was noted
    • Diagnosis:
      • Colon polyp, ascending colon, s/p polypectomy
      • Colon polyp, tranverse colon, s/p polypectomy
      • Colon polyp, descending colon, s/p polypectomy + cliping
      • Colon polyp, rectum, s/p polypectomy + cliping
      • Colon diverticulum, ascending colon
      • Multiple small colon polyp, trasnverse colon to sigmod colon
      • Internal hemorrhoid
  • 2023-11-04 CT - abdomen
    • History and indication: Abdominal pain and nudules
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion. Indistinct contour of pancreatic body and tail. Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity.
      • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
      • Atherosclerosis of aorta.
    • IMP:
      • A large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor.
      • Enlarged LNs around the tumor. Some soft tissues in peritoneal cavity r/o tumor seeding.
      • Liver cirrhosi with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
  • 2023-11-04 SONO - abdomen
    • Findings
      • Bile duct: Hard to access CBD because of cavenous transformation of main portal vein
      • Portal vein: Cavenous transformation of protal vein at hilar area
      • Pancreas: Part of head and part of tail masked. The relationship of tumor and pancreas is hard to access
      • Spleen: Measured 6.8 x 4.7 cm
      • Ascites: Massive
      • A huge, more than 11 cm heteroechoic, multi-nodular tumor was noted upper abdomen with celiac trunk involve.
    • Diagnosis:
      • Upper abdominal tumor, huge, with celiac trunk involve
      • Cavenous transformation of main portal vein
      • Splenomegaly, mild
      • Ascites, massive
    • Suggestion:
      • arrange admission for work up

[MedRec]

  • 2023-11-17 SOAP Radiation Oncology Wang YuNong
    • Plan: Palliative CCRT is indicated.
      • CT-simulation will be arranged on 2023/11/20.
      • Plan to deliver 45 Gy/ 25 fx to the gross tumor and LAPs with partial simultaneous boost.
      • RT will start around 11/23.
  • 2023-11-15 SOAP Hemato-Oncology He JingLiang
    • S: abdominal adenocarcinoma, but CA199 WNL
      • apply major illness, refer to GS for port-A
      • C/T with FOLFOX
  • 2023-11-04 ~ 2023-11-09 POMR Gastroenterology Su WeiZhi
    • Discharge diagnosis
      • Pancreatic tumor, rule out pancreatic cancer, status post biopsy
      • Alcoholic cirrhosis of liver
    • CC
      • abdominal distension and weight loss (12kg in 2 months)
    • Present illness
      • This 50-year-old man without medical history was refferred to to our GI OPD on 2023-11-05 from LMD. His chief complaint was abdominal distension and weight loss (12kg in 2 months). Accompanied symptoms included mild abdmonial pain sometimes, dyspepsia, soft stool passage for months. There were no no fever, no chills, no nausea, no vomitting, no chest tightness, no dysuria. Alcoholic abuse was told.
      • Echo 2023/11/04: upper abdomianl huge tumor with celiac trunk involve. Ascites was told by LMD. Lab data showed no leukocytosis of WBC:7.77K, HB:9.1, TBI:1.88, r-GT:24, ALP:111.
      • Physical examination showed abdominal distension with lower abdominal tenderness.
      • Under the impression of abdmonial pain and ascites, r/o upper abdomianl huge tumor, he was admitted for further evlauaiton and managemnt.
    • Course of inpatient treatment
      • After admission, we kept monitoring his vital sign and prescribed medication for hypertension.
      • KUB showed stool retention in bowl.
      • ABD Liver CT with contrast on 11/4 showed (1) a large mass (10.8cm) at upper abdomen with duodenum, stomach, celiac trunk, common hepatic artery, splenic artery, SMA, SMV, splenic vein and portal vein invasion r/o pancreatic tumor. (2) enlarged LNs around the tumor. (3) some soft tissues in peritoneal cavity r/o tumor seeding. (4) liver cirrhosis with portal hypertension, GV, collateral circulation, ascites and splenomegaly.
      • Adequate iv hydration with nako.5 500ml QD for NPO.
      • We arranged anesthetic EGD and colonscopy on 11/6. EGD showed Reflux esophagitis, LA classification, antrum gastric ulcer, multiple, antrum, s/p biopsy. Colonscopy revealed multiple small colon polyp, trasnverse colon to sigmod colon, s/p polypectomy + cliping, and internal hemorrhoid. Nexium QD was given since 2023-11-07.
      • CT guided biopsy was arranged on 2023-11-07, pending pathology report. Follow-up lab data on 2023-11-08 showd mildanemia with HB:8.3. LPRBC 2U was given.
      • Under stable condition, he was discharged and turned to OPD folloed-up.
    • Discharge prescription
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ8H if pain

[chemotherapy]

  • 2023-11-30 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-21 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 30min (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-18

On 2023-12-18, the patient exhibited pancytopenia, including severe grade 3 anemia. Blood product transfusion was administered the same day.

  • 2023-12-18 WBC 2.95 x10^3/uL
  • 2023-12-18 HGB 6.7 g/dL
  • 2023-12-18 PLT 98 *10^3/uL

Low levels of serum sodium, potassium, calcium, magnesium, and albumin were also detected. Taita No.5 electrolyte solution, KCl, and MgSO4 were prescribed.

  • 2023-12-18 Na (Sodium) 130 mmol/L
  • 2023-12-18 K (Potassium) 3.0 mmol/L
  • 2023-12-18 Albumin (BCG) 3.1 g/dL
  • 2023-12-18 Ca (Calcium) 1.91 mmol/L
  • 2023-12-18 Mg (Magnesium) 1.6 mg/dL

A positive stool occult blood test (1+) was identified on 2023-12-17. The patient is currently receiving Panzolec (pantoprazole) and Hemoclot (tranexamic acid).

Medication reconciliation found no discrepancies.

701500949

231218

[lab data]

2023-11-02 Ferritin 667.6 ng/mL
2023-10-26 FLT3-D835 (bone marrow) Undetectable
2023-10-25 MPO stain Positive (3+)
2023-10-25 ANAE stain Negtive
2023-10-25 CAE stain Positive
2023-10-18 NPM1 (qualitative)(BM) Undetectable
2023-10-18 FLT3/ITD (bone marrow) Undetectable
2023-10-18 JAK2-single site (BM) Undetectable
2023-10-18 BCR/abl (BM) PhiladChr (qual) Undetectable
2023-10-16 Von willebrand factor 100.8 %
2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 TSH (NM) 2.348 uIU/ml
2023-10-12 T3 (NM) 95.975 ng/dl
2023-10-12 Free T4 (NM) 1.190 ng/dl

2023-10-13 HBV-DNA-PCR Target Not Detected IU/mL
2023-10-12 HBsAg Nonreactive
2023-10-12 HBsAg (Value) 0.41 S/CO
2023-10-12 Anti-HBc Reactive
2023-10-12 Anti-HBc-Value 4.57 S/CO
2023-10-12 Anti-HCV Nonreactive
2023-10-12 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-11-18 CXR (supine)
    • S/P PICC catheter insertion via left forearm.
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-11-15, -10-13 CXR (erect)
    • S/P PICC catheter insertion via left forearm.
    • Borderline cardiomegaly
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-10-16 SONO - abdomen
    • mild fatty liver (incomplete exam of liver)
    • gallbladder polyps
    • fatty infiltration of pancreas
    • bilateral renal cysts
  • 2023-10-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 43) / 131 = 67.18%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mitral valve prolapse, posterior mitral leaflet with moderate MR
      • Concentric LVH; impaired LV relexation
      • Mild AR (aortic regurgitation), trivial TR (tricuspid regurgitation) and trivial PR (pulmonary regurgitation)
      • Preserved RV systolic function
  • 2023-10-13 Peripherally Inserted Central Catheters, PICC
    • Indication of PICC: leukemia
    • Under the echo guiding, we successful puncture left basilic vein. PICC catheter was advanced to SVC smoothly, total into 35 cm.
    • SVO2 65%, estimated Fick Cardiac index 2.86L/min/m2 (normal range cardiac index 2.5~4 L/min/m2)
  • 2023-10-12 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Acute myeloid leukemia
    • Specimen submitted in formalin consists of a piece of tan, rod shape bone marrow tissue measuring 2.5 cm in length. All for section in one cassette after decalcification.
    • Sections show 80-90% cellularity. Blasts account for about 40-50% of all nucelated cells.
    • The immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-). The results are consistent with acute myeloid leukemia. Please correlate with the clinical presentation and lab studies.

[MedRec]

  • 2023-11-12 ~ 2023-11-23 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Acute myeloblastic leukemia, not having achieved remission; Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
      • Urinary tract infection, urine culture growth Enterococcus faecalis
    • CC
      • for C2 chemotherapy with 5 + 2 (Cytarabine + Idarubicin).
    • Present illness
      • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD.
      • He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines. He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
      • At arrival to ER, the laboratory showed WBC:30610, Hb:9.8, PLT:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9. Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%.
      • The bone marrow was done on 10/12 23 and pathology (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable. Blood transfusion with LPRBC 2U was given on 10/23 23. The FLT3-D835/NPM1/FLT3/ITD/JAK2 - single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked. PICC was inserted on 10/13 23.
      • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF 66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
      • Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered, C1 on 10/13-10/20 23.
      • This time, he is admitted for C2 chemotherapy with 5+2 (Cytarabine + Idarubicin).
    • Course of inpatient treatment
      • After admission, blood transfusion with LPRBC for anemia, hydration, chemotehrapy with 5+2 (Cytarabine + Idarubicin) was administered on 11/13-11/17 23,
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • After chemotherapy, he suffered from fever noted, so gave Cefim for infection control, followed-up PICC culture growth Staphylococcus epidermidis, and remove PICC catheter, blood culture not growth, urine culture growth Enterococcus faecalis.
      • Followed-up the lab of CBC/DC showed neutropenia (WBC: 1830/uL, Neutrophil: 49%, ANC: 896.7), so gave protective isolation.
      • Re checked the lab of CBC/DC showed WBC: 1510/uL, Neutrophil: 52.1%, ANC: 789.
      • After treatment. he denide having a fever, vomiting, diarrhea, or any uncomfortable. He can be discharged on 2023/11/23, take oral antibiotic with Ceficin back home, the OPD follow-up will be arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Smecta (dioctahedral smectite 3mg) 1# PRNTIDAC
      • Urosin (atenolol 100mg) 0.5# QD
      • Mosapin (mosapride citrate 5mg) 1# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-11-01 SOAP Hemato-Oncology He JingLiang
    • O: 2023-11-01 Plt 6K
    • P: 2023-11-01 BT Plt 2u
  • 2023-10-11 ~ 2023-10-28 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Acute myeloblastic leukemia, not having achieved remission Blast:41%, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3(-), and PAX5(-) S/P chemotherapy with 7 + 3 (Cytarabine + Idarubicin) on 10/13-10/20 23
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
    • CC
      • spontaneous ecchymosis over bilateral hands & bilateral thight for 1-2 months
    • Present illness
      • This 72-year-old, had history of hypertension for 3 years under oral medication treatment at LMD. He suffered form spontaneous ecchymosis over bilateral hands & bilateral thight and gum bleeding for 1-2 months and body weight loss about (70 -> 65kg) within 1 month and poor appetite were also noted. The patient did not take painkillers or chinese herbal medicines.
      • He visited to LMD for aid and ecchymosis & gum bleeding progression was developed in recent one week and transferred to our ER on 10/11 23.
      • At arrival to ER, the laboratory showed WBC:30610, Hb:Hb:9.8, PL:11K, LDH:1038, Seg:18, Metamyelocyte:4.0%, Myelocyte:10%, promyelocyte:3%, Blast:41% on 2023/10/9.
      • Under the impression of Leukocytosis rule out acute myeloblastic leukemia, not having achieved remission Blast:41%. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, hydration and bone marrow was done on 10/12 23 and pathology was pending. The FLT3-D835/NPM1/FLT3/ITD/JAK2-single site/MPO/ANAE/CAE/(AML+ALL/Myeloid/AML/21-30/BcR/abL Philadelphia chromosome/bone marrow cell chromosomes (self-paid) were checked.
      • PICC was inserted on 10/13 23. Chemotehrapy with 7 + 3 (Cytarabine + Idarubicin) was administered on 10/13-10/20 23, smoothly without obvious side effect.
      • Vemlidy 1# po qd was added due to anti-Hbc positive.
      • We arranged abdominal sono & heart echo for perpare chemotherapy evaluation and which showed mild fatty liver (incomplete exam of liver) gallbladder polyps and LVEF:66%, adequate LV systolic function with normal resting wall motion, mitral valve prolapse, posterior mitral leaflet with moderate MR , concentric LVH; impaired LV relexation, mild AR, trivial TR and trivial PR.
      • The WBC idex from 30610 -> 25680 -> 3490 and blast:41%–>40.9%–>2.9 were noted post C/T treatment.
      • Bone marrow, iliac, biopsy (10/17 23) proved acute myeloid leukemia, immunohistochemical stains CD34(+), CD117(+), MPO(+), CD68(+), CD163(focal +), CD3 (-), and PAX5(-). The BCR/abl/NPM1/FLT3/ITD/JAK2 showed Undetectable.
      • Blood transfusion with LPRBC 2U was given on 10/23 23. Followed-up the lab of CBC/DC showed neutropenia (WBC: 1010/uL, Band: 1.2%, Neutrophil: 9.9%, ANC: 112.11). No more fever was noted and good appetite. He was discharged on 10/28 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • MgO 250mg 2# TID
      • Through (sennoside 12mg) 1# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-10-11 - SOAP Medical Emergency Lin QingXiang
    • S: Triage Revised As Needed System: 3
      • The patient’s white blood cell count was high on an outpatient blood test, and they were suspected of having leukemia and transferred in.
    • O:
      • BP: 191/86; HR: 112; BT: :36.2’C; RR: 18;
      • SpO2: 97%
      • GCS: E4V5M6 alert, and oriented.
      • General-looking: acute ill looking
      • HEENT: supple neck, no injected throat, no pale conjunctiva, no icteric sclera
      • Heart: no murmur, regular heart beat
      • Chest: bilateral clear breathing sounds. symmetrical
      • Abdomen: flat and soft, normal bowel sound, no tenderness
      • Extremitis: warm, freely movable, no pitting edema
      • Neurologic: well muscle power of four limbs, stable gait. isocoric pupil with light reflex
    • A
      • preliminary impression: R23.3 Spontaneous ecchymoses
      • Limb Ecchymosis, Oral bleeding, suspect leukemia, WBC 31k, Hb 9.8, Plt 11k -> LRP 2U, OA Hema (GBard: outpatient hematology)
      • HTN
      • Lab
        • 2023/10/09 20:53 ALT = 27 U/L;
        • 2023/10/09 20:53 Creatinine = 0.95 mg/dL;
        • 2023/10/09 20:53 CRP = 0.3 mg/dL;
        • WBC = 30.61 x10^3/uL; HGB = 9.8 g/dL;
        • PLT = 11 x10^3/uL;
  • 2023-10-09 - SOAP Family Medicine Ye JiaZe
    • S
      • Multiple ecchymosis red papules non itchy over ext, off and on for days
        • tarry stool -
        • bloody stool -
        • recent URI -
        • body weight loss (BWL) -
        • referred from LMD
      • 2023-10-09 2040 voice chat consultation
      • Occupation: noodle/pasta, retired
      • Current med: atenolol, losartan, red yeast rice
    • O
      • BP: 186/93 mmHg; HR: 123 pulse/min; Weight: 65.6 kg
      • Lab
        • 2023/10/09 D-dimer = 704.00 ng/mL(FEU);
        • 2023/10/09 INR = 1.06;
        • 2023/10/09 CBC
          • WBC = 30.61 x10^3/uL;
          • HGB = 9.8 g/dL;
          • PLT = 11 x10^3/uL;
          • Blast = 41.0 %;
      • hard & soft palate ecchymosis
      • general skin red papules
    • P
      • hema OPD F/U
      • ER if condition deteriorated

[chemotherapy]

  • 2023-12-15 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
  • 2023-11-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-2 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-5 ((2+5) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + palonosetron 250ug D1,3 + NS 250mL D1,3
  • 2023-10-13 - idarubicin 10mg/m2 15mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7 ((3+7) idarabicin/cytarabine Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug D1,4 + NS 250mL D1,4

Acute myeloid leukemia: Induction therapy in medically-fit adults - 2023-10-16 - https://www.uptodate.com/contents/acute-myeloid-leukemia-induction-therapy-in-medically-fit-adults

  • AML without mutated FLT3 - For newly diagnosed AML without mutated FLT3, we recommend treatment with a seven-day continuous infusion of cytarabine plus an anthracycline for three days (so-called “7+3 therapy”), based on the favorable balance of outcomes and toxicity.
    • Administration – The regimen that is most often used is:
      • Cytarabine - 100 to 200 mg/m2/day by continuous intravenous (IV) infusion for days 1 to 7
      • Anthracycline
        • Daunorubicin - 60 to 90 mg/m2 IV on days 1 to 3 or
        • Idarubicin - 12 mg/m2 IV on days 1 to 3
  • AML with mutated FLT3 - For patients with FLT3-mutated AML, we recommend addition of either midostaurin (for any FLT3 mutation) or quizartinib (for FLT3 with internal tandem repeats [ITD]) to intensive induction chemotherapy
    • Administration
      • Midostaurin
        • Administered orally 50 mg twice daily on days 8 through 21. Cytarabine and an anthracycline are administered, as described above. (See ‘AML without mutated FLT3’ above.)
        • Strong CYP3A4 activators and inhibitors may alter exposure to midostaurin and its active metabolites; alternatives to agents that strongly affect CYP3A4 should be considered [17].
      • Quizartinib
        • Administered 35.4 mg orally once daily on days 8 to 21 of 7+3 therapy.
        • A boxed warning for quizartinib notes QT prolongation, torsades de pointes, and cardiac arrest. The QT interval should be assessed prior to initiating quizartinib and periodically during treatment. Hypokalemia and hypomagnesemia should be corrected. Treatment should not be initiated if the QT interval (corrected by Fridericia’s formula [QTcF]) is >450 ms. The dose of quizartinib should be reduced when used concomitantly with strong CYP3A inhibitors.
      • The US Food and Drug Administration (FDA) and the European Medicines Agency approved midostaurin in combination with chemotherapy for newly diagnosed AML with mutated FLT3 in adults. The US FDA approved quizartinib in combination with 7+3 induction therapy for AML that is positive for FLT3-ITD, but not for other FLT3 mutations; quizartinib is available only through a Risk Evaluation and Mitigation Strategy (REMS) in the US.

==========

(not posted yet)

2023-11-01 WBC 2.15 x10^3/uL
2023-10-28 WBC 1.40 x10^3/uL
2023-10-27 WBC 1.01 x10^3/uL
2023-10-25 WBC 0.96 x10^3/uL
2023-10-23 WBC 0.87 x10^3/uL
2023-10-21 WBC 1.07 x10^3/uL
2023-10-19 WBC 1.82 x10^3/uL
2023-10-16 WBC 3.49 x10^3/uL
2023-10-12 WBC 25.68 x10^3/uL
2023-10-09 WBC 30.61 x10^3/uL

2023-11-01 HGB 7.7 g/dL
2023-10-28 HGB 8.0 g/dL
2023-10-27 HGB 8.1 g/dL
2023-10-25 HGB 8.7 g/dL
2023-10-23 HGB 7.6 g/dL
2023-10-21 HGB 8.1 g/dL
2023-10-19 HGB 7.7 g/dL
2023-10-16 HGB 8.9 g/dL
2023-10-12 HGB 10.3 g/dL
2023-10-09 HGB 9.8 g/dL

2023-11-01 PLT 6 10^3/uL
2023-10-28 PLT 40
10^3/uL
2023-10-27 PLT 56 10^3/uL
2023-10-25 PLT 91
10^3/uL
2023-10-23 PLT 17 10^3/uL
2023-10-21 PLT 32
10^3/uL
2023-10-19 PLT 9 10^3/uL
2023-10-16 PLT 48
10^3/uL
2023-10-12 PLT 148 10^3/uL
2023-10-09 PLT 11
10^3/uL

preparing blood on 2023-11-29, -11-12, -10-28, -10-23, -10-19, -10-11

2023-12-18

[anemia]

Pre-existing anemia was identified in this patient prior to the initiation of the standard 7+3 regimen on 2023-10-13. Following completion of three cycles (one 7+3 and two 5+2), it is anticipated to possibly lead to pancytopenia within three weeks. Therefore, RBC transfusions should be provided as needed to manage the patient’s anemia.

2023-10-25

[WBC nadir 870/uL on 2023-10-23, no blast found after 2023-10-16]

In AML patients undergoing the 7+3 induction chemotherapy regimen, a nadir leukocyte level, specifically below 200/uL, was linked to a higher probability of achieving complete remission (CR). This indicates that patients who experience a more significant decrease in their leukocyte levels during chemotherapy tend to have a more favorable prognosis in terms of reaching CR. Ref: Association of leukocyte nadir with complete remission in Indonesian acute myeloid leukemia patients undergoing 7+3 remission induction chemotherapy. F1000Res. 2022 May 5;11:495. doi: 10.12688/f1000research.110320.2. PMID: 35721596; PMCID: PMC9194516.

The patient started the standard 7+3 regimen on 2023-10-13 and recent lab data suggest that the nadir was reached on 2023-10-23 with a WBC of 960/uL. Based on the aforementioned study, this correlates with a reduced chance of achieving CR.

  • 2023-10-25 WBC 0.96 x10^3/uL
  • 2023-10-23 WBC 0.87 x10^3/uL *
  • 2023-10-21 WBC 1.07 x10^3/uL
  • 2023-10-19 WBC 1.82 x10^3/uL
  • 2023-10-16 WBC 3.49 x10^3/uL
  • 2023-10-12 WBC 25.68 x10^3/uL
  • 2023-10-09 WBC 30.61 x10^3/uL

However, looking at the percentage of blasts in the WBC differential count, no blasts were detected after 2023-10-16. This indicates at least a short-term effect of the treatment.

  • 2023-10-16 Blast 2.9 %
  • 2023-10-12 Blast 40.9 %
  • 2023-10-09 Blast 41.0 %

2023-10-20

[pancytopenia]

The onset of pancytopenia is an expected consequence following the initiation of the standard 7+3 chemotherapy regimen on 2023-10-13. In response to this, the patient received a transfusion of 2 units of leukocyte-poor red blood cells (LPRBC) and 2 units of leukocyte-reduced platelets (LRP) on 2023-10-19, a standard procedure in such cases. This intervention proceeded without any complications.

  • 2023-10-19 WBC 1.82 x10^3/uL

  • 2023-10-16 WBC 3.49 x10^3/uL

  • 2023-10-12 WBC 25.68 x10^3/uL

  • 2023-10-19 HGB 7.7 g/dL

  • 2023-10-16 HGB 8.9 g/dL

  • 2023-10-12 HGB 10.3 g/dL

  • 2023-10-19 PLT 9 *10^3/uL

  • 2023-10-16 PLT 48 *10^3/uL

  • 2023-10-12 PLT 148 *10^3/uL

2023-10-18

[von Willebrand factor (VWF)]

The von Willebrand factor (VWF) test results showed normal on 2023-10-16, it means that the amount of VWF in the blood is within the normal range. However, this does not necessarily mean that the person does not have von Willebrand disease (VWD).

There are several types of VWD, and some people with VWD may have normal VWF levels. For example, people with type 2N VWD have normal levels of VWF antigen and VWF activity, but the VWF molecules are not functioning properly.

Other possible reasons for normal VWF levels in a person with VWD include:

  • The person has a mild form of VWD. (unknown)
  • The person is taking a medication that is increasing VWF levels. (less likely, this patient is not taking desmopressin, tranexamic acid or aminocaproic acid)
  • The person has recently had a blood transfusion. (probably, blood transfusion done at MER on 2023-10-11)
  • The person is pregnant or breastfeeding. (not applicable)

If a person with normal VWF levels has a history of bleeding or a family history of VWD, they may still need further testing to rule out VWD. This may include tests such as the ristocetin cofactor (RCo) assay and the VWF multimer analysis.

2023-10-16

[leukopenia]

There is no identified history of AML and/or MDS from PharmaCloud or HIS5 records, suggesting this is a newly diagnosed de novo AML in this patient.

The patient was started on the standard 7+3 cytarabine/idarubicin chemotherapy regimen on 2023-10-13. The patient’s white blood cell count (WBC) was high on 2023-10-09, but quickly decreased to 3.49K/uL on 2023-10-16. While a WBC of 3.49K/uL is considered mild leukocytopenia, a decrease in all three types of blood cells (pancytopenia) is expected within the first three weeks after starting the 7+3 regimen.

  • 2023-10-16 WBC 3.49 x10^3/uL
  • 2023-10-12 WBC 25.68 x10^3/uL
  • 2023-10-09 WBC 30.61 x10^3/uL

[hypertension]

Per the records, the patient visited the family medicine department on 2023-10-09 and has a history of hypertension, managed with atenolol, losartan, and red yeast rice. Although no antihypertensive medications are currently listed as active, the latest blood pressure reading of 130/63 mmHg (taken on 10/16 at 08:39) does not indicate significant hypertension. Therefore, there’s no immediate necessity to reintroduce antihypertensive agents. However, it’s advisable to continue monitoring blood pressure to determine if there’s a need to resume these medications.

[risk stratification]

If AML is strongly suspected, genetic analysis is recommended for risk stratification and to determine the presence of actionable mutations (such as FLT3), which may warrant the consideration of additional treatments like midostaurin or potentially quizartinib.

[antiviral prophylaxis]

  • Lab
    • 2023-10-12 Anti-HBc Reactive
    • 2023-10-12 Anti-HBc-Value 4.57 S/CO

The American Society of Clinical Oncology and the Infectious Disease Society of America recommend that severely neutropenic patients undergoing intensive chemotherapy receive prophylactic antibacterial and antifungal therapy and that patients who are seropositive for hepatitis B core antibody or herpes simplex virus with leukemia receive antiviral prophylaxis. Ref: Antimicrobial Prophylaxis for Adult Patients With Cancer-Related Immunosuppression: ASCO and IDSA Clinical Practice Guideline Update. J Clin Oncol. 2018 Oct 20;36(30):3043-3054. doi: 10.1200/JCO.18.00374. Epub 2018 Sep 4. PMID: 30179565.

Vemlidy (tenofovir alafenamide) is currently used to reduce the risk of reactivation of HBV infection. However, laboratory results for herpes simplex virus are not yet available.

[prophylaxis of bacterial infection in neutropenia]

Severe and prolonged cytopenias are a common occurrence with intensive remission induction therapy, as the patient is likely to develop pancytopenia within three weeks of receiving the standard 7+3 regimen. Transfusions of red blood cells and platelets should be given as needed. However, the routine use of granulocyte colony-stimulating factor (G-CSF; filgrastim) and other myeloid growth factors is not usually recommended.

High-risk patients of chemotherapy-induced neutropenia are those who are expected to be neutropenic (ANC < 500 cells/uL) for > 7 days.

Guidelines from the American Society of Clinical Oncology (ASCO) and Infectious Diseases Society of America (IDSA) recommend consideration of fluoroquinolone prophylaxis in patients at high risk for profound prolonged neutropenia (anticipated ANC <= 100 cells/uL for > 7 days)

Consensus-based National Comprehensive Cancer Network (NCCN) guidelines suggest strong consideration of fluoroquinolone prophylaxis for high-risk patients: those undergoing allogeneic HCT, neutropenic patients receiving induction chemotherapy for acute leukemia, and any patient in whom the duration of anticipated neutropenia is > 10 days.

Ciprofloxacin and levofloxacin have been studied most extensively. Ciprofloxacin has greater in vitro activity than levofloxacin against P. aeruginosa, but levofloxacin has greater in vitro activity against gram-positive bacteria (eg, alpha-hemolytic streptococci) and is given only once daily compared with twice daily for ciprofloxacin.

[prophylaxis of invasive fungal infection in neutropenia]

Continuing from the previous pharmacist’s note:

  • Prophylaxis against Candida infections:
    • For patients with acute leukemia undergoing initial-induction or salvage-induction chemotherapy who are expected to develop severe oral and/or gastrointestinal mucositis, fluconazole (400 mg orally once daily) is recommended.
    • Alternative agents include itraconazole, voriconazole, posaconazole, micafungin, caspofungin, and anidulafungin.
  • Prophylaxis against invasive mold infections and Candida spp:
    • For selected patients who are expected to experience prolonged severe neutropenia (ANC < 500 cells/uL for > 7 days) due to intensive chemotherapy for AML or advanced MDS, it is suggested that prophylaxis with posaconazole or voriconazole rather than targeted anti-Candida prophylaxis with fluconazole.
    • An alternative for patients who cannot receive voriconazole or posaconazole is isavuconazole.
  • Dosing of posaconazole and voriconazole:
    • Posaconazole delayed-release tablets:
      • Loading dose: 300 mg (three 100 mg tablets) every 12 hours on the first day
      • Maintenance dose: 300 mg (three 100 mg tablets) daily starting on the second day
    • Posaconazole oral suspension: 200 mg three times daily
    • Voriconazole: 200 mg orally twice daily

[chemotherapy dose to remain the same for patient with normal lab results]

For patients receive standard 7+3 regimen, it is recommended to assess for comorbidities that may affect the ability to tolerate intensive therapy.

  • Heart disease
    • Special attention to cardiac function is required because of the large volumes of intravenous (IV) fluids administered during remission induction therapy and the routine use of anthracyclines.
  • Liver disease
    • Liver disease may affect the dose and schedule of anthracycline administration.
  • Kidney disease
    • Renal insufficiency might affect the schedule and dose of cytarabine and influence management of tumor lysis syndrome.

The patient’s liver and kidney function tests on 2023-10-16 were normal. His 2D transthoracic echocardiography on the same day showed an M-mode Teichholz measurement of 66, adequate left ventricular systolic function, and normal resting wall motion. There is no evidence of tumor lysis syndrome (no serum phosphate was tested). Therefore, there is no need to adjust the patient’s current standard 7+3 chemotherapy dose.

  • 2023-10-16 AST 14 U/L

  • 2023-10-16 ALT 21 U/L

  • 2023-10-16 BUN 18 mg/dL

  • 2023-10-16 Creatinine 0.70 mg/dL

  • 2023-10-16 eGFR 117.82 ml/min/1.73m^2

  • 2023-10-16 Bilirubin total 0.60 mg/dL

  • 2023-10-16 Bilirubin direct 0.08 mg/dL

  • 2023-10-16 DBI/TBI 13.33 %

  • 2023-10-16 K(Potassium) 3.6 mmol/L

  • 2023-10-16 Uric Acid 6.3 mg/dL

  • 2023-10-16 Ca (Calcium) 2.08 mmol/L

[nadir response assessment]

A bone marrow biopsy is done at the lowest point of the patient’s blood counts (hematologic nadir), which is usually between days 14 and 22 of treatment. However, for patients who are not receiving midostaurin (a drug used to treat AML), the nadir assessment does not have to be done on day 22.

Further treatment decisions are based on the results of the bone marrow biopsy:

  • Hypoplasia: If the biopsy shows that the bone marrow is hypoplastic (meaning that there are fewer than 20% blood cells) and that the blasts (cancer cells) have been cleared (meaning that there are fewer than 5% blasts remaining), the patient’s blood counts will be monitored and they will receive supportive care until their blood counts recover.
  • Persistent blasts: If the biopsy shows that the bone marrow is not hypoplastic and/or that there are 5% or more blasts remaining, the patient should start a second cycle of induction therapy without delay, if they are able to tolerate it.

If the results of the bone marrow biopsy are unclear, another bone marrow biopsy should be done 5 to 7 days later.

700726873

231215

[MedRec]

  • 2023-11-14, -07-18 SOAP Metabolism and Endocrinology Zhang JiaHui
    • Diagnosis
      • Inflammatory spondylopathies in disease classified elsewhere [M49.80]
      • Chondromalacia of patella [M22.40]
      • Contusion of knee [S80.00XA]
      • Unspecified monoarthritis, lower leg [M13.161]
      • Contracture of joint, other specified sites [M24.50]
      • Chondromalacia of patella [M22.40]
      • Unspecified internal derangement of knee [M23.90]
      • Degeneration of lumbar or lumbosacral intervertebral disc [M51.36]
      • Unspecified monoarthritis, lower leg [M13.161]
      • Contracture of joint,other specified sites [M24.50]
      • Psychoneurosis with fibromyalgia [F48.9]
      • Herpes zoster [B02.9]
    • Prescription x3
      • cortisone acetate 25mg 2# QD
      • cortisone acetate 25mg 0.5# QN
      • Tulip (atovastatin 20mg) 0.5# QD

700199573

231214

[exam findings]

  • 2023-09-13 CT - abdomen
    • Findings:
      • There is long segmental dilatation of the small intestine and the transition zone in the right upper pelvis mesentery.
        • Adhesion band induce mechanical small bowel obstruction is suspected.
      • Prior CT identified several enlarged nodes in aortocaval space are noted again, stationary.
        • Non-regional metastatic lymph nodes (M1b) are highly suspected.
        • Please correlate with PET scan.
      • S/P hysterectomy
      • There is ascites.
      • S/P nasogastric tube insertion
    • Impression:
      • Adhesion band induce mechanical small bowel obstruction is suspected.
      • Non-regional metastatic lymph nodes (M1b) in aortocaval space are highly suspected. Please correlate with PET scan.
  • 2023-08-29 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, left, frozen + debulking surgery — High-grade serous carcinoma
        • Fallopian tube, left, ditto — Tumor invasion microscopically
      • Endometrium, uterus, debulking surgery — Free of tumor invasion
      • Myometrium, uterus, ditto — Free of tumor invasion
      • Cervix, uterus, ditto — Free of tumor invasion
      • Ovary, right, ditto — Tumor invasion microscopically
        • Fallopian tube, right, ditto — Tumor invasion
      • Omentum ttissue, omentectomy — Tumor invasion microscopically
      • Peritoneal tumors, excision — Tumor invasion
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/6)
      • Lymph node, L’t obturator, ditto — Free of tumor metastasis (0/5)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/8)
      • Lymph node, R’t obturator, ditto — Free of tumor metastasis (0/13)
      • Lymph node, L’t paraaortic, ditto — Tumor metastasis (3/3) with extracapsular extension (1/3)
      • Lymph node, R’t paraaortic, ditto — Tumor metastasis (4/5) with extracapsular extension (2/4)
      • AJCC Pathologic staging: pT3cN1b, if cM0; stage IIIC
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen + debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + bilateral paraaortic LN dissection + peritoneal tumor excision)
      • Specimen type: uterus, peritoneal tumors, omentum and lymph nodes
      • Specimen size:
        • L’t ovary (frozen): opened, solid and cystic mass measured 19.7 x 19.3 x 5.2 cm with necrosis and serous fluid
        • L’t fallopian tube (frozen): normal appearance, 5 cm in length, up to 0.5 cm in diameter
        • R’t ovary (frozen): normal appearance, 2 x 1.7 x 0.7 cm
        • R’t fallopian tube (frozen): solid mass at fimbrial area measured 6.5 x 6.2 x 3.5 cm
        • Uterus: 7.8 x 3.9 x 3.3 cm and 66 gm, no tumor seeding
        • Omentum: 28 x 12 x 0.5 cm, normal appearance
        • Peritoneal tumors: five tumors, up to 3.6 x 2.8 x 1.3 cm
      • Tumor site: left ovary
      • Tumor size: 19.7 x 19.3 x 5.2 cm
      • Tumor appearance: solid and cystic mass
      • Specimen integrity: intact
      • Lymph nodes: pelvic lymph nodes + bilateral paraaortic LNs
      • Representative sections as A1: bilateral parametria, A2-A3: cervix, A4: endometrium+ myometrium, B1-B2: peritoneal tumors, C: omentum, D: L’t iliac LNs, E: L’t obturator LNs, F: R’t iliac LNs, G: R’t obturator LNs, H: L’t paraaortic LNs and I: R’t paraaortic LNs [Reference: frozen section: F2023-00383 FSA1-A2: L’t ovarian tumor, A1: fallopian tube and A2-A8: ovarian mass, FSB: R’t tubal mass, B1-B2: R’t tubal tumor, B3: ovary and B4-B5: R’t fallopian tube]
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma
      • Histologic grade: high grade
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: tumor invasion microscopically
      • Right tube involvement: present
      • Left tube involvement: tumor invasion microscopically
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Bilateral parametria: tumor invasion
      • Uterine serosa involvement: absent
      • Omentum involvement: tumor invasion microscopically
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Lymph nodes metastasis: tumor metastasis (7/40) with extracapsular extension (3/7) in total number
      • Immunohistochemistry: WT-1(+), PAX-8(+), P53(aberrant expression), ER(+, scatter) and vimentin(-)
      • Ascites cytology: positive
      • Perineural invasion: present
      • Lymphovascular space invasion: present
  • 2023-08-29 Body fluid cytology - ascites
    • DIAGNOSIS: Adenocarcinoma
    • MACROSCOPIC DESCRIPTION: 40cc, orange, turbid
    • MICROSCOPIC DESCRIPTION: Smears show dense clusters of atypical tumor cells with nuclear hyperchromasia and irregular contour.
  • 2023-08-29 Frozen Section
    • L’t ovary tumor, FSA1-FSA2 — Adenocarcinoma
    • R’t ovary tumor, FSB — Adenocarcinoma
  • 2023-07-11 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • There are large cystic tumors (up to 18cm)in bilateral adnexa, r/o bilateral ovarian malignancy.
      • There are peritoneal tumors, r/o peritoneal carcinomatosis.
      • Diffuse enlarged lymph nodes in aortocaval region.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3c(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIA__(Stage_value)
    • Impression:
      • Bilateral ovarian tumors with peritoneal tumors, aortocaval lymph nodes, r/o ovarian malignancy with carcinomatosis and lymph nodes metastasis.
      • If proven ovarian malignancy, cstage T3cN1M0.
  • 2023-07-10 Gynecologic ultrasonography
    • Imp: R/O Bilateral Ovarian mass

[MedRec]

  • 2023-08-27 ~ 2023-09-25 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Left ovarian cancer (High-grade serous carcinoma) AJCC Pathologic staging: pT3cN1bcM0; stage IIIC status post debulking surgery on 2023/08/29
      • Female pelvic peritoneal adhesions (postinfective)
      • Acute posthemorrhagic anemia
      • Ileus, unspecified
      • Left ovarian mass, frozen + debulking surgery —> High-grade serous carcinom, AJCC Pathologic staging: pT3cN1bcM0; stage IIIC
    • CC
      • Abdominal mass noted for 1 month.
    • Present illness
      • This is a 49 years old unmarried female, G1P0AA1, without ANY underlying disease. She had found a palpable mass at her abdomen since 2023/07. Accompanied with mild decreased appetite. She denied marked abdominal fullness, dysuria, bowel behavior change or abnormal vaginal bleeding. Her menstrual cycle was as follows: duration/interval 2days/28days.
      • Due to the palpable mass, she went to LMD for help and the echogram revealed suspected adnexa mass. Therefore, she was transferred to our hospital for further evaluation.
      • The GYN echogram on 2023/07/10 revealed uterus 6027mm with EM 5.8mm and a fundal myoma 4X4cm, right adnexa mass 5130mm, left adnexa mass 154*101mm, bilateral hydronephrosis and asites.
      • The abdominal CT checked on 2023/07/11 revealed large cystic tumors (up to 18X16cm) in bilateral adnexa, peritoneal tumors and diffuse enlarged lymph nodes in aortocaval region, suspected bilateral ovarian malignancy, cstage T3cN1M0.
      • The tumor marker examination revealed CA125 level was 633.1U/mL, CA199 level was 3.67U/mL, and CEA level was 1.35ng/mL. Under the impression of huge pelvic cystic tumor with solid parts, suspected bilateral ovarian malignancy with carcinomatosis, she was admitted for further cancer survey, work-up (GI panendoscopy) and further treatment.
    • Course of inpatient treatment
      • The female was admitted on 2023/08/27 because of ovarian cancer, stage IIIc, and she underwent debulking and enterolysis on 2023/08/29. After flatus, her eating, defecation and self voiding were okay. However, nausea and vomit occurred since 2023/09/07 after eating for almost one week.
      • KUB revealed ileus, and she started to NPO with IV fluid. Her ileus improved on 9/15, 9/17, 9/19 and 9/25 plain abdomen; bowel sound was also improved day by day. We kept observation, and started to let her undergo water and juice intake since 2023/09/16 am. She could tolerated well when trying porridge and fulldiet. Her urination and ambulation were also okay.
      • An episode of fever was noted on 9/19, which subsided later, and the blood culture yieleded GPC. We gave augmentin to her, and there were no more fever with normal CRP. Since all of her condition were improved, she may be discharged on 2023/09/25 with OPD follow up.
    • Discharge prescription
      • naproxen 250mg 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • MgO 250mg 2# QID

[surgical operation]

  • 2023-08-29
    • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + para-aortic LN dissection + pelvic tumor excision) + enterolysis
    • Finding
      • left ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
        • LOV – 17x15cm tumor with mixed solid mass and multicystic parts with some brown fluid (>1000 c.c) inside, suspected LOV cancer
        • Frozen report – high grade (serous?) adenocarcinoma
        • left tube – np
      • right ovary and tube (unruptured during surgery, removed intact and then cut open outside the body)
        • ROV – 2x2cm, grossly no tumor invasion
        • right tube – enlarged 6x6cm tumor with solid mass, suspected cancer invasion,
        • Frozen report – high grade (serous?) adenocarcinoma
      • uterus: seemed free of cancer invasion
      • peritoneal tumors 3~4#, 1~2cm over low pelvis (CDS site between cervix and rectum), cancer invasion likely
      • omentum – seemed free of cancer invasion
      • left iliac LNs
      • left obturator LNs
      • right iliac LNs
      • right obturator LNs
      • left para-aortic LNs – enlarged mass 1~2cm, cancer metastasis?
      • right para-aortic LNs – enlarged mass 2~3cm, cancer metastasis?
      • liver, bwoels and other peritoneum – seemed free of cancer invasion
      • After the operation, optimal debulking surgery was achieved.
      • Residue tumor: 3~4 small tumors < 1cm , over low pelvis (CDS site between cervix and rectum)
      • A 7mm JP drain was placed in CDS

[chemotherapy]

  • 2023-12-14 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 425mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-11-16 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 580mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-10-21 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-12-14

According to the eGFR laboratory data since Nov, the patient’s renal function has decreased in the past two weeks. The dose of carboplatin has been adjusted accordingly (2023-12-14 425mg <- 2023-11-16 580mg), while the dose of paclitaxel does not require adjustment due to the change in renal function.

  • 2023-12-13 eGFR 72.29 ml/min/1.73m^2
  • 2023-11-29 eGFR 124.35 ml/min/1.73m^2
  • 2023-11-15 eGFR 119.82 ml/min/1.73m^2
  • 2023-11-01 eGFR 122.29 ml/min/1.73m^2

Furthermore, no adjustments are needed for the drugs listed on the active medication list other than those used in chemotherapy, based on the renal function test results from 2023-12-13.

700734229

231214

[lab data]

2023-12-13 Influenza A Ag Negative
2023-12-13 Influenza B Ag Negative

2023-12-04 Rubella IgM Negative Index
2023-12-04 Rubella IgM Value 0.05
2023-12-04 Measles virus IgM Ab Negative Ratio
2023-12-04 MeaslesIgM Value 0.1 Ratio
2023-12-04 Mumps Virus IgG Positive AU/mL
2023-12-04 Mumps Virus IgGValue >300.0 AU/mL
2023-12-04 Mumps Virus IgM Negative Index
2023-12-04 Mumps IgM Value <0.5 Index

2023-11-27 Anti-HBs 13.70 mIU/mL

2023-11-27 Anti-HCV Nonreactive
2023-11-27 Anti-HCV Value 0.12 S/CO

2023-11-27 HBsAg Nonreactive
2023-11-27 HBsAg (Value) 0.37 S/CO

2023-11-27 Anti-HAV IgM Nonreactive
2023-11-27 Anti-HAV IgM Value 0.20 S/CO
2023-11-27 Anti-HAV IgG Reactive
2023-11-27 Anti-HAV IgG Value 9.77 S/CO

[MedRec]

  • 2023-11-22 ~ 2023-12-04 POMR Qiu ShengKang
    • Discharge diagnosis
      • Sepsis, suspect EBV infection
      • Fever, suspect EBV infection
      • Mixed hyperlipidemia
      • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
      • Chronic ischemia heart diseasae
      • Hypertensive heart disease
      • Unspecified abdominal pain
    • CC
      • fever and chills for 4 days.
    • Present illness
      • This is a 65-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
      • He sufferes from fever and chills for 4 days. He came to our ER for help on 11/21. He came back from Thaiand on 11/19. At ER, vital sign showed BP:143/83; PR:113; BT:39.5’C; RR:18; Con’s:E4V5M6, SPO2:93%. Lab data showed WBC:8420, CRP:4, Cr:1.19. Influenza A and B Ag showed negative. Urine analysis showed negative. CxR showed no infiltration. Abdomen CT with and without showed fatty liver, grade 5 and gallstones.
      • Empirical antibiotic with Cefoxitin was givne for infection control.
      • Under the impression of fever cause unknown, he is admitted to our ward for treatment on 2023-11-22.
    • Course of inpatient treatment
      • After admission, empirical antibiotic with Cefoxitin was shifted to Mepem and Doxymycin were given for fever flarep since 11/24. Urine culture showed Group B streptococci. Pending culture. we consulted Meta Qiu QuanTai for TG>2000 on 11/23. We checked Myocardial perfusion SPECT with persantin and no obvious finding. We kept follow up lab data. Cardiac and abdominal echo were done and no obvious abnormality. For the diffused rash over skin, we consulted dermatology and they suggested Sinpharderm and Mycomb used. Spike fever and chills persisted during admission. Series of studies for fever of unknown origin were taken.
      • Fever subsided after above. Lab data finally showed Epstein-Barr virus infection. His WBC and CRP decreased. We shifted tagocid + mepem to cefoxitin. He complaint of palpable mass in his anus and above his anus so we consulted CRS. The mass was ligated.
      • His vital sign was stable today so he was discharged and referred for OPD foolow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
  • 2022-11-22 ~ 2022-11-25 POMR Cardiology Ke YuLin
    • Discharge diagnosis
      • Angina pectoris
      • single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting toleft anterior descending artery on 2022/11/23
      • Hypertensive heart disease
      • Mixed hyperlipidemia
      • Erosive esophagitis, Los Angeles Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by Panendoscopy on 2021/10/21
    • CC
      • episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks
    • Present illness
      • This is a 64-year-old male ex-smoker (2ppd 20+ years and quit 20+ years) with the past history of Hypertension, mixed Hyperlipidemia for years, Chronic ischemic heart disease by CT scan at 2020/06 showed mod calcification (score 192) with 20-50% stenosis of LAD and LCX and erosive esophagitis LA Classification grade A, Superficial gastritis, gastric ulcers, multiple, antrum, duodenal ulcers by PES on 2021/10/21 under regular medication control at our OPD.
      • This time, he was admitted via our OPD because of episode of short of breath with moving a Sofa from 1st floor to 4th floors about three months ago and still exertional dyspnea with chest discomfort while walking up to 2nd floor and exacerbated in recent two weeks. The symptoms without associated with cold sweating or radiation pain to back, without dizziness, palpitation or acid regurgitation. It may be relieved after rest without try NTG, the duration was several minutes. So he came to our CV OPD for further help.
      • At CV OPD, heart CTA was arrange on 2022/11/11 and revealed Calcification of the coronary arteries (LAD=60, LCX=14, RCA=8, Left main trunk=82, total calcium score=219, uisng AJ-130 method); Left anterior descending coronary artery: 50% stenosis at S6. (Se402 IM78); Left circumflex coronary artery: >75% stenosis at S11. (Se402 IM87) and Right coronary artery: 50% stenosis at S1. (Se402 Im113)
      • Cardiac catheterization was indicated and suggested. After well explanation the risk and the procedures to the patient and family, he was admitted to ward for further evaluation and management.
    • Course of inpatient treatment
      • During admission, cardiac catheterization was arranged on 11/23 after well explained the risks and the procedures to the patient and family. N/S hydration was given to reduce the incidence of contrast induced renal injury.
      • Coronary angiography was done via right radial artery smoothly which revealed single vessel coronary artery disease status post percutaneous coronary intervention with drug eluting stenting to left anterior descending artery.
      • The patient denied any chest discomfortable but chronic exertional dyspnea persistent after PCI.
      • After intervention, we go on aspirin 1# qd and added plavix 1# qd use. The right wrist cath wound healed well. Neither ecchymosis nor hematoma developed. Follow up cardiac markers and EKG after PCI were unremarkable. His urine output remained adequate after PCI and follow up renal function is improving.
      • We also arrange echocardiography on 2022-11-24 for dyspnea evaluation andrevealed
        • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
        • Normal LV and RV systolic function(78%)
        • Mild aortic valve sclerosis with trivial AR; mild MR.
        • Mildly dilated proximal ascending aorta (35 mm), mild aortic root calcification.
      • Under stable hemodynamics, he was discharged on 11/25 and OPD followed up was arranged.
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Linicor (niacin 500mg, lovastatin 20mg) 1# HS
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Norvasc (amlodipine 5mg) 1# QD
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QD
  • 2017-01-04 Gastroenterology Xu RongYuan
    • Diagnosis
      • Mixed hyperlipidemia [E78.2]
      • Chronic hepatits, unspecified [K73.9]
    • Prescription x3
      • Olbetam (acipimox 250mg) 1# BID
      • Lipanthyl Supra (fenofibrate 160mg) 1# QD

700783400

231214

[exam findings]

  • 2023-11-24 CTA - chest
    • Without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Chest
        • Moderate Rt pleural effusion with dependent volume loss of RLL and patchy opacities at LLL as well as a nodular lesion lingula of the lungs.
        • Mediastinum and hila: no enlarged LN or mass.
        • Thoracic aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber and well opacification.
        • Heart: normal size of cardiac chambers. conventric LVH?
        • Pleura: unremarkable, no effusion or thickening or nodule.
        • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • a large soft-tissue tumor in the lower part of Rt kidney (at 92mm in longest dimension) and a huge soft-tissue tumor at Rt posterior perirenal/pararenal space (15cm in longest dimension).
        • with several LAP at para-aortic region.
        • several small renal cysts and atrophic pancreatc tail.
        • unremarkable of the liver, GB, spleen, Lt adrenal gland,
        • bile ducts: No dilatation.
        • Mild atherosclerotic change of the abdominal aorta and bilateral common iliac arteries.
        • marginal spurs of multiple vertebrae due to spondylosis.
        • compression fracture of L2 vertebral body
    • Impression:
      • large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space with several metastatic LAP at para-aortic region.
      • Lt lung metastasis or infection?

[MedRec]

  • 2023-12-13 ~ 2023-12-14 POMR Family Medicine Ye JiaZe

    • Discharge diagnosis
      • B-cell lymphoma without treatment, diagnosed at Taipei Veterans General Hospital in 2017.
      • Hyperkalemia
      • Right pleural effusion
      • Chronic kidney disease, stage 3 (moderate)
    • CC
      • decline of consciousness level and dyspnea on 2023/12/13 morning.
      • vomiting once after NG tube feeding
    • Present illness
      • The 83-year-old man had past history of
        • Hypertension
        • Type II diabetes mellitus
        • Arrythmia
        • Urolithiasis status post DJ insertion
        • Low grade B-cell lymphoma on 2017/11
      • According to his son, the patient had B-cell lymphoma without treatment in 2017, diagnosed at TPEVGH. He was admitted to our Oncology ward on 2023/11/24 for disturbance. Laboratory data revealed hypercalcemia. Chest CTA (2023/11/24) showed large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space, with several metastatic LAP at para-aortic region. Lt lung metastasis or infection? Renal biopsy was suggested to the family, they refused schedule and preferred supportive care.
      • This time, he had decline of consciousness level and dyspnea on this morning. Vomiting once after NG tube feeding was also note. There was no cough, abdominal pain, nor tarry stool. Desaturation with SpO2: 75% by EMT. He was sent to our ER for help. At ER, his GCS was E2V1M1. TPR: 37.9, 130, 26. BP: 102/54mmHg. PE showed bilateral breathing sounds rhonchi. Abdomen flat and soft. Laboratory data showed anemia, HGB 8.3g/dL, elevation for Lactic Acid 7.3 mmol/L, hs-Troponin I 216.5 pg/ml, CRP=11.8 mg/dL. U/A showed pyuria. CXR disclosed Right pleural effusion and ground glass opacity in right lung and LLL. Pending B/C and S/C. Due to poor prognosis, the family asked for palliative care. FM was consulted for hospice care. The patient was admitted to our hospice ward on 2023/12/13.
    • Course of inpatient treatment
      • After admission, vital signs were unstable. Morphine was given as 3mg SC Q6H, other sedatives were given PRN as neccessary according to his symptoms. His condition had downhilled fast which low blood pressure was noticed during the night. He had expired on 2023.12.14 04:54. We had informed the family and mental support was done to the family.
  • 2023-11-24 ~ 2023-12-08 POMR Hemato-Oncology Gao WeiYao

  • 2023-11-24 VS Note on Admission Day

    • Summary
      • The 83 y/o man has HTN, DM, ARRYTHMIA, UROLITHIASISS/P DJ INSERTION.
      • He was admitted through ER with the chief complaint of concious disturbance for 6 days. A series of studies at ER supported that a large Rt renal cancer and largest malignant tumor in Rt posterior perirenal/pararenal space. with several metastatic LAP at para-aortic region. Lt lung metastasis and HYPERCALCEMIA and hypernatremia were noted.
    • Plan to do:
      • On critical condtition
      • Correct hypercalcemia, hyperuricemia, hypernatremia and blood sugar.
      • Tissue proof of Rt renal tumor (lymphoma or kidney ca ??) with regional and distant metastases.
  • 2021-11-06 ~ 2021-11-19 POMR Urology

    • Discharge diagnosis
      • Left ureteral stone status post left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17
      • Left hydronephrosis status post left percutaneous nephrostomy on 2021/11/10
      • Urinary tract infection with E-coli
      • Infectious gastroenteritis and colitis, unspecified
      • Type 2 diabetes mellitus with hyperglycemia
      • Hypertensive heart disease without heart failure
    • CC
      • Tenesmus and chills for 1 day
    • Present illness
      • This is a 81-year-old male with underlying parkinsonism, type II diabetes mellitus with insulin control for years, BPH, Hypothyroidism under medication control, arrhythmia under Eliquis and hypertension for years. This time, he had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice.
      • He had tenesmus and chills last night, and symptoms relieved after defecated soft stool twice. He came to our ER for help. At ER, PE found pale conjunctiva. Lab data showed WBC 17550, Hb 10.8, CRP 8.83, Cre 1.54, Pyuria (WBC >100, OB 3+, Bact 3+), Stool OB 2+.
      • KUB revealed Compression fracture of L2, Radiopaque spot(s) at left renal region r/o renal stone(s), Stool retention in the bowel.
      • Under the impression of UTI, he came to our ward to do further management and examination.
    • Course of inpatient treatment
      • After admission, the surgery of left percutaneous nephrostomy on 2021/11/10. Antibiotic with Tapimycin (11/11~) due to his fever not improved. After antibiotic treatment, his fever much improved.
      • The surgery of left ureterorenoscopic lithotripsy with double J stenting on 2021/11/17. With clinical improvement and stable condition, she was discharged and would be followed up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
      • Urief (silodosin 8mg) 1# QN
      • Ceficin (cefixime 100mg) 1# BID

==========

2023-11-27

[enhancing patient care through shared medical records from Far Eastern Memorial Hospital]

Per the PharmaCloud database, the patient was diagnosed with “Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT-lymphoma)” at Far Eastern Memorial Hospital, with his last visit on 2023-08-24. The patient should be requested to provide the examination results and treatment details from that hospital to enable our medica team a more comprehensive consideration of the current situation.

[optimizing calcitonin Use for hypercalcemia management]

The patient, who has hypoalbuminemia, shows a corrected calcium level of 3.1 mmol/L (12.4 mg/dL) and is currently receiving Miacalcic (calcitonin) at 100 IU SC Q6H.

  • 2023-11-27 Ca (Calcium) 2.91 mmol/L

  • 2023-11-26 Ca (Calcium) 3.03 mmol/L

  • 2023-11-24 Ca (Calcium) 3.08 mmol/L

  • 2023-11-27 Albumin (BCG) 3.0 g/dL

  • 2023-11-24 Albumin (BCG) 3.2 g/dL

For severe hypercalcemia, the maintenance dose of calcitonin can be up to 8 units/kg Q6H to Q12H, starting with an initial dose of 4 units/kg Q12H. Since the current administration of 100 IU Q6H is below the recommended dosage, this may extend the duration of therapy. It’s advisable to limit calcitonin therapy to a period of 24 to 48 hours to avoid tachyphylaxis.

Given that the serum calcium level has not exceeded 3.5 mmol/L (14 mg/dL) and is trending downwards, the combined use of calcitonin with bisphosphonates for a long-term effect may not be essential.

[basal insulin initiation for consistent hyperglycemia]

All recorded blood glucose levels in the TPR panel fall between 230 and 380 mg/dL during this hospitalization, frequently exceeding 300 mg/dL, despite the current use of Insulin Actrapid, NovoRapid, and Trajenta. Therefore, it is advisable to introduce basal insulin (a long-acting type) starting with a daily dose of 2 units, with evaluations every other day to determine if further adjustments are necessary.

[replacing D5W with NS in hyperglycemic hydration plan]

Given the patient’s obvious hyperglycemia, it is advisable to switch from D5W to NS for hydration purposes.

[evaluating causes of hypercalcemia: beyond hyperthyroidism]

The lab results showed no elevation in TSH, Free-T4, or T3, suggesting that hyperthyroidism is an unlikely cause of the hypercalcemia. Could osteolytic bone metastases and local cytokines be contributing factors?

  • 2023-11-27 TSH 1.012 uIU/mL
  • 2023-11-27 Free-T4 1.08 ng/dL
  • 2023-11-27 T3 0.31 ng/mL

700701383

231213

[MedRec]

  • 2023-12-05 Cardiac Surgery Xu ZhanYang
    • Discharge diagnosis
      • Adenocarcinoma of the gastric antrum; status post subtotal gastrectomy on 2023-11-02; status post Port-A catheter implantation through the right internal jugular vein on 2023-12-06
      • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
      • Hypertension
      • Type 2 diabetes mellitus
      • Asthma
      • Hepatitis B carrier
    • CC
      • Expected hospitalization for Therapeutic catheter implantation - Port-A catheter implantation surgery.
    • Present illness
      • This is a 62-year-old male patient with a history of hypertension, type 2 diabetes, and asthma for several years. He is also a carrier of Hepatitis B. His surgical history includes:
        • C5-6-7 herniated intervertebral disc (HIVD) and stenosis; status post discectomy and spinal fusion on 2013-07-30
        • Anal fistula and hemorrhoids; status post fistulotomy and hemorrhoidectomy on 2015-07-08
        • Benign prostatic hyperplasia; status post transurethral resection of the prostate on 2019-04-17
        • Prostate cancer; status post radical prostatectomy and pelvic lymph node dissection on 2019-06-26
        • Prostate cancer and phimosis; status post bilateral orchiectomy on 2019-12-25.
      • He was diagnosed with adenocarcinoma of the gastric antrum in 2023 and underwent subtotal gastrectomy on 2023-11-02 at National Yang Ming Chiao Tung University Hospital.
      • Further chemotherapy is needed. The patient was then referred to the cardiovascular surgery department for Port-A catheter implantation. The surgery is scheduled for 2023-12-06, and the patient was admitted on 2023-12-05 for elective Port-A catheter implantation.
    • Course of inpatient treatment
      • After admission, the patient underwent Port-A catheter implantation through the right internal jugular vein on 2023-12-06. Following the surgery, wound management skills education was performed. The patient was discharged home on 2023-12-06.
    • Discharge prescription
      • Sindine Aq Soln (povidone iodine 10%) QD EXT
      • Acetal (acetaminophen 500mg) 1# QID
      • Lactul (lactulose 666mg/mL) 10mL PRNTID
  • 2023-11-23 SOAP Hemato-Oncology Gao WeiYao
    • A:
      • Metchronous double cancer (prostate first and gastric ca later 2023)
        • The term metachronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose more than six months after the diagnosis of the first malignancy. These may be in the same, or in different, organs.
        • The term synchronous is used in oncology to refer to two (or more) independent primary malignancies, when the second (or third, etc.) malignancy arose within six months of the diagnosis of the first malignancy. These may be in the same, or in different, organs.
      • Adenocarcinoma of gasric antrum , pT3N3aMx, stage IIIb post subtotal gastrectomy on 2023-11-02 at YiLan YanMing Hospital.
  • 2019-11-11 SOAP Urology LinJiaDa
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Date: 2019-10-07
      • Start androgen deprivation therapy (ADT) on 2023-10-01. Monitor for efficacy for a period of time.
      • If the prostate-specific antigen (PSA) level does not decrease by at least 50% after 6 months, chemotherapy should be considered.
      • Germline mutation testing should be considered.
  • 2019-04-16 ~ 2019-04-19 POMR Urology Lin JiaDa
    • Discharge diagnosis
      • N40.1 Benign prostatic hyperplasia status post transurethral resection of the prostate on 2019/04/17
      • R97.2 Elevated prostate specific antigen status post Transrectal ultrasound guided (TRUS) biopsy on 2019/04/17
    • CC
      • urinary frequency, weak stream and nocturia 4-6 times/night.
    • Present illness
      • This 58-year-old man has histories of 1) C5-6-7 HIVD was diagnosed at CGMH 4-5 years ago; 2) Hemorrhoid s/p operation 13 years ago at CGMH; 3) Anal fistula post fistulotomy on 2015/07/08; 4) BPH under medication treatment for 2+ years.
      • He has LUTS such as urinary frequency, weak stream and nocturia 4-6 times/night. He received follow-up at urologic clinic periodically for BPH treatment. He complained symptoms more severe in this month and visited our urologic clinic ask surgery.
      • PSA:7.619 ng/mL. Transrectal echo revealed benign prostatic hyperplasia (36.8 cc). Though some alpha-blockers were prescribed, but no significant effect was noted.
      • Under the impression of benign prostatic hyperplasia and elevated prostate specific antigen (PSA), we advised the patient to receive laser TURP and TRUSP biopsy. After well explaining, the patient agreed.
      • This time, he was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, the surgery of transurethral resection of the prostate and transrectal ultrasound guided (TRUS) biopsy was performed on 2019/04/17.
      • Postoperative course was uneventful and continued N/S bladder irrigation.
      • Removed Foley done smoothly on 4/19 with fair urination, he was discharged today and would be followed up at urologic clinic.
    • Discharge prescription
      • Atanaal (nifedipine 5mg) 2# PRNQ6H
      • MgO 250mg 1# QID
      • Lactam (acetaminophen 500mg) 1# QID
      • cephalexin 500mg 1# QID

[surgical operation]

[chemotherapy]

  • 2023-12-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 720mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-12-13

The PharmaCloud records show that this patient recently refilled his prescription for metformin and Sevikar (amlodipine, olmesartan) on 2023-12-03 for a 28-day supply. These drugs have been included in the active medication list.

Zytiga (abiraterone) has been in use since early 2021 and continues to be part of the patient’s treatment regimen. Androcur (cyproterone) was administered from 2019-10 to 2020-01, with two doses of Leuplin (leuprorelin) given on 2019-10-01 and 2019-10-31 prior to the initiation of Zytiga.

It is advisable that patients receiving abiraterone should also receive a gonadotropin-releasing hormone (GnRH) analog concurrently (or have had a bilateral orchiectomy).

701260169

231213

[exam findings]

  • 2023-04-14 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right, simple mastectomy —- Solid papillary carcinoma with invasion
      • Resection margins, ditto — Free of tumor invasion
      • Lymph node, right axillary sentinel area, frozen (F2023-00167) — Free of tumor metastasis (0/2)
      • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 19.9 x 18.2 x 3.4 cm
      • Skin: 17.2 x 4.4 cm
      • Nipple: 1.6 x 1.3 cm
      • Tumor: 2.7 x 1.9 cm
      • Resection margins: Free, 0.7 cm away from closest base, at least 2.8 cm away from peripheral margins
      • Lymph node: right axillary sentinel LNs, sent for frozen section (F2023-00167)
      • Representative sections as A1: four peripheral margins, A2: base, A3-A7: tumor, A8: skin + nipple [Reference: frozen F2023-00167 FSA1-A2: right axillary sentinel LNs}
    • MICROSCOPIC EXAMINATION
      • Histologic type: solid papillary carcinoma with invasion and focal ductal carcinoma in situ, intermediate grade
      • Size of invasive carcinoma: 2.7 x 1.9 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free of tumor invasion
      • Nodal status: Free of tumor metastasis (0/2)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: not identified
      • Perienural invasion: not identified
    • IMMUNOHISTOCHEMISTRY
      • Synaptophysin(+, diffuse), chromogranin-A(+, diffuse) for tumor and P63(+, rim pattern) for DCIS
      • Please refer to S2023-05519 for ER, PR, Her2/neu and Ki67 status
  • 2023-03-24 Patho - breast biopsy (no margin)
    • Breast, right, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism and increased N/C ratio.
    • Immunohistochemical study demonstrates ER: positive (strong, 99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.

[MedRec]

  • 2023-05-10 SOAP General and Gastroenterological Surgery Zhang YaoRen
    • O: Conclusion of the Multidisciplinary Cancer Team Meeting - Meeting Date: 2023-04-28
      • FEC x6 followed by AI for 5 years.
  • 2023-05-01 ~ 2023-05-03 POMR General and Gastroenterological Surgery Zhang YaoRen
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast invasive carcinoma status post port A insertion on 2023/05/02. pT2N0M0, stage IIA. ECOG:0.
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • Present illness
      • Under surgery of right breast simple mastectomy + SLNB on 2023/04/14.
      • Pathology: solid papillary carcinoma with invasion,size 2.7 cm,Gr 2, pT2N0M0, stage IIA.
      • Adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles were suggest.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of port A insertion. Arrange 1st adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023-05-03.
  • 2023-04-13 ~ 2023-04-15 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Right breast invasive carcinoma status post simple mastectomy + sentinel lymph node biopsy  on 2023/04/14. cT2N0M0, stage IIA. ECOG:0.
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
    • CC
      • noted a palpable mass at right breast and stabbing pain over 2 months.
    • Present illness
      • This 40-year-old female patient has past history of hypertension and Type 2 diabetes mellitus over 3 years with regular medicine control. She denied cancer history. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at right breast and stabbing pain over 2 months. She came to our OPD for help. Breast sono showed right breast heteregeneous tumor, 10’ region, suggest biopsy. Right breast 9’ region and left 12’ region angulated tumors, suggest close follow up. Core needle biopsy revealed invasive carcinoma, ER: positive (strong,99%), PR: positive (strong,99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative. CA-153:10.123 U/ml, CEA:2.247 ng/ml. PET and abdomen echo showed no obvious lesion for metastasis. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 4x4 cm without discharge. left breast P scar. The nipple was dimping without exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of simple mastectomy + SLNB.  
    • Course of inpatient treatment
      • After admission, right breast simple mastectomy + SLNB was performed on 2023/04/14. The wound is clean and dry. Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
  • 2023-04-10 SOAP General and Gastroenterological Surgery
    • O
      • 2023/03/31 PET scan
        • A glucose hypermetabolic lesion in the right breast, compatible with primary breast malignancy.
        • Mild glucose hypermetabolism in two small right axillary lymph nodes, in a small left axillary lymph node and in the right pulmonary hilar region. Inflammatory process is more likely.
        • Glucose hypermetabolism in a focal area in the body of the pancreas.
        • Increased FDG accumulation in both kidneys and colon.
      • Lab
        • 2023/03/31 Anti-HCV (NM) = Negative;
        • 2023/03/31 Anti-HCV Value (NM) = 0.032;
        • 2023/03/31 Anti-HBc (NM) = Negative;
        • 2023/03/31 Anti-HBc Value (NM) = 2.410;
        • 2023/03/31 Anti-HBs (NM) = Positive;
        • 2023/03/31 Anti-HBs value (NM) = 480.000 mIU/mL;
  • 2023-03-29 SOAP General and Gastroenterological Surgery
    • S: Rt breast ca proved by CNB on 2023-03-24
    • O
      • 2023/03/24 PATHO - breast biopsy (no need margin)
        • Breast, right, core needle biopsy — Invasive carcinoma of no special type
        • ER: positive (strong,99%), PR: positive (strong, 99%), Her2/neu: negative (0), Ki-67 inedex: 40%, p63: negative.
  • 2023-03-22 SOAP General and Gastroenterological Surgery
    • S: breast lump
    • O
      • premenopausal
      • menarche 13 y/o
      • G0P0
      • FH of breast ca (-)
      • Hormone (-)
      • A 4 cm elastic firm mass in rt breast
  • 2021-05-14 SOAP Metabolism and Endocrinology
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QDAC
      • Ankomin (metformin 500mg) 1# BIDAC
      • Zulitor (pitavastatin 4mg) 1# QNAC
      • Amepiride (glmepiride 2mg) 0.5# QDAC
      • Galvus Met (vidagliptin 50mg, metformin 500mg) 1# BIDAC
  • 2021-01-22 SOAP Metabolism and Endocrinology
    • Prescription x3
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Ankomin (metformin 500mg) 2# BIDCC
      • Zulitor (pitavastatin 4mg) 1# QN
  • 2020-12-12 SOAP Metabolism and Endocrinology
    • A/P
      • Complete metabolic profiles
      • Diet control
      • Prescribe metformin 500 TID
      • SMBG QDAC at home
      • RTC 2 W later
    • Prescription
      • Ankomin (metformin 500mg) 1# TIDCC

[surgical operation]

  • 2023-04-14
    • Surgery: Simple mastectomy and sentinel lymph node biopsy        
    • Finding:
      • a 3x2x2 cm slight firm mass in rt breast
      • SLN 0/1  

[chemotherapy]

  • 2023-09-27 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-09-07 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-08-17 - docetaxel 75mg/m2 138mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-28 - docetaxel 75mg/m2 140mg NS 250mL 1hr (D Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-06 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-15 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1100mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-25 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1088mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-03 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr + cyclophosphamide 600mg/m2 1083mg NS 500mL 1hr (AC(lipo) Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-12-13

[leukopenia, diarrhea]

Review of lab data from HIS5 reveals that the last documented episode of leukopenia occurred on 2023-10-04, exceeding two months ago. Serial WBC counts demonstrate a period of low values approximately one week after docetaxel administration. However, recent data is insufficient to confirm or rule out the current presence of leukopenia.

  • 2023-10-04 WBC 1.52 x10^3/uL <- leukopenia
  • 2023-09-27 WBC 6.85 x10^3/uL <- docetaxel
  • 2023-09-13 WBC 3.17 x10^3/uL
  • 2023-09-07 WBC 6.27 x10^3/uL <- docetaxel
  • 2023-08-23 WBC 2.94 x10^3/uL
  • 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel

This patient is currently taking Nolvadex (tamoxifen citrate 10mg/tablet) 1# BID, a medication that is generally not linked to leukopenia.

Moreover, the lab results indicate increased levels of myelocytes and metamyelocytes. It might be important to investigate further to determine if these findings have clinical significance.

No significant episodes of diarrhea were found documented in the recent medical history.

2023-08-21

[leukopenia]

The patient underwent 4 rounds of liposome doxorubicin and cyclophosphamide treatment on 2023-05-03, 2023-05-25, 2023-06-15, and 2023-07-06 without any signs of leukopenia.

However, a week following the initial dose of docetaxel on 2023-08-04, leukopenia was detected. Consequently, Granocyte (lenograstim 250ug) was administered the same day.

  • 2023-08-17 WBC 7.32 x10^3/uL <- docetaxel
  • 2023-08-06 WBC 3.47 x10^3/uL
  • 2023-08-04 WBC 1.12 x10^3/uL <- leukopenia
  • 2023-07-28 WBC 4.20 x10^3/uL <- docetaxel
  • 2023-07-06 WBC 4.19 x10^3/uL
  • 2023-06-15 WBC 4.65 x10^3/uL
  • 2023-05-25 WBC 7.70 x10^3/uL
  • 2023-05-10 WBC 7.11 x10^3/uL
  • 2023-04-13 WBC 5.66 x10^3/uL

Docetaxel is associated with a high incidence of leukopenia. (UpToDate: 84% to 99%; grades 3/4: 49%; grade 4: 32% to 44%)

The patient received a second dose of docetaxel on 2023-08-17. Prophylactic G-CSF is scheduled for 2023-08-22 and 2023-08-23. Currently, there’s no indication of newly emerging leukopenia.

700136759

231208

[exam findings]

  • 2023-11-30 CT - neck
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • No identifiable source of infection is seen in the neck.
      • The oral cavity shows no evidence of focal lesion.
      • The mouth floor and submandibular regions are normal. No focal lesion is identified.
      • The salivary and submandibular gland remain intact.
      • No neck lymphadenopathy is visualized.
      • The thyroid appears normal in size and enhancement.
      • Fibrocalcified change over right apical lung, may be old TB.
  • 2023-12-04, -11-27, -11-22 CXR
    • Linear infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Scoliosis of the T-spine with convex to right side.
    • Enlargement of cardiac silhouette.
    • Old fracture of left 7th rib.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-11-23 CT - chest
    • Indication: multiple myeloma, R/O ITP pneumonia over bilateral lungs
    • Chest CT with and without IV contrast ehnancement shows:
      • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered. Viral or bacterial infection are possible. PCP or CMV infection is less likely.
      • Fibrocalcified lesions are noted at right upper lobe and lu ill-defined opacity is found.
      • Permeative change of the bony structure is found. Multiple myelooma is compatible
    • Imp:
      • Diffuse interstitial change at bilateral lung fields with sparing of the peripheral lungs and combined with mild right pleural effusion is found. Pneumonia is considered.
  • 2023-11-20, -11-17 CXR
    • Linear and patchy infiltration projecting at both lung is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Scoliosis of the T-spine with convex to right side.
    • Enlargement of cardiac silhouette.
    • Old fracture of left 7th rib.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-11-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 29.7) / 127 = 76.61%
      • M-mode (Teichholz) = 73.1
      • 2D (M-Simpson) = 67.8
    • Conclusion:
      • Normal AV with mild AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, dilated IVC size
  • 2023-11-07 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Plasma cell myeloma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of a piece of gray-brown and hard bony tissue, measuring 1.0 x 0.3 x 0.3 cm. All for section after decalcification.
    • MICROSCOPIC EXAMINATION
      • The sections show hypercellular marrow (50%). The marrow space is largely replaced by a population of small to medium-sized immature and mature CD138+ plasma cells, constitue 90% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
  • 2023-11-07 Skull AP + Lat.
    • Multiple nodular defects in the skull are suspected. Please correlate with brain CT.
  • 2023-11-07 Long Bones series
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
  • 2023-11-06 Patho - bone marrow biopsy
    • Bone marrow, post iliac creast, biopsy — plasma cell myeloma
    • The specimen submitted consists of 1 bone marrow tissue fragment measuring 3.4x 0.2x 0.2 cm in size, fixed in formalin. Grossly, it is brownish and elastic to hard.
    • Microscopically, it shows hypercellularity (about 60%) and marked proliferation of plasma cells (>=70% of bone marrow cellularity). Some mature eryhtroid cells and megakaryocytes are present. No blast is identified.
    • Immunohisotchemical stain reveals CD34(-), CD117(-), CD138 (diffuse +), MPO(+), CD71(focal+), CD61(focal +), Kappa chain(-), lambda chain(+, restriction).
  • 2023-10-20 KUB + L-spine Lat.
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • S/P posterior longitudinal transpedicular screws and rods fixation with paraspinal bone grafting or disc cage implantation L3-5.
  • 2023-10-13 Patho - interveterbral disc
    • Bone and joint, vertebra, L3-4-5 TPS-RF revision and L3-4 TLIF — Confirmed
    • Specimen submitted in formalin consists of multiple pieces of tan, irregular tissue with the largest piece measuring 1 x 0.5 x 0.3 cm. All tissue for section in one cassette after decalcification.
    • Section shows pieces of bone, degenerated ligament, and cartilage.
  • 2023-10-06 MRI - L-spine
    • Without-contrast multiplanar spine MRI revealed:
      • post-OP change from L4 to L5.
      • high SI chnage on STIR in the sacral multifidus muscles. Moderate to severe atrophic change in the bilateral lower L-spine multifidus muscles, more on the left side was noted.
      • unremarkable change in the visible cord.
      • decreased SI on T2WI in the L2/3, L4/5 and L5/S1 disc spaces; high SI change on T2WI in the L3/4 disc; focal high SI change on T2WI in the posterior aspects of the L5/S1 and L4/5 discs. Herniated disc in the L3/4 disc caused moderate bilateral L3-4 lateral recess stenosis and moderate anterior indentation on the L3-4 thecal sac.
      • hyperemic endplate change in the lower L3 vertebral body and upper S1 vertebral body. Focal high SI change on STIR in the bilateral iliac bones was noted.
      • degenreative change at the L-spine facet joints.
    • IMP
      • moderate bilateral L4-5 lateral recess stenosis;
      • high SI change on bone marrow of the bilateral iliac bones. Please correlate with contrast-enhanced study.
      • r/o discitis in the L3/4 disc.
  • 2023-09-25 Exercise Electrocardiogram, Treadmill exercise test (TET)
    • Findings
      • The patient exercised according to the CORNELL for 11:40 min:s, achieving a work level of max METS: 8.3.
      • The resting heart rate of 70 bpm rose to a maximal heart rate of 146 bpm.
      • This value represents 100 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 143/77 mmHg, rose to a maximum blood pressure of 146/72 mmHg.
      • The exercise test was stopped due to Target heart rate maximal, Arrhythmias, Fatigue.
    • Conclusion
    • Positive for myocardial ischemia
    • PVCs that develop with exercise
  • 2023-09-25 Bronchodilator Test
    • Normal ventilatory function
    • Not significant bronchodilator reversibility
  • 2023-04-06 ECG - 8C high level
    • Sinus bradycardia with 1st degree A-V block
    • ICRBBB in V2
  • 2023-04-06 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed: Hip, BMD is 0.726 gms/cm2, about 1.8 SD below the peak bone mass (77%) and 0.0 SD at the mean of age-matched people (100%).
    • IMP: osteopenia
  • 2023-04-06 CT - chest
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs: Fibrotic change at bilateral apical lungs is found. Pleural based nodule at left upper lobe measuring 0.53cm in largest dimension.
    • IMP: Fibrotic change at bilateral apical lungs. Pleural based nodule at left upper lobe.

[MedRec]

  • 2023-10-30 SOAP Cardiology Zhang HengJia
    • S: stable CAD, PAC, PVC, Anxiety possible old TB, has no UAP and DOE is not getting worse, Home BP: WNL, BS: no crackles, no rales, no wheezes, HS: no s3, s4, no sys m, no leg edema, s/p spine op, uneventful
    • A/P: regular exercise and diet control, F/U blood biochemistry, keep current Rx; F/U in 1 m, then she will go back to California
    • Prescription
      • Concor (bisoprolol 5mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QD
  • 2023-10-11 ~ 2023-10-16 POMR Neurosurgery Li DingZou
    • Discharge diagnosis
      • L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome status post L3-4-5 Transpedicular screw fixation revision and L3-4 Transforaminal Lumbar Interbody Fusion on 2023/10/12
      • Postlaminectomy syndrome
      • Cardiac arrhythmia
      • Hyperlipidemia
    • CC
      • Low back and right buttock pain with right knee pain in reccent two months.
    • Present illness
      • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back and right buttock pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication. She visited our neurosurgery clinic for help. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbar spine MRI showed L3-4 stenosis and spondylolsihtesis, compatable with adjacent syndrome. We had fully inform to patient and her family about the condition, treatment plan, surgical procedure and risks. She was admitted for revision diskectomy.
      • No trauma history
      • No cancer history        
    • Course of inpatient treatment
      • Post-operative course was uneventful. Analgesic agents was used for wound pain control. Her discomfort was relieved a lot. The wound was clear and dry. She was discharged home and outpatient follow-up was mandatory.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# QID
      • Celebrex (celecoxib 200mg) 1# BID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Lyrica (pregabalin 75mg) 1# BID
      • Toricam (piroxicam 10mg/gm) ASORDER TOPI
  • 2023-10-06 ~ 2023-10-07 POMR Neurosurgery Li DingZou
    • Discharge diagnosis
      • L3-4 spondylolsihtesis, spinals stenosis and compatable with adjacent syndrome.
      • Postlaminectomy syndrome, not elsewhere classified
      • Mixed hyperlipidemia
      • Cardiac arrhythmia, unspecified
      • Anxiety disorder, unspecified
      • Insomnia, unspecified
    • CC
      • low back pain with right knee pain in reccent two months
    • Present illness
      • This 75-year-old female patient who hyperlipidemia and cardiac arrhythmia umder medicinal control. She complained of low back pain with right knee pain in reccent two months. It would be worsened by arising, forward bending or prolonged sitting/standing, and relieved by bed rest. There was intermittent claudication.
      • She visited our neurosurgery clinic. L-spine x-ray showed status post L4-5 trans-pedicular screw-rod fixation. Lumbat spine MRI on schedule.
      • She had serve painful this night. She came to our ER for help. Tramadol IVD st for pain control.
      • Lumbar spine MRI showed L3-4 stenosis/ spondylolsihtesis, compatable with adjacent syndrome. Revision surgery considerated.
      • Previous NSAID was ineffective. She was admitted for pain control.
      • No trauma history
      • No cancer history        
    • Course of inpatient treatment
      • After admission. pain control was given.
      • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
      • Explained the image finding to her and her daughter. Revision surgery considerated. Hold Aspirin since today. The surgery is scheduled for next Wednesday. She was arrange discharge today. Re-admission on next Tuesday.
  • 2023-10-06 SOAP Ophthalmology Xu WeiCheng
    • S: 2013-07 glaucoma under xalatan, no discomfort
    • Prescription x3
      • Xalatan (latanoprost 50ug/mL) 1 drop HS OU
      • Ementin (emedastine 2.5mg/5mL) 1 drop BID OU
  • 2023-10-06 SOAP Neurosurgery Li DingZou
    • S: LBP and right knee radiated pain for 2 weeks; ineffective to pain killer; relief by rest;
    • Prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 0.5# PRNTID
      • Neurontin (gabapentin 100mg) 1# PRNTID
  • 2023-10-02 SOAP Cardiology Zhang HengJia
    • A: newly Dx of CAD, with mild TET ischemic changes, PFT is WNL
    • P: GDMT with ASA, BB and statin, regular exercise and diet control, F/U in one m
    • Prescription
      • Concor (bisoprolol 5mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QD
      • Nitrostat (nitroglycerin 0.6mg) 1# ASORDER SL for angina
  • 2023-09-06 SOAP Cardiology Zhang HengJia
    • S: a case of PAC, arrhythmia and DOE referred after health wellness checkup, by TC V Yang Lee Hwua; no UAP, DOE is not getting worse, home BP WNL, BS: no rales, no wheezes, HS: No s3, s4, no systolic murmur, no leg edema, Lab exam: anemia
    • A: Cardiac dysrhythmia, PAVC, PVC, Anxiety possible old TB, Insomnia,
    • P: TET for DOE and chest pain, and PFT for possible restrictive lung, also advise hema clinic W/U for anemia

[consultation]

  • 2023-11-13 Infectious Disease
    • Q
      • for pnrumonia over both lungs
      • This 75-year-old woman, a patient of myltiple myeloma IgG type was diagnosed in Nov 2023.
      • This time, fever with chills and dyspnea were noted and antibiotic with Cefim + Targocid was given and CXR (11/12 23) showed bilateral pnrumonia.
      • We need expertise to evaluate her condition thanks!
    • A
      • 75-year-old multiple myeloma female patient has low grade fever for 6 days during hospitalization, followed by diffuse alveolar infiltrations over both lungs on this morning chest X-ray film, especially right lung.
      • Acute pulmonary edema is the first impression, that IV diuretic recommended first.
      • Pulmonary edema may be related to frequent transfusion and underlying impaired heart function.
      • For possible superimposed pneumonia, patient is receiving Targocid, Mepem and oral Baktar now.
    • Suggestion:
      • Continue the present antibiotic regimen
      • Arrange echocardiography and give diuretic.
      • Follow up CxR 2 days later.
      • Check sputum culture report, PJP-PCR.
  • 2023-10-07 NeuroSurgery
    • Q
      • CC: pain over lower back and right thigh to knee with right leg paralysis and numbness for 2 weeks
        • paralysis, numbness, severe pain over right knee and thigh, cannot walk freely
        • bending down can alleviate the symptoms
      • PHx:
        • lumbar laminectomy L4-5 in TSGH 20 years ago
        • arrthymia
      • lumbar spine X ray and knee X ray already done in clinic –> came here for MRI
    • A
      • A case of 75 y/o female, arrythmia under aspirin tx; s/p L4-5 TPS-RF 20 yrs ago.
      • LBP with right knee pain for weeks.
      • A MRI at ER showed L3-4 stenosis/spondylolsihtesis, compatable with adjacent syndrome.
      • P: pain control; Revision surgery considerated;

[immunochemotherapy]

  • 2023-12-07 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D15)
  • 2023-11-30 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D8)
  • 2023-11-23 - Velcade (bortezomib) 1.3mg/m2 1.9mg ST SC (VTd C1D1)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-12-01 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or thalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism (grade 3 and 4) was reported in 3% of patients in a clinical trial receiving VTd despite antithrombotic prophylaxis. In addition, reported risk of thromboembolism (grade 3 and 4) was 5% in the Td arm of this study.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Thalidomide: Dosage adjustment of thalidomide is not required for either preexisting renal or hepatic dysfunction.
    • Pregnancy warning
      • Thalidomide can result in severe, life-threatening human birth defects. Pregnancy testing is required within 24 hours prior to initiation of thalidomide therapy.

Bortezomib - 2023-11-24 - https://www.uptodate.com/contents/bortezomib-drug-information

  • Multiple myeloma, first-line therapy: Note: Bortezomib regimens also containing melphalan should be avoided in patients who are potential candidates for hematopoietic cell transplantation.
    • VMP regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, 11, 22, 25, 29, and 32 of a 42-day treatment cycle for 4 cycles, followed by 1.3 mg/m2 on days 1, 8, 22, and 29 of a 42-day treatment cycle for 5 cycles (in combination with melphalan and prednisone). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose.
    • First- line therapy, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
      • VRd (or RVd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 8 cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for up to 8 induction cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 3 cycles, followed by conditioning/transplant, followed (after hematologic recovery in patients without progression) by 1.3 mg/m2 (or last tolerated dose from cycle 3) on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with lenalidomide and dexamethasone) for 2 cycles.
      • VRd (or RVd) regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle (in combination with lenalidomide and dexamethasone) for 9 induction cycles, followed by 1.3 mg/m2 (or last tolerated dose from cycle 9) on days 1 and 15 of a 28-day treatment cycle (in combination with lenalidomide) for 6 consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle (in combination with lenalidomide and dexamethasone) for 6 induction cycles (with mobilization after the third induction cycle), followed by conditioning/transplant, followed by 2 additional consolidation cycles 3 months after transplant.
      • VTd regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 3 induction cycles (in combination with thalidomide and dexamethasone), followed by tandem transplant, followed by (3 months after second transplant) 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days for 2 consolidation cycles (in combination with thalidomide and dexamethasone).
      • VTd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with thalidomide and dexamethasone) for 4 induction cycles, followed by conditioning/transplant.
      • CyBorD (or VCd) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 induction cycles (in combination with cyclophosphamide and dexamethasone), followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 42-day treatment cycle (as a single agent) for 4 maintenance cycles or 1.5 mg/m2 on days 1, 8, 15, and 22 of a 28-day treatment cycle for 4 cycles (may continue beyond 4 cycles) in combination with cyclophosphamide and dexamethasone.
      • PAD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 3 cycles (in combination with doxorubicin and dexamethasone), followed by conditioning/transplantation, and then maintenance bortezomib 1.3 mg/m2 once every 2 weeks for 2 years.
      • Daratumumab-containing regimens: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day cycle (in combination with daratumumab, lenalidomide, and dexamethasone; DVRd regimen) for 4 induction cycles and 2 post-transplant consolidation cycles or 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day cycle (in combination with daratumumab, thalidomide, and dexamethasone; DVTd regimen) for up to 4 pretransplant induction cycles and 2 posttransplant consolidation cycles or 1.3 mg/m2 two times a week during weeks 1, 2, 4, and 5 of the first 6-week cycle (cycle 1; 8 doses/cycle), followed by 1.3 mg/m2 once a week during weeks 1, 2, 4, and 5 for eight 6-week cycles (cycles 2 to 9; 4 doses/cycle) in combination with daratumumab, melphalan, and prednisone; after cycle 9, daratumumab is continued as a single agent.
      • VD regimen: IV: Induction: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle (in combination with dexamethasone) for 4 cycles, followed by autologous cell transplantation.
      • Patients ≥65 years of age: IV: 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for 9 cycles, in combination with either melphalan and prednisone or melphalan, prednisone, and thalidomide.
    • Maintenance therapy in transplant-eligible patients (following induction and transplant; in patients intolerant to or unable to receive maintenance therapy with lenalidomide): IV: 1.3 mg/m2 once every 2 weeks for 2 years. For high-risk patients, maintenance therapy with a proteosome inhibitor ± lenalidomide may be considered.
  • Multiple myeloma, relapsed/refractory:
    • Single-agent therapy: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle. Therapy extending beyond 8 cycles may be administered by the standard schedule or may be given once weekly for 4 weeks (days 1, 8, 15, and 22), followed by a 13-day rest (days 23 through 35). Retreatment may be considered for patients who had previously responded to bortezomib (either as monotherapy or in combination) and who have relapsed at least 6 months after completing prior bortezomib therapy; initiate at the last tolerated dose. Administer twice weekly for 2 weeks on days 1, 4, 8, and 11 of a 21-day treatment cycle (either as a single agent or in combination with dexamethasone) for a maximum of 8 cycles.
    • Relapsed or refractory disease, other dosing/combinations: Note: Refer to protocol for dosage adjustment details.
      • VRd (or RVd) regimen: IV: 1 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles (in combination with lenalidomide and dexamethasone), followed by maintenance therapy (if response or stable disease) of 1 mg/m2 (or the dose tolerated in cycle 8) on days 1 and 8 of a 21-day treatment cycle (± lenalidomide and/or dexamethasone) until disease progression or unacceptable toxicity.
      • DVd regimen: SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 every 21 days (in combination with daratumumab and dexamethasone) for up to 8 cycles.
      • VPd regimen: IV, SUBQ: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for 8 cycles, followed by 1.3 mg/m2 on days 1 and 8 of a 21-day treatment cycle until disease progression or unacceptable toxicity (in combination with pomalidomide and dexamethasone).
      • SVd regimen: SUBQ: 1.3 mg/m2 on days 1, 8, 15, and 22 every 35 days (in combination with selinexor and dexamethasone) until disease progression or unacceptable toxicity.
      • Bortezomib/Doxorubicin (liposomal) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for at least 8 cycles or until disease progression or unacceptable toxicity (in combination with liposomal doxorubicin).
      • CyBorD (or VCD) regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 21-day treatment cycle for up to 8 cycles, followed by 1.3 mg/m2 on days 1, 8, 15, and 22 of a 35-day treatment cycle for up to 3 cycles (in combination with cyclophosphamide and dexamethasone).
      • Bendamustine/Bortezomib/Dexamethasone regimen: IV: 1.3 mg/m2 on days 1, 4, 8, and 11 of a 28-day treatment cycle for 4 cycles (if no response) or for up to a maximum of 8 cycles (in combination with bendamustine and dexamethasone).

==========

2023-12-08

[thrombocytopenia]

The C1D15 dose of Velcade (bortezomib) in the VTd regimen was administered on 2023-12-07. As mentioned in the pharmacist’s note from 2023-12-04, the severe thrombocytopenia observed may not be entirely due to the VTd regimen.

  • 2023-12-07 PLT 49 *10^3/uL
  • 2023-12-04 PLT 16 *10^3/uL
  • 2023-12-01 PLT 33 *10^3/uL

Severe thrombocytopenia, with platelet counts falling below 30K to 50K/uL, significantly increases the risk of bleeding and often necessitates treatment. However, the relationship between platelet count and bleeding risk can vary depending on the underlying condition and may be unpredictable. Therefore, platelet product transfusion may be required in this situation.

2023-12-04

[thrombocytopenia]

Severe thrombocytopenia emerged in mid and late Nov, necessitating multiple blood transfusions.

  • 2023-12-04 PLT 16 *10^3/uL BT (scheduled on 2023-12-05)
  • 2023-12-01 PLT 33 *10^3/uL
  • 2023-11-30 PLT 44 *10^3/uL
  • 2023-11-29 PLT 12 *10^3/uL
  • 2023-11-28 PLT 12 *10^3/uL
  • 2023-11-27 PLT 11 *10^3/uL
  • 2023-11-26 PLT 2 *10^3/uL
  • 2023-11-25 PLT 1 *10^3/uL BT
  • 2023-11-24 PLT 1 *10^3/uL
  • 2023-11-23 PLT 2 *10^3/uL
  • 2023-11-22 PLT 2 *10^3/uL
  • 2023-11-21 PLT 4 *10^3/uL
  • 2023-11-20 PLT 1 *10^3/uL
  • 2023-11-19 PLT 1 *10^3/uL BT
  • 2023-11-18 PLT 3 *10^3/uL
  • 2023-11-17 PLT 1 *10^3/uL
  • 2023-11-15 PLT 2 *10^3/uL
  • 2023-11-13 PLT 6 *10^3/uL BT
  • 2023-11-11 PLT 7 *10^3/uL
  • 2023-11-09 PLT 28 *10^3/uL BT
  • 2023-11-08 PLT 6 *10^3/uL
  • 2023-11-07 PLT 71 *10^3/uL
  • 2023-11-06 PLT 44 *10^3/uL
  • 2023-11-05 PLT 27 *10^3/uL
  • 2023-11-04 PLT 3 *10^3/uL BT
  • 2023-10-16 PLT 79 *10^3/uL
  • 2023-10-14 PLT 93 *10^3/uL BT (2023-10-12)
  • 2023-10-06 PLT 176 *10^3/uL BT
  • 2023-07-12 PLT 172 *10^3/uL
  • 2023-04-06 PLT 180 *10^3/uL

The initial session of the VTd regimen was given on 2023-11-23. Notably, the thrombocytopenia episode was present even prior to this treatment. Anemia and thrombocytopenia are frequent complications in multiple myeloma (MM) patients (Ref: Patients With Multiple Myeloma Have a Disbalanced Whole Blood Thrombin Generation Profile. Front Cardiovasc Med. 2022 Jun 27;9:919495. doi: 10.3389/fcvm.2022.919495. PMID: 35833182; PMCID: PMC9271700). The thrombocytopenia should not be solely attributed to the use of bortezomib.

2023-12-01

[antiviral prophylaxis key to reducing HZ]

Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. It is recommended that antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VTd. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on QW135 during treatment. Primary prophylaxis with G-CSF is not indicated.

700193556

231208

[diagnosis] - 2023-04-18 admission note

  • Malignant neoplasm of retroperitoneum
  • Retroperitoneum extraskeletal Ewing sarcoma, s/p tumor resection 2022/11/18, pT2N0M0, Stage IIIA
  • Chronic viral hepatitis B without delta-agent
  • Hypertension
  • Anxiety disorder, unspecified
  • Generalized anxiety disorder
  • Dysthymic disorder

[past history] - 2023-04-18 admission note

  • Hypertension,under medication control
  • s/p LM on 2018-07
  • Dysthymic disorder,under medication control
  • s/p hernia operation
  • s/p uterine myoma operation
  • TAE, open radical nephrectomy,partial intestine resection were performed on 2022/11/17, 11/18

            

[allergy]

Demerol 50 mg/1 mL/amp (Meperidine):anaphylactic shock

[family history]

Father:DM No cancer, CVA, CAD history in her family

[exam findings]

  • 2023-10-30 Gynecologic ultrasonography
    • R/O Uterine myoma
  • 2023-10-26 KUB
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-10-26 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2023-10-05 CT - abdomen
    • History and indication: Retroperitoneum Ewing sarcoma s/p OP and C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left nephrectomy. S/P Port-A infusion catheter insertion.
      • A patchy density (2.2cm) at RLL.
      • Colonic diverticula.
      • Grade 4 fatty liver with liver cysts (up to 2.2cm).
      • Tiny renal cysts.
      • Gallbladder stones (up to 1.3cm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P left nephrectomy. No evidence of tumor recurrence.
  • 2023-07-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 26) / 88 = 70.45%
      • M-mode (Teichholz) = 70.5
    • Conclusion:
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Trivial pulmonary regurgitation; mildly dilated pulmonary trunk (27 mm).
  • 2023-07-10 CT - abdomen
    • Indication: Retroperitoneum extraskeletal Ewing sarcoma
    • Abdominal CT with and without enhancement revealed:
      • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
      • s/p colon. op.
      • Hepatic cysts at S2 of liver up to 2.0cm in largest dimension is found.
      • s/p left nephrectomy.
    • Imp:
      • s/p left nephrectomy.
      • s/p colon. op.
      • NO evidence of recurrent/residual tumor in the study.
  • 2023-04-12 MRA - abdomen
    • History
      • 20221107 CT: A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis. R/O liposarcoma
      • 20221121 PATHO - Kidney total resection
        • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor (PNET)
        • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
        • Pathologic stage: pT2N0G2; Stage IIIA if cM0
        • refer to oncology and RT
    • Findings:
      • S/P left nephrectomy.
      • There are several hepatic cysts in both lobes and the largest one 1.8 cm in size at S3.
      • Two gallstones (up to 1.3 cm) are noted.
      • Tiny renal cysts on right kidney.
      • There is no focal abnormality in the biliary system, pancreas, spleen.
      • There is no evidence of ascites or lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • S/P left nephrectomy.
      • There is no evidence of tumor recurrence.
  • 2023-03-15 SONO - nephrology
    • Chronic change with right small sized kidney.
    • Abscent of left kidney.
  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 24) / 78 = 69.23%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR and trivial TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2022-12-10 SONO - Joint soft tissue
    • Finding:
      • Focal engorgement and non-compressible to probe of left cephalic vein
      • Hyperechoic lesion was noted within left cephalic vein; however, partial flow was still noted
    • Impression And Suggestions:
      • Suspected left cephalic vein thrombosis
  • 2022-11-21 Patho - kidney partial/total resection
    • PATHOLOGIC DIAGNOSIS
      • Retroperitoneum, tumor excision — Compatible with extraskeletal Ewing sarcoma/primitive neuroectodermal tumor(PNET)
      • Kidney, left, radical nephrectomy — Focal infarction and free of tumor involvement
      • Pathologic stage: pT2N0G2; Stage IIIA if cM0
    • MACROSCOPIC EXAMINATION
      • Procedure: Radical nephrectomy + retroperitoneal tumor excision
      • SpecimenSize: 16.5 x 12.3 x 5.6 cm and 590 gm, including left kidney: 9.5 x 5.9 x 4.8 cm and Gerota fascia: 2.5 cm in thickness
      • Tumor Site: Retroperitoneum
      • Tumor Size: 7.0 x 6.2 x 4.5 cm
      • Gross Tumor Pattern: Well circumscribed, dark brown and hemorrhagic mass
      • Representative parts are taken for section and labeled: A1= margins, A3-A10= tumor, A11= Retroperitoneal soft tissue, A12= kidney.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Compatible with extraskeletal Ewing sarcoma/PNET
      • Mitotic rate: 5/10 high power fields
      • Necrosis: Present (5%)
      • Histologic Grade (FNCLCC): Grade 2
        • Tumor Differentiation: Score=3
        • Mitosis Count: Score=1 (0 to 9 mitosis per 10 HPF)
        • Necrosis: Score=1 (<50%)
      • Margins: Free; Distance of sarcoma from closest margin: 0.1 cm
      • Lymphvascular invasion: Present
        • Renal artery invasion: Present
      • Pathologic staging
        • Primary tumor: pT2 (tumor > 5 cm and <=10 cm)
        • Regional lymph nodes: Negative (0/4 regional LN) (Number of involved/Number of examined)
        • Distant metastasis: Not applicable
      • IHC: Cytokeratin(-), LCA(-), S100(-), CD56(focal+), Synaptophysin(-), and CD99(strong and diffuse membrane staining)
      • Kidney: Free of tumor with mild interstitial nephritis and focal infarction
  • 2022-11-21 Patho - small intestine resection for tumore
    • Small intestine, jejunum, segmental resection – Heterotopic pancreas
    • The sections show a picture of heterotopic pancreas, composed of nests of admixture of pancreatic acini, ducts and islets in submucosa and mascularis propria. The adjacent small intestine shows mild acute serositis.
  • 2022-11-17 Embolization (TAE) - abdomen
    • TAE of left renal artery via right common femoral artery puncture using Seldinger technique revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Under local anesthesia, a 4 Fr arterial sheath was inserted into right common femoral artery smoothly.
      • The RH-catheter was inserted into left renal artery.
      • No definite tumor stain.
      • TAE of left renal artery was performed using 10mg some gelfoam pieces.
      • No procedure-related complication during the whole procedure. Thanks for your further care.
  • 2022-11-16 CXR
    • Intimal calcification of thoracic aorta.
  • 2022-11-07 CTA - abdomen
    • History and indication: left retroperitoneal massfor evaluation and surgery
    • With and without contrast CT of abdomen-pelvis revealed:
      • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
      • Colonic diverticula.
      • Grade 4 fatty liver with left liver cyst (1.8cm).
      • Tiny renal cysts.
      • Normal appearance of spleen, pancreas, adrenals.
      • Gallbladder stones (up to 1.3cm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • A heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
  • 2022-10-31 Whole body PET scan
    • The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?), suggesting biopsy for further investigation.
    • Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up.
    • Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • No other focal area of abnormal increased FDG uptake from head to bilateral thigh regions.
  • 2022-10-29 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 69 x 33 mm
    • Endometrium
      • Thickness: 4.0 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 4.0 mm
  • 2022-10-13 Myocardial perfusion SPECT with treadmill
    • The Tc-99m MIBI stress myocardial perfusion SPECT performed after stress revealed mildly decreased perfusion of radioactivity to the apex of LV. The Tc-99m MIBI rest myocardial perfusion SPECT revealed reperfusion of radioactivity to the defect. The stress and rest LVEFs were 90% and 90%, respectively. The cine wall motion study revealed synchronized contraction of LV.
    • IMPRESSION:
      • Probably mild myocardial ischemia at the apex of LV.
      • Normal performance of global LV cardiac function.
  • 2022-10-13 CT - low dose for lung cancer screening, without contrast
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs: Paraspinal fibrotic change at right lower lobe is found.
        • Minimal wedge shaped infiltration at left lower lobe, r/o recent inflammation.
    • IMP: Right lower lobe paraspinal fibrosis. Suspected focal fibrosis at left lower lobe
  • 2022-10-13 MRI - cerebrovascular
    • Without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI), cerebral TOF MRA revealed:
      • Mild brain atrophic change. Mild periventricular white matter small vessel disease.
      • Tortuosity of intracranial and extracranial arteries in MRA studies (including bilateral subclavian arteries, CCAs, ICAs, ECAs, MCAs, ACAs, PCAs and VAs and BA).
    • IMP: Mild Brain atrophy. Mild periventricular white matter small vessel disease. Mild arteriosclerosis with vessel tortuosity.
  • 2022-10-13 MRI - upper abdomen with and without contrast
    • Imaging study of upper abdomen for health examination revealed:
      • Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, suspected liposarcoma or others.
      • Hepatic cyst at left lobe liver up to 2.1cm is found.
    • IMP:
      • Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma. Suggest further treatment.
  • 2022-04-16 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 58 x 35 mm
    • Endometrium
      • Thickness: 3.2 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 3.2 mm
  • 2020-08-08 Gynecologic ultrasonography
    • Uterus Position: AVF
      • Size: 55 x 33 mm
    • Endometrium
      • Thickness: 4.3 mm
    • Cul-De-Sac: No fluid
    • Bilateral adnexae: free
    • IMP: EM 4.3 mm

[MedRec]

  • 2023-10-25 SOAP Infectious Disease Peng MingYe
    • S: Right leg dog bite 3 days ago, now wound healing, no surrounding erythema or swelling
    • A: No sign of wound infection or cellulitis, topical Biomycin first
    • Prescription
      • Biomycin (neomycin, tyrothricin) BID TOPI
  • 2023-02-17 ~ 2023-02-21 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of retroperitoneum
      • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0
      • Positve of anti-HBc
      • Anxiety
    • Present illness
      • This is a 59-year-old female with past history of
        • Hypertension, under medication control
        • s/p LM on 2018-07
        • Dysthymic disorder, under medication control
        • s/p hernia operation
        • s/p uterine myoma operation
      • According to the patient,left kidney tumor was noted after examination. She came to our uro OPD for further examination. MRI showed Retroperitoneal tumor at left side, 7.3cm, r/o liposarcoma.Surgery was suggested.
        • 2022/10/31 PET scan showed 1. The left retroperitoneal tumor shown on the previous abdomen MRI reveals mildly increased FDG uptake; the nature is to be determined (liposarcoma or others ?) 2. Glucose hypermetabolic lesions in the esophagus, D/3 and bilateral palatine tonsils, probably chronic inflammation process, suggesting follow-up. 3. Glucose hypermetabolism in level II lymph nodes of bilateral cervical regions, probably reactive nodes. 4. Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
        • 2022/11/07 Abdomen CTA showed a heterogeneous tumor (8.5cm) at left paraaortic region with mass effect at left kidney causing left hydronephrosis.
        • 2022/11/17 Abd TAE was done and smooth.
        • 2022/12/26 Focal engorgement and non-compressible to probe of left cephalic vein showed suspected left cephalic vein thrombosis.
      • RT to the preOP tumor bed (Lt kidney region): 36 Gy/ 18 fx since 2022/12/14-2023/01/22.
      • Under the impression of Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, so she was admission for adjuvant C/T on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received Baraclude 0.5mg/tab (Entecavir) 1# qdac for postive og anti-HBc. Anxiety improves after session with psychologist before chemotherapy. Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
        • Team A = Vincristin 2mg (D1) 10 mins + Adriamycin 37.5mg/m2 (D1-D2) 15 mins + Endoxan 1200mg/m2 (D1) 1 hour on 2023/2/20-2/21.
        • Team B = IFx 1800mg/m2 (D1-D5) drip 1 hour + VP-16 100mg/m2 (D1-D5) drip 1-2 hrs (next time).
      • Under the stable condition without GI tract problem, so she can be discharge on 2023/02/21. OPD follow up is arranged.
  • 2023-01-19 SOAP Hemato-Oncology
    • O: s/p adjuvnat R/T with 44 Gy/ 22 fx to the pre-OP tumor bed, from 2202-12-13 or -14 to 2023-01-12
  • 2022-12-22 SOAP Hemato-Oncology
    • A/P
      • Strategy: Adjuvant R/T followed by adjuvant C/T
      • Already suggest discuss with her psychiatrist for the phobia of C/T
  • 2022-12-06 SOAP Radiation Oncology
    • Plan: Adjuvant RT then adjuvant C/T is suggested. CT-simulation will be arranged on 2022/12/08. Plan to deliver 44~45 Gy/ 22~25 fx to the preOP tumor bed. RT will start around 12/12 or 13.

[consultation]

  • 2023-03-15 Nephrology
    • Q
      • This is a 59-year-old female with past history of
        • Hypertension, under medication control
        • s/p LM on 2018-07
        • Dysthymic disorder, under medication control
        • s/p hernia operation
        • s/p uterine myoma operation.
      • Retroperitoneum sarcoma, pT2N0G2; Stage IIIA if cM0, she received adjuvant chemotherapy on 2023/02/20-21(C1).
        • Regimen Q3W as alternating between team A and B every three weeks for approximately 17 times.
          • Team A = Vincristin 2mg (D1) 10mins + Adriamycin 37.5mg/m2 (D1-D2) 15mins + Endoxan 1200mg/m2 (D1) 1hour on 2023/2/20-2/21.
          • Team B = IFx 1800mg/m2 (D1-D5) drip 1hour + VP-16 100mg/m2 (D1-D5) drip 1-2hrs (next time).
      • This time, she suffered from poor intake for 2 weeks. Blood analysis showed Impaired renal function (BUN/Cr: 39/2.19 mg/dl and hyperkalemia: 5.2 mmol/L)
      • For acute kidney injury, favor dehydration due to poor intake related, we need your further evaluation and management.
    • A
      • This 59-year-old madam with a history of retroperitoneum sarcoma, s/p operation, pT2N0G2; Stage IIIA if cM0, received adjuvant chemotherapy (Vincristine, Adrimycin, Endoxan) on 2023/2/20-21(C1). I’m consulted for impaired renal function. The patient stated her appetite was decreasing after last hospitalization, but she tried to drink water around 2000ml per day and she ate fish, eggs and mild with salty flavor recently. She has started taking Entecavir and Chinese herbal medicine recently. She denied use of medications from other hospital, LMD or pharmacy. She also did not use of NSAIDs recently. There’s no fever, chills, diarrhea, decreasing urine output, or obvious body weight loss. Renal echo on 2023/03/15 shows no evidence of hydronephrosis of right kidney.
      • Impression: AKI, dehydration? Medication (Chinese herbal medicine or entecavir)?
      • Suggestion:
        • Hydration with saline based intravenous fluid, such as D5S or NS and follow up her renal function. You could also follow up serum calcium next time while checking the laboratory data.
        • Check urinalysis.
        • May temporarily discontinuation of Chinese herbal medicine if renal funcition dose not improve or even worse.
      • Thank you for your consultation. I’ll follow up this patient.
  • 2022-11-24 Cardiology
    • Q
      • For hypertension control
      • This is a 59-year-old female with past history of
        • Hypertension, under Norvasc 1# QD, Cardiolol 1# QD (previously PRNQD), Atanaal PRNQ8H, control
        • s/p LM on 2018-07
        • Dysthymic disorder
        • s/p hernia operation
        • s/p uterine myoma operation
      • This time she was admitted for TAE (2022/11/17) and open radical nephrectomy (2022/11/18).
      • In recent 4 days,her BP control was not good,highest up to 180-190.
      • She suffered from stomache distension, GERD-like sensation,nausea, vomitting in recent three days. Pantoprazole and imperan was prescribed
      • 2022/11/21: Creatinine: 1.37, eGFR: 41.94, CrCl 48, height: 158cm, weight: 72.4kg
      • We consult for your further evaluation and management, thank you!
    • A
      • I was consulted for poor BP control
      • O
        • Formerly controoled with Norvasc 1# QD and inderal 1# QD
        • Lab
          • 2022-11-21 BUN 8 mg/dL
          • 2022-11-21 Creatinine 1.37 mg/dL
          • 2022-11-19 BUN 26 mg/dL
          • 2022-11-19 Creatinine 1.94 mg/dL
        • EKG: NSR
        • CXR: normal heart size
      • Impression:
        • Hypertension, poor contorl
      • Sugggestion:
        • The causes of poor control of BP during admission, including insomnia, pain, NS hydration, abdomen distension and any other discomfort, if present such problem, please correct it.
        • May uptitrate Norvasc to 1# BID PO
        • if high BP > 150/90 mmHg still, may add Carvedilol (6.25) 1# BID PO
  • 2022-11-22 Psychosomatic medicine
    • Q
      • For post-op anxiety evaluation and medication adjustment.
      • This is a 59-year-old female with past history of
        • Hypertension,under medication control
        • s/p LM on 2018-07
      • She had regular follow up in our psy OPD before, and was diagnosed with dysthymic disorder, and GAD.
      • Medication Zoloft 1# QD and Eurudin 0.5# HS was used now.
      • This time,under the impression of left kidney tumor, suspected liposarcoma, she was admitted to our ward for scheduled TAE (2022/11/17), open radical nephrectomy and resection of segmental of small intestine (2022/11/18).
      • After operation, she complained about having nightmare during these days. She was abnormally sensitive to pain and very scared, even scared of nurses.
      • She is in a very anxious mood. We consulted for your further evaluation and management, thank you!
    • A
      • This 59 y/o married woman, now still work as an administrative staff, has been followed up in our PSY OPD since 2020/07 for low and anxious mood, anhedonia, insomnia, psychomotor retardation, muscle tension, distracted attention, fatigue, guilty feeling or inattention, suicidal and negative thinking for more than 6 months. Stressor: the passing of her mother at that time. After regularly took meds in our PSY OPD, her mood symptoms improved, but still has decreased sleep lasting: only sleeping for 3 hours, because she didn’t want to rely on sleeping pills, she took only half a tablet of Eurodin.
      • In recent few days, she developed low and anxious, even agitated mood, hypervigilance, decreased frustration tolerance, phobic and avoidant behaviors, guilty feelings, worthlessness feelings, grief reaction, suicidal ideation, rumination of the past events, following the stressors: her father passed away recently, she has to be hospitalized and can’t participate in the funeral arrangements, experienced sudden pain during TAE and was shocked by the doctor’s reaction, felt terrible because she was too scared and it took three attempts to complete the examination, felt extremely nervous and scared about undergoing invasive treatments, cried when the TAE area hurt, and thought about jumping off a building at that time.
      • She also had transient VH following the procedure, seeing ice cream and SpongeBob. (ChatGPT: In the context of psychology or psychotherapy, “VH” typically stands for “vividness of mental imagery” or “vividness of hallucinations.”)
      • MSE: tearfulness, low and anxious mood, distressful feelings, anticipatory anxiety about the following procedure: removing stitches.
      • IMP:
        • Adjustment reaction with anxious and fearfulness mood
        • r/o Persisted depressive disorder
        • Generalized anxiety disorder
      • Suggestion:
        • Carthasis and mental support, discuss the coping skill.
        • Keep Zoloft and Eurodin. Anxiedin 0.5mg 1# BID. Alprazolam 0.5mg 1# PRNQ8H if anxious or before procedure.
        • Arrange PSY OPD follow up.
  • 2022-11-18 Diagnostic Radiology
    • Q
      • This is a 59-year-old female with past history of
        • Dysthymic disorder
        • s/p hernia operation
        • s/p uterine myoma operation
      • This time she was admitted for TAE and open radical nephrectomy.
      • 2022/10/13 MRI: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma or others
      • 2022/11/07 CTA: Retroperitoneal soft tissue mass about 7.3cm in largest dimension at left side with heterogenoeus appearance, r/o liposarcoma, suspect Psoas muscle invsion and renal vessel invasion.
      • We consulted for left kidney and Tumor TAE,thank you !
    • A
      • According to the clinical history and imaging findings, TAE is indicated.

[chemotherapy]

  • 2023-12-08 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-09-22 - vincristine 2mg NS 50mL 10min D1 + cyclophosphamide 1200mg/m2 2000mg NS 500mL 1hr D1 (omitting doxorubicin for single kidney and SOB)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-25 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-07-26 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-07-06 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 1650mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 120mg NS 500mL 2hr] D1-3 (less ifosfamide)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-06-19 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-05-24 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-04-18 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophophamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL + aprepitant 125mg D1-3
  • 2023-03-20 - [mesna 800mg NS 250mL 30min (1hr before ifosfamide) + ifosfamide 1200mg/m2 2000mg NS 500mL 1hr + mesna 800mg NS 250mL 30min (4hr after ifosfamide) + mesna 800mg NS 250mL 30min (8hr after ifosfamide) + etoposide 80mg/m2 130mg NS 500mL 2hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg] D1-3
  • 2023-02-20 - vincristine 2mg NS 50mL 10min D1 + doxorubicin 37.5mg/m2 60mg NS 100mL 15min D1-2 + cyclophosphamide 1200mg/m2 2000mg NS 500mL D1
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Granocyte (lenograstim 250ug) CGRAN01

  • 2023-04-23 3# 2023-04-18 IPD
  • 2023-03-28 3# 2023-03-28 OPD
  • 2023-03-27 3# 2023-03-14 IPD
  • 2023-03-25 2# 2023-03-25 EPD
  • 2023-03-24 2# 2023-03-14 IPD
  • 2023-03-14 1# 2023-03-14 IPD
  • 2023-03-07 2# 2023-03-07 OPD
  • 2023-03-01 3# 2023-03-01 OPD

WBC

  • 2023-04-11 WBC 6.19 x10^3/uL 2023-04-23 G-CSF x3
  • 2023-03-28 WBC 1.93 x10^3/uL * 2023-03-28 G-CSF x3
  • 2023-03-23 WBC 2.23 x10^3/uL * 2023-03-24 G-CSF x2, 2023-03-25 G-CSF x2, 2023-03-27 G-CSF x3
  • 2023-03-20 WBC 12.17 x10^3/uL 2023-03-20 ifosfamide + etoposide
  • 2023-03-19 WBC 28.21 x10^3/uL
  • 2023-03-17 WBC 1.99 x10^3/uL *
  • 2023-03-14 WBC 3.29 x10^3/uL 2023-03-14 G-CSF x1
  • 2023-03-07 WBC 2.41 x10^3/uL * 2023-03-07 G-CSF x2
  • 2023-03-01 WBC 0.35 x10^3/uL * 2023-03-01 G-CSF x3
  • 2023-02-17 WBC 3.17 x10^3/uL 2023-02-20 vincristine + doxorubicin + cyclophosphamide
  • 2023-01-19 WBC 3.65 x10^3/uL

VDC/IE (vincristine, doxorubicin, and cyclophosphamide alternating with ifosfamide and etoposide) - Bone Cancer - Version 3.2023 - 2023-04-04 - https://www.nccn.org/professionals/physician_gls/pdf/bone.pdf - BONE-B, 2 OF 6, p27

  • ref
    • Addition of ifosfamide and etoposide to standard chemotherapy for Ewing’s sarcoma and primitive neuroectodermal tumor of bone. N Engl J Med 2003;348:694-701.
    • Randomized controlled trial of interval compressed chemotherapy for the treatment of localized Ewing sarcoma: A report from the Children’s Oncology Group. J Clin Oncol 2012;30:4148-4154.

Treatment for Localized Disease, Neoadjuvant chemotherapy - Treatment of Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/treatment-of-ewing-sarcoma

  • Interval-compressed VDC/IE
    • For patients age < 18 years with localized ES, we recommend interval-compressed therapy with alternating cycles of vincristine/doxorubicin/cyclophosphamide (VDC) and ifosfamide/etoposide (VDC/IE) given every two weeks with hematopoietic growth factor support, rather than every three weeks without growth factor support.

Interval compressed chemotherapy for Ewing sarcoma - 2023-06-20 - https://www.uptodate.com/contents/image?imageKey=ONC%2F110260

  • ref
  • Induction chemotherapy
    • Regimen A
      • Timing
        • Weeks 1, 5, and 9
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Doxorubicin
          • 37.5 mg/m2
          • IV over 1 to 15 minutes
          • days 1 and 2
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen B
      • Timing
        • Weeks 3, 7, and 11
      • Drug
        • Ifosfamide
          • 1800 mg/m2
          • IV over 1 hour
          • days 1 to 5, with mesna
        • Etoposide
          • 100 mg/m2
          • IV over 1 to 2 hours
          • days 1 to 5
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 6
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
  • Consolidation chemotherapy (Local therapy between weeks 13 and 15. Surgery at week 13, if it is planned. Start of RT delayed to week 15 if surgery also undertaken.)
    • Regimen A
      • Timing
        • Surgery alone - Weeks 15 and 19
        • RT alone - Weeks 13 (with the start of RT) and 25
        • Surgery and RT - Weeks 15 (with the start of RT) and 27
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Doxorubicin
          • 37.5 mg/m2
          • IV over 1 to 15 minutes
          • days 1 and 2
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen B
      • Timing
        • Surgery alone - Weeks 17, 21, 25, and 29
        • RT alone - Weeks 15, 19, 23, and 27
        • Surgery and RT - Weeks 17, 21, 25, and 29
      • Drug
        • Ifosfamide
          • 1800 mg/m2
          • IV over 1 hour
          • days 1 to 5, with mesna
        • Etoposide
          • 100 mg/m2
          • IV over 1 to 2 hours
          • days 1 to 5
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 6
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.
    • Regimen C
      • Timing
        • Surgery alone - Weeks 23 and 27
        • RT alone - Weeks 17 and 21
        • Surgery and RT - Weeks 19 and 23
      • Drug
        • Vincristine
          • 2 mg/m2 (maximum 2 mg)
          • IV over 1 minute
          • day 1
        • Cyclophosphamide
          • 1200 mg/m2
          • IV over 30 to 60 minutes
          • day 1, with mesna
        • Filgrastim
          • 5 mcg/kg per day (maximum 300 mcg)
          • starting day 3
            • Daily filgrastim until absolute neutrophil count > 750 x 10^6/L and platelet count > 75 x 10^9/L. Proceed with next cycle of chemotherapy 24 hours after last filgrastim dose.

==========

2023-12-08

[reconsidering doxorubicin in VDC/IE regimen for enhanced efficacy]

The VDC/IE regimen typically includes doxorubicin as a component, but it has been excluded since 2023-09-22. Given that the last 2D echocardiography on 2023-07-31 showed a LVEF of 70% with no apparent cardiotoxicity from doxorubicin, reintroducing doxorubicin could be considered if the patient tolerates it well. This would ensure the completeness of the regimen and potentially enhance its therapeutic effectiveness.

The patient’s condition of having a single kidney should not necessitate the omission of doxorubicin, as there is no requirement for dosage adjustment of doxorubicin for any level of kidney impairment.

The risk of cardiomyopathy associated with doxorubicin is related to the cumulative dose, with incidences ranging from 1% to 20% for cumulative doses between 300 mg/m2 and 500 mg/m2. According to our hospital records, the patient’s cumulative dose is still significantly below 300 mg/m2. Additionally, the chemotherapy preparation room is vigilant in monitoring cumulative doses, ensuring they do not exceed the safe lifetime limit, and will notify the relevant parties as the patient approaches this threshold.

2023-07-27

Upon review of the PharmaCloud database and hospital HIS5 records, no medication reconciliation issues were identified.

[leukopenia and anemia]

The administration of the alternating chemotherapy regimen of VDC/IE and the nadir of WBC (< 1K/uL) and HGB (< 9g/dL) are as follows. It seems that the trough of WBC occurs around the 10th day after the administration of VDC, indicating a stronger correlation with VDC in terms of timing than with IE. As for HGB, the changes are not as dramatic as for WBC, but it can be confirmed that during the patient’s receipt of the VDC/IE regimen, the overall HGB level shows a decreasing trend. In addition, it’s worth mentioning that the patient received several transfusions and G-CSF during the treatment period, which are also factors influencing WBC and HGB.

  • 2023-07-26 VDC regimen
  • 2023-07-12 HGB 7.9 g/dL
  • 2023-07-06 IE regimen
  • 2023-06-28 WBC 0.16 x10^3/uL
  • 2023-06-28 HGB 8.1 g/dL
  • 2023-06-19 VDC regimen
  • 2023-06-01 HGB 8.6 g/dL
  • 2023-05-24 IE regimen
  • 2023-04-27 WBC 0.33 x10^3/uL
  • 2023-04-18 VDC regimen
  • 2023-03-20 IE regimen
  • 2023-03-17 HGB 8.7 g/dL
  • 2023-03-01 WBC 0.35 x10^3/uL
  • 2023-02-20 VDC regimen

2023-06-20

  • Based on the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. Therefore, we have not identified any issues related to medication reconciliation.
  • The patient is currently undergoing an alternating chemotherapy regimen of VDC/IE, and has been admitted for her 3rd round of VDC treatment during this hospitalization. Although no instances of hemorrhagic cystitis have been reported after the first two doses of cyclophosphamide, the protocol of the source trial for this treatment (http://ascopubs.org/doi/suppl/10.1200/jco.2011.41.5703/suppl_file/Protocol_JCO.2011.41.5703.pdf) specifically mandates the use of mesna with cyclophosphamide and ifosfamide (see page 11). If the decision is made to continue administering cyclophosphamide without mesna, it would be prudent to increase the patient’s hydration and strongly encourage frequent voiding.

2023-04-19

  • To prevent potential neutropenia, granulocyte colony-stimulating factor (G-CSF) is prescribed prophylactically.
  • This patient primarily seeks medical care at our hospital, and no medication reconciliation issues have been found for the time being.

700599605

231208

[exam findings]

  • 2023-12-20 CT - chest
    • Indication: right breast cancer s/p chemotherapy dyspnea r/o ILD
    • Chest and abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: areas of decreased attenuation at RML, LLL, and RLL.
        • linear opacities at lower medial region of RLL.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the great vessels in the hila and mediastinum are normal in distribution and appearance. no coronary arterial calcificatiion.
      • eart: normal size of cardiac chambers.
      • Chest wall and visible lower neck: s/p Lt mastectomy.
      • Visible abdominal contents:
        • unremarkable of the liver, GB, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
      • Visualized bones: unremarkable.
    • Impression:
      • suspect mild obstructive small airway disease in lungs.
      • mild linear atelectasis or interstial inflammation at lower medial region of RLL.
  • 2023-08-31, -03-16 SONO - abdomen
    • Fatty metamorphosis of pancreas
    • Mild fatty liver.
  • 2023-07-18 Patho - breast biopsy (no need margin)
    • Breast, left, core needle biopsy — Chronic inflammation, fibrosis, and hematoma
  • 2023-07-17 Patho - soft tissue debridement
    • Breast, right, debridement — mastitis with necrosis
  • 2023-04-12 Patho - breast simple/partial mastectomy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, R’t breast, nipple sparing simple mastectomy — Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
      • Skin and nipple, ditto — Free of tumor invasion
      • Surgical margins and base, ditto — Free of tumor invasion, 0.3 cm at closest base margin
      • Lymph nodes, R’t axillary, dissection — Free of tumor metastasis (0/5)
      • AJCC Pathologic Anatomic Stage — pT2N0, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MACROSCOPIC EXAMINATION
      • Breast: 18.3 x 16.3 x 5.2 cm
      • Skin: 13.9 x 4.9 cm
      • Nipple: detached, 1.7 x 1.2 x 1.0 cm
      • Tumor: 3.3 x 2.7 cm
      • Resection margins: Free, 0.3 cm away from closest base
      • Representative sections as follows: A1: nipple, A2: four unlabelled peripheral margins, A3: base, A4–A6: lesion at skin site, A7: skin, A8-A9: non-tumor breast, A10-A14: tumor [Reference: F2023-00159, FSA1-A2: R’t axillary sentinel LNs, FSB: breast safety margin, FSC: tumor site safety margin]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%
      • Size of invasive carcinoma: 3.3 x 2.7 cm
      • Histologic grade (Nottingham histologic score): grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1
      • Margins: Free, 0.3 cm from closest base margin and at least 3.6 cm away from unlabelled peripheral margins
      • Nodal status: free of tumor metastasis (0/5)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: Present
      • Perienural invasion: not identified
      • Lesion at skin site: 0.9 x 0.6 cm, ruptured epidermal cyst with foreign body reaction and abscess
      • Immunohistochemistry:
        • Please refer to S2023-05808
        • E-cadherin(+), synaptophysin(+, focal), chromogranin-A(-) and P63(-) for tumor
  • 2023-04-10 CT - abdomen
    • Findings
      • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
      • A nodule (1.1cm) at duodenum.
      • Liver cysts (up to 0.6cm).
      • Cystic lesions (1.2cm, 3.5cm) at bil. adnexa.
      • Duodenal diverticulum.
    • IMP:
      • Heterogeneous density of pancreatic head and body. Some LNs at hepatic hilar region.
      • A nodule (1.1cm) at duodenum.
  • 2023-03-28 Patho - breast biopsy (no need margin)
    • Breast, right, 11 o’clock, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study demonstrates:
      • ER: positive (moderate, 95%)
      • PR: positive ( strong, 90%)
      • Her2/neu: negative (1+)
      • Ki-67 inedex: 30%
      • E-cadherin: positive
      • p63:negative.
  • 2023-03-22 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, a lower C or upper T-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, knees, and feet.
  • 2023-03-14 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • Breast, right, 1 o’clock, core needle biopsy — Invasive carcinoma of no special type
      • Breast, right, 11 o’clock, core needle biopsy — fibrocystic change
    • Immunohistochemical study demonstrates
      • ER: positive (strong, > 95%),
      • PR:positive (moderate, 80%),
      • Her2/neu: negative (1+),
      • p63: negative,
      • Ki-67 inedex: 10%.

[MedRec]

  • 2023-12-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S: Zoladex (goserelin) 3M since 2023-12-20
    • A: Dermatitis, hand foot syndrome after chemotherapy
    • Prescription x3
      • Nolvadex (tamoxifen citrate 10mg) 1# BID
  • 2023-11-06 SOAP Gastroenterology Chen JianHua
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-10-26 ~ 2023-10-31 POMR Plastic and Reconstructive Surgery Wei LinGui
    • Discharge diagnosis
      • Cellulitis over medial supra-malleolar region of right lower leg
      • Right breast invasive carcinoma, pT2N0M0, stage IIA. ER(95%) PR(90%) HER(1+) Ki67:30%. ECOG:1
      • Carrier of viral hepatitis B
    • CC
      • Suffered from right leg redness for a month ago
    • Present illness
      • This 42-year-old female patient was a viral hepatitis B carrier for 10 years with regular medicine control.
      • She also was a victim of Right breast invasive carcinoma s/p simple mastectomy and axillary lymph node sentinel lymph node + bilteral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects and left prophylactic mastectomy on 2023/04/11.
      • Pathology showed invasive carcinoma of no special type with focal neuroendocrine differentiation, 10%, size 3.3 cm, Gr 2, pT2N0M0, stage IIA.
      • She received 3rd adjuvant chemotherapy with Lipo dox 35mg/m2 + Endoxan 600mg/m2 on 2023/06/14.
      • She suffered from right leg redness for a month ago, because using the fascia gun too hard. Physical assessment revealed right leg wound about 3X3 cm, which was red, swollen, locally heated, and swelling painful, with no discharge or foul smell.
      • Under the impression of right leg cellulitis, she was admitted for antibiotic treatment. she was admitted to our PS ward for further vealuation and treatment.  
    • Course of inpatient treatment
      • After admission, right foot wound redness, swelling, local heat, no discharge and foul smell.
      • Under antibiotic with Soonmelt 1200mg Q8H.
      • Right leg wound care with Aq-BI wet.
      • Analgesic agent was given.
      • Attention wound condition.
      • Because her wound was well healing and her whole condition was stable, she was discharged and OPD follow-up was arranged.
    • Discharge prescription
      • Curam (amoxicillin 875mg, clavulanic acid 125mg; 1000mg) 1# Q12H 7D
  • 2023-10-04 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O: neutrpenia 187, give g-CSF x3
    • P: 5th chemotherapy with Taxotere
    • Prescription
      • cephalexin 500mg 1# QID 3D
      • Granocyte (lenograstim 250ug) SC 3D
  • 2023-09-27 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • P: Taxotere since 2023/09/27
  • 2023-09-20 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-09-08
      • The patient’s liver enzymes have increased due to chemotherapy.
      • So chemotherapy is not recommended at this time.
      • The patient will receive a combination of R/T + Tamoxifen + menopausal hormone therapy. The pharmacist will be consulted to determine whether anti-hormone drugs have any impact on hepatitis.
  • 2023-09-11 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • A/P: GOT,GPT elevation–>hold chemotherapy
  • 2023-04-10 ~ 2023-04-16 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Right breast invasive carcinoma status post bilateral nipple sparing mastectomy + right sentinel lymph node biopsy + bilateral low-costal advancement flaps resurface of bilateral anterior thoracic soft tissue defects on 2023/04/11. cT2N0M0, stage IIA. ECOG:0
      • Carrier of viral hepatitis B
    • CC
      • noted a palpable mass at right breast over 2 months.
    • Present illness
      • This 42-year-old female patient has past history of carrier of viral hepatitis B over 10 years with regular medicine control. She denied cancer history. She went to Janpan on 2023/03.
      • She noted a palpable mass at right breast over 2 months. She came to our OPD for help. Breast sono showed a lesion right breast tumor (1’region, 11’region) r/o malignancy suggest biopsy.
      • Core needle biopsy revealed invasive carcinoma, ER positive (strong, >95%), PR positive(moderate, 80%), Her2/neu negative(1+), p63 negative, Ki-67 inedex 10%. CA-153 14.159 U/ml, CEA 1.383 ng/ml.
      • Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • PE: symmetrical of bilateral breasts. A hard, nontender, movable mass and irregular margin at right breast around 3x3 cm without discharge. The nipple was dimping without exudative nor bloody discharge and right nipple retraction. The right breast skin had no cellulite change.
      • Under the impression of right breast invasive carcinoma, she was admitted for surgery of right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy .        
    • Course of inpatient treatment
      • After admission, right nipple sparing mastectomy + SLNB and left breast prophylactic simple mastectomy was performed on 2023/04/11. The wound is clean and dry.
      • Under the stable condition, she was discharged today, wound will be follow up in OPD.
    • Discharge prescription
      • Acetal (acetamnophen 500mg) 1# QID
      • Zcough (benzonatate 100mg) 1# TID
      • Actein (acetylcysteine 200mg) 1# TID

[surgical operation]

[chemotherapy]

  • 2023-11-29 - docetaxel 75mg/m2 143mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-11-09 - docetaxel 75mg/m2 145mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-18 - docetaxel 75mg/m2 140mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-09-27 - docetaxel 75mg/m2 140mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-07-18 - cyclophosphamide 600mg/m2 1118mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-14 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-24 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 3hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-03 - cyclophosphamide 600mg/m2 1127mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

TAC (Docetaxel, Doxorubicin and Cyclophosphamide) (breast) - https://www.swagcanceralliance.nhs.uk/wp-content/uploads/2020/10/TAC-1.pdf

==========

2023-12-21

A review of the patient’s medical records on 2023-12-20, revealed the development of dermatitis or hand-foot syndrome following chemotherapy treatment.

It is noteworthy that the patient is concurrently receiving 3 medications for her breast cancer - docetaxel, tamoxifen, and goserelin (Zoladex Depot - goserelin 10.8mg/syringe, SC on 2023-12-20, Q3M) - all of which have been associated with dermatological adverse reactions in the literature. The reported incidence of these reactions for each medication is as follows:

  • Docetaxel:
    • Alopecia: 56% to 76% (potentially permanent)
    • Dermatological reactions: 20% to 48% (5% with severe presentation)
    • Nail disease: 11% to 41%
    • Onycholysis: <1%
  • Tamoxifen:
    • Skin changes: 6% to 19%
    • Skin rash: 13%
    • Alopecia: 5%
    • Diaphoresis: 6%
  • Goserelin:
    • Acne vulgaris (females): 42%
    • Diaphoresis (females: 16% to 45%; males: 6%)
    • Seborrhea (females: 26%)
    • Alopecia (females: 1% to 5%)
    • Ecchymoses (females: 1% to 5%)
    • Hair disease (females: 4%)
    • Pruritus: 2%
    • Skin discoloration (females: 1% to 5%)
    • Skin rash: 6%
    • Xeroderma (females: 1% to 5%)

The development of subsequent skin symptoms may be difficult to definitively attribute to docetaxel, and further observation and follow-up is warranted.

As for the skin symptoms that have already occurred, the preliminary recommendation is to prescribe Sinphraderm and/or Mycomb to relieve them.

2023-12-08

The TAC regimen, which includes docetaxel at 75 mg/m2 Q3W (initiated on 2023-09-27), followed 4 courses of doxorubicin and cyclophosphamide from 2023-05-03 to 2023-07-18. Docetaxel has been linked to dermatologic side effects such as alopecia (56% to 76%, with potential permanence), skin reactions (20% to 48%; severe reactions in 5%), and nail disorders (11% to 41%), as per UpToDate. To address these skin issues, a consultation with a dermatologist is recommended. The aim is to manage the patient’s comfort effectively while maintaining the current chemotherapy schedule and dosage.

Leukopenia episodes were noted on 2023-08-09, 2023-10-04, and 2023-11-15. Prompt administration of G-CSF was carried out in response to these occurrences. Currently, there are no indications of leukopenia.

  • 2023-11-15 WBC 2.68 x10^3/uL
  • 2023-10-04 WBC 1.03 x10^3/uL
  • 2023-08-09 WBC 2.21 x10^3/uL

700811854

231207

[exam findings]

  • 2023-11-17 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Old fracture of right clavicle.
  • 2023-11-17 ECG
    • Sinus rhythm with short PR
    • Low voltage QRS
    • Borderline ECG
  • 2023-11-15, -11-13, -11-07 KUB
    • S/P CBD and p-duct stenting.
    • Degeneration and spondylosis of L-S spine.
    • Non-specific small bowel and colon gas pattern.
  • 2023-11-06 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: biliary decompression
    • Symptoms: panc CA with Jaundice
    • Diagnosis:
      • Obstructive jaundice, pancreatic head cancer related, s/p TPS, EST and biliary stenting
      • GB non-opacification
      • S/P P duct stenting
      • Reflux esophagitis
    • Suggestion:
      • f/u amylase & lipase
  • 2023-11-03 Peripheral Vascular Test - Artery, lower limbs
    • Atherosclerosis: Mild
    • Conclusions:
      • Bilateral common femoral arteries distal segment mild plaques, no stenosis
      • Right superficial femoral artery very proximal segment and distal segment mild plaques, no stenosis; left superficial femoral artery very proximal segment mild plaques, no stenosis
      • Bilateral popliteal arteries proximal segment mild plaques, no stenosis
      • Bilateral posterior tibial arteries no significant stenosis
      • Right anterior tibial artery middle segment plaques with mild stenosis; left anterior tibial artery no significant stenosis
  • 2023-10-30 PET scan
    • Increased FDG uptake in the pancreatic head region, compatible with the adenocarcinoma of pancreas with regional lymph node metastasis.
    • Two small nodules 5 mm in S5 and S6 of the liver showm on the previous abdomen MRI, however, reveal no increased FDG uptake. Please correlate with other imaging modalities for further evaluation.
    • Increased FDG accumulation in bilateral kidneys, bilateral ureters, and colon, probalby physiological uptake of FDG.
  • 2023-10-28 CT - chest
    • Indication: For pancreas head tumor survey
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • Senile fibrotic change is noted at lung fields.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
      • Visible abdomen:
        • Low density lesion at pancreatic uncinate process measuring 5.4cm in largest dimension. Regional lymphadenopathy (n=2) are found.
        • The IHDs and CBD are dilated probably due to tumor compression.
        • One enhanced dot at liver dome is found. The lesion is too small to be characterized.
        • There is no evidence of destructive bone lesion.
        • Linear gallstone is found.
        • Suggest clinical correlation
    • Imp:
      • pancreatic cancer at uncinate process of the pancreas. 5.4cm with regional lymphadenopathy
      • Gallstone.
  • 2023-10-27, -10-24 CXR
    • Old fracture of right clavicle.
    • Atherosclerosis of the aorta.
    • Ground glass opacity in bilateral lower lungs.
    • Normal appearance of trachea and bil. main bronchus.
  • 2023-10-23 Patho - pancreas biopsy
    • Labeled as “pancreas”, EUS fine needle biopsy — adenocarcinoma.
    • Section shows necrotic tissue with adenocarcinoma.
    • IHC stains: CA19-9 (+), CK7 (+), CK20 (focal +), CEA (+), CK19 (+).
  • 2023-10-23 SONO - abdomen
    • Diagnosis:
      • Pancreatic head tumor
      • Fatty liver, mild
      • Liver calcification, right
      • CBD dilatation
      • Bilateral IHD dilatation
      • GB stone
      • Renal cysts, LK
      • Minimal ascites
      • Right pleural effusion
    • Suggestion:
      • the two liver tumors noted by MRI in S5 and S6 could not be found.
  • 2023-10-20 MR Cholangiography, MRCP
    • Indication: r/o Pancreatic head tumor
      • 20231017 CEA:5.14 ng/mL (<5), CA199:487.67 U/mL (<35).
    • Findings:
      • There is a well-defined, mild heterogeneous mass in the pancreatic head, measuring 4.6 cm in size (the largest dimension), causing marked dilatation of the CBD, CHD, IHDs, and pancreatic duct.
        • This mass shows hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor contrast enhancement.
        • Adenocarcinoma of the pancreatic head (T3) is highly suspected.
        • Please correlate with EUS.
      • There is one enlarged node 1 cm in RMQ mesentery that is c/w metastatic node (N1).
      • There are two small nodules 5 mm in S5 and S6 of the liver, showing equivocal mild hyperintensity on T2WI (Srs:3 Img:18) and marked hyperintensity on DWI (Srs:104 Img:19).
        • Metastases (M1) are highly suspected.
        • Please correlate with sonography.
        • Follow up MRI 3 months later is indicated.
      • A stone 4 x 1 cm in the gallbladder is suspected. Please correlate with sonography.
      • There are several renal cysts on both kidney and the largest one measuring 2.1 cm in size at left upper pole.
      • Minimal right side Pleura effusion is highly suspected.
      • Mild ascites is highly suspected. Please correlate with sonography.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage): T: T3 (T_value) N: N1 (N_value) M: M1 (M_value) STAGE: IV (Stage_value)
  • 2023-10-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 25) / 91 = 72.53%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated both atria and RV, grade 1 LV diastolic dysfunction
      • Mild AR, MR, TR
  • 2023-10-16 CXR
    • Fracture of right clavicle.
    • Atherosclerosis of the aorta.
  • 2023-10-16 ECG
    • Sinus bradycardia
    • Left axis deviation
  • 2023-10-15 ECG
    • Sinus rhythm with short PR with occasional Premature ventricular complexes
    • Left axis deviation
    • Abnormal ECG

[MedRec]

  • 2023-10-15 SOAP Medical Emergency Chen YuLong
    • S: JUST AAD FROM DaJia KuangTien Hospital, TOCC(-)
      • GENERAL DISCOMFORT 2 DAYS AGO, BW LOSS FOR 10+ KG IN RECENT 6 MO
      • PH; HTN, DM NKDA
      • Cloud:
        • 2023/10/14
          • WBC 7.2k Hb12.3 MCV 90.1 PLT 141k
          • K 3.17 Na 140 Glu 193 BUN 16 Cr 1.19 GPT 279 Ti- CRP 0.2 Alb 3.1 TBI 1.9 GGT 293 ALP 133 Lip 42 NH 3 56
          • PT 10.5 sec APTT 29.2sec
          • PH 7.428 PCO2 34.6
          • Urine Light Yellow, Clear
        • Stool (2023/10/15) Brown Soft N/A
      • 2023/10/15 Discharge diagnosis (DaJia KuangTien Hospital)
        • Biliary sepsis due to acute cholangitis
        • Biliary obstruction due to suspect malignant tumor at pancreatic head
        • Acute gastric erosions with H. pylori
        • GERD Gr.A
        • CAD with 3 VD
        • DM
        • HCVD
      • Medication:
        • GLIMET
        • CONCOR 1.25
        • QTERN 5MG/10MG (Dapagliflozin;Saxagliptin)
        • Aspirin
        • Isosorbide 5-Mononitrtate (60)
        • NORVASC
        • DOXABEN XL
    • O:
      • Vital Sign: BP:105/62; HR:85; BT:36.5’C; RR:16;
      • Con’s:E4V5M6
      • SpO2:96%
      • MILD ICTERIC, ANEMIC
      • CLEAR BS, RHB
      • ABD; SOFT AND CONVEXED, NONTENDER
      • EXT; NO EDEMA
    • Preliminary impression: C25.9 Malignant neoplasm of pancreas, unspecified
      • Pancrea head tumor, ?GB stones, CBD dilatation, ALT 279, TBI 1.9, GGT 293, Alp 133, AAD from DaJia KuangTien Hospital. No fever, V/S stable in ER observation. OA GI
      • HTN; DM
  • 2023-10-11 SOAP General and Gastrointestinal Surgery
    • S
      • Chief complaint: a palpable mass over L’t upper back for years
      • Present illness: According to the patient & family, the patient suffered from a palpable mass over L’t upper back for years. Due to pain, sign & symptom exacerbation, the patient called at our OPD for help.
      • Past history: No Hx of operation, No Hx of type 2 DM, HTN
      • Allergy: NKA
      • Travel Hx: Nil
      • Family Hx: No significant finding in pedigree
    • O
      • Skin: a 4x4 cm plapble soft mass over L’t upper back with local tenderness,
    • A
      • L’t back tumor
    • P
      • suggest excision or closely observation, education, & OPD follow up
      • F/U the tumor yearly

700348263

231206

[lab data]

2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.24 S/CO
2023-07-26 Anti-HBs 39.06 mIU/mL
2023-07-26 Anti-HBc Nonreactive
2023-07-26 Anti-HBc-Value 0.31 S/CO
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-12-02 KUB
    • There is no evidence of destructive bone lesion.
    • Stool impaction at the abdominal cavity is noted.
    • Non-specific bowel gas at abdominal cavity is found.
    • s/p stent placement at right iliac region.
  • 2023-12-02 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • Massive right pleural effuison
    • There is no evidence of destructive bone lesion.
  • 2023-11-22 SONO - chest
    • Echo diagnosis
      • Pleural effusion, moderate, to massive right
      • Atelectasis, RLL
  • 2023-10-27 PET
    • A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
    • Prominent glucose hypermetabolism in the right lateral chest wall. Metastasis should be watched out.
    • Glucose hypermetabolism in a lymph node in the right anterior prevascular space and in a right paratracheal lymph node, suggesting metastatic lymph nodes.
    • Glucose hypermetabolism in a focal area in the right supraclavicular fossa. A metastatic lymph node can not be ruled out.
    • Mild glucose hypermetabolism in a pleura-based focal area in the anterior aspect of the upper lobe of right lung. The nature is to be determined (inflammation? metastasis of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture.
  • 2023-10-03 CT - chest
    • Indication: ca of lung, pStage IIIB, pT3N2M0.
    • Comparison was made with CT on 2023/04/14
      • Lungs:s/p right upper lobe lobectomy, staple line along superior posterior Rt major fissure.
        • no abnormal nodule or mass in the Rt remnant lungs or bronchial stump. a 5mm nodule in inferior lingular segment.
        • mosaic attenuation changes in both lungs on inspiratory images.
      • Mediastinum and hila: enlarged LNs in Rt paratracheal space and Rt anterior prevascular space.
        • extensive coronary arterial calcification
      • Thoracic aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: dilated right (3.3cm) and left pulmonary arteries.
      • Heart: normal size of cardiac chambers. midseptal hypertrophy of IVS and extensive calcified mitral annulus
      • Pleura: moderate Rt-sided effusion with loculation.
      • Chest wall and visible lower neck: unremarkable.
      • Extensive atherosclerotic change of the abdominal aorta.
      • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
      • lingular nodule 5mm.
      • extensive 2V-CAD.
  • 2023-08-01 Nerve Conduction Velocity, NCV
    • Findings
      • MNCV: decreased CMAPs amplitude of left median nerve and left tibial nerve; slow motor conduction of bilateral ulnar nerves across elbow
      • SNCV: decreased SNAPs amplitude of all examined nerves; slow sensory conduction velocity of bilateral median and ulanr nerves
      • F-wave: delayed responses of right ulnar and left tibial nerves
      • H-reflex: delayed responses of bilateral lower limbs
      • Thermal quantitative sensory test showed abnormal warm threshold in left upper and lower limbs.
    • Conclusion
      • This NCV study suggested bilateral lumbosacral radiculopathy with left tibial axonal injury, bilateral ulnar neuropathy across elbow, bilateral median distal neuropathy with the possibility of right lower cervical radiculopathy.
      • Thermal quantitative sensory test suggested small fiber neuropathy.
      • Please correlate with clinical features.
  • 2023-06-26 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, upper lobe, lobectomy —- Squamous cell carcinoma, moderately differentiated
      • Lymph node, lobar, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/4)
      • Lymph node, right, group No.2+4, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/3)
      • Lymph node, right, group No.7, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/ 4)
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/2)
      • Lymph node, right, group No.10, lymphadenectomy —- Squamous cell carcinoma, metastatic (2/4)
      • Lymph node, right, group No.11, lymphadenectomy —- Squamous cell carcinoma, metastatic (1/2)
      • Lymph node, right, group No.12, lymphadenectomy —- Squamous cell carcinoma, metastatic (3/4)
      • AJCC 8th edition pTNM Pathology stage: pStage IIIB, pT3N2(if cM0)
    • MACROSCOPIC EXAMINATION:
      • Specimen: Lung, size: 16.2 x 9.5 x 3.5 cm, 210 g
        • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.6 x 1.5 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 6.0 x 4.5 x 2.8 cm
      • Gross tumor patterns: poorly defined
      • Tissue for sections: A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung, non-tumor; A5-8: tumor; B: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Invasive squamous cell carcinoma, keratinizing
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Present, Lymphatic and Venous
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 1.9 cm
        • Specify closest margin: parenchymal resection margin
        • Bronchial resection margin: 2.1 cm
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: please see diagnosis
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor >5 cm but <=7 cm in greatest dimension;
        • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
  • 2023-06-12 Cardiopulmonary Exercise Testing
    • Conclusions
      • submaximal exercise by RER < 1.09
      • low exercise capacity (VO2 50%, WR 23%)
      • spirometry was moderate obstructive ventialtory impairment with significant reversibility (FVC 78 -> 90%, FEV1 66 -> 83%)
      • low inpiratory muscle strength (MIP 51%, MEP 84%)
      • No SpO2 desaturation below 90%
      • normal cardiac response during exercise
      • slow HR response slope during exercise
      • work efficiency low
      • anaerobic threshold indeterminant
      • oxygen pulse normal
      • BP response high
      • EKG: no specific findings
      • Health-related quality of life, CAT= 5,
    • Impression and suggestion:
      • Treat underlying asthma
      • Exercise training for low exercise capacity
      • Treat obstructive ventilatory impairment
      • Perform breathing exercise for low respiratory muscle strength
      • Survey and treat slow HR response
  • 2023-06-09 Tc-99m MDP bone scan
    • Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulder, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-06-08 PET
    • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
    • Glucose hypermetabolism in a right paratracheal lymph node. The nature is to be determined (inflammation? a metastatic lymph node of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right pulmonary hilar region. Inflammation is more likely.
    • Increased FDG accumulation in the colon, both kidneys and left ureters. Physiological FDG accumulation may show this picture.
  • 2023-06-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (155 - 39) / 155 = 74.84%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; impaired LV relexation
      • Mild MR, mild AR, mild to moderate TR
      • Mild pulmonary hypertension
      • Preserved RV systolic function
  • 2023-06-07 ECG
    • Left axis deviation
    • Left anterior fascicular block
  • 2023-05-29 Patho - pleural/pericardial biopsy
    • Lung, RUL, CT-guide biopsy —- squamous cell carcinoma, moderately differentiated
    • Sections show solid sheets of hyperchromatic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis. Focal keratinization is seen.
    • The immunohistochemical stains reveal CK5/6(+), p40(+), TTF-1(-), and CD56(focal +). The results are supportive for the diagnosis.
  • 2023-04-19 24hr Holter ECG
    • Baseline was sinus bradycardia (average HR: 53bpm, range between: 48-61bpm)
    • Chronotropic incompetence noted
    • A few isolated VPCs / VPC couplets
    • A few isolated APCs / APC couplets
    • 4 episodes of short-run AT, max 21 beats
    • No long pause
  • 2023-04-19 MRA - brain
    • acute ischemia stroke
    • Image quality: no gross motion artifacts
      • moderate dilated intraventricular and extraventricular CSF spaces
      • old lacunar infarction in the bilateral basal ganglia and right thalamus.
      • unremarkable change in the skull base
      • MRA of the intracranial vessels revealed mild stenosis at left distal VA; mild prominent bilateral PCom infundibuli.
    • IMP:
      • no evidence of recent infarction
  • 2023-04-18 Neurosonology
    • Moderate atheromatous lesions in L CCA bifurcation; mild to moderate atheromatous lesions in R distal CCA to CCA bifurcation; mild atheromatous lesions in R ICA and ECA.
    • Elevated resistance (RI) and decreased flow in bilateral cervical VAs, suspect distal stenosis.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except relatively elevated flow velocity in R M1 (PS/ED= 126/15 cm/s)
    • Normal bilateral ophthalmic arterial flows.
  • 2023-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 30) / 146 = 79.45%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, LV and AoR, LVH, grade 1 LV diastolic dysfunction
      • Mild AR, MR, TR and PHTN
  • 2023-04-15 CT - brain
    • Indication: acute ischemia stroke
    • Without contrast helical Head CT - 4mm thickness in each slice from the axial and saggital projections showed
    • Image quality: no motion artifacts
      • mild dilated intraventricular and extraventricular CSF spaces
      • unremarkable change in the brain parenchyma
      • unremarkable change in the skull base
      • artherosclerotic change at the bilateral distal VAs and bilateral cavernous ICAs.
    • IMP: no acute intracranial hemorrhage
  • 2023-04-14 CT, CTA - brain (head, neck)
    • Head CT with IV contrast enhancement shows:
      • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
      • The ACAs, MCAs and VA are patent.
      • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
      • No evidence of ICH, SAH or SDH.
      • No evidence of space occupying lesion in the brain parenchyma is found.
      • Suggest clinical correlation
    • IMp:
      • Marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries is found.
      • The ACAs, MCAs and VA are patent.
  • 2023-04-14 CT - chest
    • hest CT without IV contrast ehnancement shows:
      • Mass like lesion at right upper lobe measuring 5.6cm in largest dimension is found.
      • Calcified coronary arteries is found.
    • Imp:
      • Right upper lobe lung mass, lung cancer is favored.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-14 CT - brain
    • Imp
      • Brain atrophy
      • No evidence of ICH, SAH or SDH.
      • No evidence of space occupying lesion in the brain parenchyma is found.
  • 2023-04-14 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2017-09-07 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MACROSCOPIC EXAMINATION
      • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic adenocarcinoma
      • Histologic Grade: (Gleason score 7 = 4 + 3)
      • Tumor Quantitation: involving 3 of 5 strips of prostatic tissue by the number of involved strips or 60 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
  • 2017-09-07 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Prostate, left, needle biopsy — Prostatic adenocarcinoma (Gleason score 7 = 4 + 3) involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • MACROSCOPIC EXAMINATION
      • Size: 5 strips, with the longest piece measuring 1 x 0.1 x 0.1 cm.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Prostatic adenocarcinoma
      • Histologic Grade: (Gleason score 7 = 4 + 3)
      • Tumor Quantitation: involving 4 of 5 strips of prostatic tissue by the number of involved strips or 80 % by the involved volume of the specimen.
        • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.

[MedRec]

  • 2023-11-19 ~ 2023-11-22 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Squamous cell carcinoma over right upper lobe, pT3N2M0 stage IIIB, post operation 3 dimensions video-assisted thoracoscopic surgery right upper lobe lobectomy and radical lymph node dissection on 2023/06/26.
      • Essential (primary) hypertension
      • Prostate cancer status post androgen deprivation therapy
      • Enlarged prostate with lower urinary tract symptoms
      • Right lower limb peripheral arterial occlusion disease post stent x 1
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14
      • Zoster without complications, herpes zoster on the right chest region
      • Right side pleural effusion
    • CC
      • for on port-A and chemotherapy
    • Present illness
      • This is a 79-year-old male with past history of
        • Squamous cell carcinoma over right upper lung, moderately differentiated, cT3N0Mx, pT3N2M0, pStage IIIB.
        • Prostate cancer status post androgen deprivation therapy;
        • Acute ischemic stroke status post tissue plasminogen activator on 2023/04/14
        • Right lower limb peripheral arterial occlusion disease post stent x 1
        • Hypertension.
      • He used to smoking 2~3 packs per day for about 40 year and quit smoking for 17 years. According to patient statement and his medical record, he was brought to our ER due to acute ischemic stroke status with dizziness, upper limbs weakness and slurry speech which was noted at around 7 pm on 2023/04/14. Brain CT showed no evidence of hemorrhage. Chest X-ray and lung computer tomograph revealed mass like lesion at right upper lobe, measuring 5.6cm in size at lung window setting.
      • Therefore, He was then refered to out patient department of chest surgeon for further investigation. Computer tomograph guide biopsy was performed on 2023/05/29 and pathology roport showed squamous cell carcinoma, moderately differentiated.
      • Then, he was admission for cancer survey on 2023/06/07 and he was done PET on 2023/06/08 showed
        • A glucose hypermetabolic lesion in the upper lobe of right lung, compatible with primary lung malignancy.
        • Glucose hypermetabolism in a right paratracheal lymph node.
      • WBBS on 2023/06/09 showed Mildly increased activity in the middle to lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
      • Cariac echogram showed 1. Adequate LV systolic function with normal resting wall motion 2. Dilated LA, septal hypertrophy; impaired LV relexation 3. Mild MR, mild AR, mild to moderate TR 4. Mild pulmonary hypertension 5. Preserved RV systolic function.
      • Bronchoscope on 2023/06/12 showed no obvious abnrmality.
      • He was underwent operation for 3D VATS RUL lobectomy + RLND on 2023/06/26.
      • RT dose: 6000cGy/30 fractions (6 MV photon) to RUL bronchial stumo and mediastinal /SCF, 2023/7/27 to 9/07.
      • Oral navelbine on 7/26, 8/02, 8/09, 8/16, 8/23, 8/30, 9/05.
      • Chest CT, 2023/10/03: enlarged Rt mediastinal LNs, lymph nodes recurrent tumor? moderate pleural effusion and pulmonary hypertension.
      • PET, 2023/10/27: A glucose hypermetabolic lesion in the right lower lung field and multipe small glucose hypermetabolic lesions in the upper and lower lobes of left lung, compatible with multiple lung metastases.
      • 2023-10-31 tumor progression, suggest C/T with CDDP+Gemzar
      • 2023-10-16 herpes zoster on the right chest region under Famvir 250 mg PO TID x 5 days.
      • This time, he was admitted for on port-A and chemotherapy.  
    • Course of inpatient treatment
      • After admission, consult CS for Port-A implantation on 2023/11/20, he can tolerance procedure well.
      • He received weekly Gemcitabine (1000mg/m2) + Cisplatin (30mg/m2) on 2023/11/21 (C1D1) smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Tramacet 37.5 & 325mg/tab 1# PO Q6H for pain control.
      • Right side pleural effusion was noted, pleural puncture was done on 2023/11/22, pleural effusion, moderate, to massive right, 1200ml serosanguious fluid was drained and sent for routine, BCS, bacteria/TB/fungus cultures and cell block and TB-PCR.
      • Atelectasis, RLL.
      • Hypertension with Exforge F.C. 5mg & 160mg/tab 1# PO QD.
      • Enlarged prostate with lower urinary tract symptoms with Urief F.C 8mg/tab 1# PO QN, Minirin Melt 60mcg/tab 1# PO HS.
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 with Bokey 100mg/cap 1# PO QD, Rivotril 0.5mg/tab 0.5# PO RRNHS if cramp, Nicametate Citrate 50 mg/tab 1# PO QD.
      • PD-L1 (22C3) was sent on 2023/11/22. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/11/22 and OPD followed up later.    
  • 2023-05-24 ~ 2023-05-30 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Right upper lung mass, pending pathology on 2023/05/29
      • Essential (primary) hypertension
      • Cerebral infarction, unspecified
      • Enlarged prostate with lower urinary tract symptoms
      • Past history of right lower limb Peripheral Arterial Occlusion Disease post stent x1
    • CC
      • BW loss 4kg and need do the tumor survey
    • Present illness
      • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy for 6 years at VGHTPE, left /p TKR, prostate cancer, T3bN0M0 under androgen deprivation therapy. Last time, he suffered from dizziness, upper limbs weakness and slurry speech around 7PM. Study image brain CT and chest x-ray were arranged, it revealed no evidence of hemorrhage by brain CT and pleural based mass like lesion at right upper lobe.
      • After Neurologist consulting, he received tPA therapy for acute ischemic stroke with National Institute of Health Stroke Scale 8 points. Post tPA therapy, the brain CTA was folllow-up, it revealed marked artherosclerotic change of biilateral CCA, ICA and intracrenial arteries. Due to lung mass, the chest CT was arranged, it revealed right upper lobe lung cancer (5.6cm) T3N0M0.
      • This time, he has BW loss 4kg in one month, but no cough, SOB or fever. He was admitted for lung biopsy on 2023/05/24.
    • Course of inpatient treatment
      • After admission, he hold Aspirin for lung biopsy 3 days. Radiologiest was consulted and aspiration smoothly on 2023/05/29. No evidence of pneumothorax after lung biopsy for 4 hours. Under the stable condition, he can be discharged on 2023/05/30. OPD follow up is arranged.
  • 2023-04-14 ~ 2023-04-20 POMR Neurology Chen PeiYa
    • Discharge diagnosis
      • Acute ischemic stroke status post Tissue plasminogen activator on 2023/04/14 (TOAST classification 4, cancer related )
      • Right upper lobe lung cancer, undetermined
      • Prostate cancer status post androgen deprivation therapy
      • Left lower limb peripheral arterial occlusive disease
      • Essential (primary) hypertension
      • Modified ranking scale 0
    • CC
      • acute dizziness, limbs weakness and slurred speech around 7PM pm 4/14
    • Present illness
      • This 78-year-old male has histories of HTN, PAOD post stenting under anti-platelet therapy (aspirin) and prostate cancer s/p androgen deprivation therapy but lost follow-up.
      • He was normal until acute generalized weakness during dinner at around 7pm on 4/14. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER. At ER, his consciousness was E4V5M5-6 and he presented with dysarthria and generalized weakness with lower limb more prominent weakness. Vital signs showed BT 36.6’C, HR 74, RR 18, BP 187/88mmHg. NIHSS was 8. Brain CT showed no evidence of hemorrhage and and CXR revealed pleural based mass like lesion at right upper lobe.
      • After evaluation and explanation to the family about the indication as well as risk of IV rt-PA therapy, he underwent rt-PA therapy (93.9Kg, 0.6mg/kg, total 56mg) smoothly. Due to lung mass, the chest CT was arranged with brain CTA which confirmed no large vessle occlusion and revealed right upper lobe lung cancer (5.6cm) T3N0M0. Then within a hour of rtPA therapy, his symptoms/signs were recovered. Hence he was admitted to SICU for post-rtPA therpay monitor and management.
    • Course of inpatient treatment
      • At SICU, we gave adequate IV hydration and kept post-rtPA therapy monitor with tight control BP. Transient oral cavity blood clot and mild bleeding were noted during the first few hours and the patien claimed that tooth extraction was done about 3 days before this event.
      • Follow-up brain CT on 3/15 showed no acute intracranial hemorrhage. There was no recurrent symptoms or focal weakness noted after admission. With stablized and improved condition, he was transfered to ward for subsequent managment and treatment.
      • After transfer, we arranged associated survey for stroke risk factor evaluation. CPA/TCD revealed moderate atheromatous lesion in carotid arteries and other cerebral atherosclerosis. ABI study suggested left lower limb PAOD. Heart echography showed LVEF 79% without significal structural abnormality. 24 hours Holter EKG report was pending. We consulted physiatrist for rehabilitation activitiy.
      • About cancer issue, we had explained to the patient about further evaluation and mangement which were necessary and we will arrange oncologist for it. With good recovery, the patient asked to be discharged soon. Hence he was discharged with oral medication and scheduled OPD follow-up including urology and oncology.
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • Diovan (valsartan 160mg) 1# QD
      • Duodart (dutasteride 0.5mg, tamsulosin 0.4mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# QD
  • 2018-02-05 Urology Lin JiaDa
    • S: PCa T3bN0M0, ADT since 2017/10/16 (androgen deprivation therapy)
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
      • Malignant neoplasm of prostate [C61]
    • Prescription
      • Leuplin depot (leuprorelin 3.75mg) Q1M SC
      • Harnalidge (tamsulosin 0.4mg) 1# QDAC
      • Androcur (cyproterone acetate 50mg) 1# TID

[consultation]

  • 2023-04-14 Neurology
    • Q
      • CVA Call
    • A
      • This 78 y/o man has a history of PAOD s/p stent and on Aspirin, HTN, and prostate cancer. He was normal until acute generalized weakness during dinner. He could barely stand on his own and presented with slurred speech. Therefore he was sent to our ER.
        • NE E4V5M5-6
        • CNs: normal EOM
        • moderate dysarthria
        • MP upper >4/>4 lower >3/>3
        • sensation: intact
        • FNF: no dysmetria
        • brain CT: no ICH
        • NIHSS 001 000 1122 00010 (8) at 21:05
        • CXR: right lung field mass lesion
      • impression: acute ischemic stroke
      • suggestion:
        • give rt-PA therapy 56mg (93.9Kg., 0.6mg/kg, total 56mg) with family’s agreement
        • do brain + chest CTA, consider EVT if LVO
        • arrange neurology ICU admission.
    • A 22:30
      • brain CTA: no LVO
      • improved dysarthria and MPs
      • had explained to the family

[chemotherapy]

  • 2023-11-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + cisplatin 30mg/m2 40mg NS 350mL 3hr
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-11-21 - gemcitabine 1000mg/m2 1800mg NS 100mL 30min + cisplatin 30mg/m2 50mg NS 350mL 3hr
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-12-06

[leukopenia improved]

The administration of Granocyte (lenograstim) for 3 consecutive days, starting from 2023-12-03, has effectively improved the patient’s condition of leukopenia.

  • 2023-12-06 WBC 2.78 x10^3/uL
  • 2023-12-04 WBC 0.91 x10^3/uL
  • 2023-12-02 WBC 0.33 x10^3/uL

2023-12-04

[leukopenia]

Two rounds of the gemcitabine and cisplatin regimen were given on 2023-11-21 and 2023-11-28. A leukopenia episode occurred on 2023-12-02, reaching a nadir WBC count of 0.33K/uL, and was treated with three consecutive days of Granocyte (lenograstim 250ug). Following this treatment, an initial increase in white blood cell count was observed.

  • 2023-12-04 WBC 0.91 x10^3/uL
  • 2023-12-02 WBC 0.33 x10^3/uL nadir
  • 2023-11-28 WBC 2.21 x10^3/uL
  • 2023-11-20 WBC 3.28 x10^3/uL
  • 2023-10-31 WBC 4.52 x10^3/uL

The second session of treatment involved a reduced dose compared to the first, utilizing two-thirds of the gemcitabine dose and 80% of the cisplatin dose. The use of G-CSF did not present any issues.

[thrombocytopenia]

Thrombocytopenia has developed, and leukocyte-reduced platelet pheresis (LRP) is being administered (2023-12-04). Please continuously monitor the patient’s PLT levels.

  • 2023-12-04 PLT 29 *10^3/uL
  • 2023-12-02 PLT 51 *10^3/uL
  • 2023-11-28 PLT 96 *10^3/uL
  • 2023-11-20 PLT 164 *10^3/uL
  • 2023-10-31 PLT 171 *10^3/uL

[EGFR testing for SCC lung cancer]

Based on the available evidence, testing for EGFR mutations in patients with squamous cell carcinoma (SCC) of the lung is a topic of debate and ongoing research. While EGFR mutations are more commonly associated with lung adenocarcinoma, there is evidence to suggest that a small percentage of SCC patients also harbor EGFR mutations (Si et al., 2022; Nishimura et al., 2023). The presence of EGFR mutations in SCC lung cancer patients is important because these mutations can predict sensitivity to EGFR tyrosine kinase inhibitors (TKIs) (Shigematsu & Gazdar, 2006). However, the efficacy of EGFR-TKIs in SCC patients with sensitive EGFR mutations remains unclear (Chang et al., 2021). Additionally, the prevalence of EGFR mutations in SCC patients has been reported to be about 1-5% Si et al. (2022).

  • Ref:
    • Si et al (2022). Clinical outcomes of egfr-tkis in advanced squamous cell lung cancer. Neoplasma, 69(04), 976-982. https://doi.org/10.4149/neo_2022_220329n348
    • Nishimura et al (2023). Next‐generation sequencing clarified why first‐line treatment with osimertinib was ineffective in an autopsied case of egfr‐mutated lung squamous cell carcinoma. Thoracic Cancer, 14(7), 709-713. https://doi.org/10.1111/1759-7714.14807
    • Shigematsu et al (2006). Somatic mutations of epidermal growth factor receptor signaling pathway in lung cancers. International Journal of Cancer, 118(2), 257-262. https://doi.org/10.1002/ijc.21496
    • Chang et al (2021). Epidermal growth factor receptor mutation status and response to tyrosine kinase inhibitors in advanced chinese female lung squamous cell carcinoma: a retrospective study. Frontiers in Oncology, 11. https://doi.org/10.3389/fonc.2021.652560

700040427

231205

[exam findings]

[MedRec]

  • 2023-07-11 ~ 2023-07-15 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • Rectal cancer with lumen narrowing and impending obstruction, cT4bN1M1a, stage IVa (r/o right upper lobe, right lower lobe and left upper lobe metastases) status post Loop-T colostomy and port-A implatation on 2023/07/12
      • Prostatic acinar adenocarcinoma (Gleason score 9 = 4 + 5 ), grade group 5, iPSA 129, stage cT4N1M0, very high risk group, status post radiotherapy, chemotherapy, and status during androgen deprivation therapy
      • Carrier of viral hepatitis B
      • Hypertension
    • CC
      • Tenesmus about 20 times per day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg for about 3 months.
    • Present illness
      • A 66-year-old male had history of
        • Prostate adenocarcinoma, Gleason score 4+5, PSA 129, cT4N1M0, grade group 5 status post transurethral resection of the prostate on 2022/09/28, status post adjuvent concurrent chemoradiotherapy (2022/11~2023/2) and Androgen deprivation therapy (2023/2~), well controlled.
        • Bladder stone status post cystolithotripsy on 2021/11/01
        • Hepatitis B carrier
        • Hypertension
      • This time, he sufferred from tenesmus about 20 times/day, abdominal fullness, sometimes fecal incontinence and weight loss 10kg in 3 months. He visited GI OPD and sigmoidoscopy revealed a ulcerative tumor at lower rectum with lumen narrowing.
      • Lab data revealed CEA 166.710 ng/ml. Biopsy showed adenocarcinoma. So, he was referred to CRS OPD. At OPD, digital examination revealed a palpable tumor lesion at middle rectum, 6cm from anal verge.
      • Chest and abdominal CT revealed thickening wall at the rectum abutting to seminal vesicle. Bilateral upper lung and right lower lung nodules, suspect metastasis. cT4bN1M1a, stage IVA.
      • PET CT also showed 1. Glucose hypermetabolism in the rectum with invasion to seminal vesicle, 2. Three glucose hypermetabolic lesions in the upper and lower lobes of the right lung and upper lobe of the left lung respectively. Lung metastases can not be ruled out.
      • After discussion with patient, he was admitted for T-loop colostomy and port-A implanation for chemotherapy and target therapy.
    • Course of inpatient treatment
      • After admission, we consulted GS for port-A implanation. Pre-op and anesthesia assessment was done. Loop-T colostomy and port-A implanation were performed smoothly on 2023/07/12.
      • After operation, no specific complain except for mild decreased appetite, bloating and wound pain, subsided by medicine.
      • Under relative stable condition, we arranged his discharge on 2023/07/15 and OPD follow up.
    • Discharge prescription
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

  • 2023-07-12
    • Surgery: T-loop colostomy        
    • Finding: T-colon was identified and T-loop colostomy was created at RUQ abdomen wall. The whole procedure was smooth. 

[radiotherapy]

[immunochemotherapy]

  • 2023-12-04 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 375mg D5W 250mL 90min + leucovorin 400mg/m2 830mg NS 250mL 2hr + fluorouracil 2400mg/m2 5000mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-30 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 360mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-10-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4850mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-09-18 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 780mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-08-14 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 180mg/m2 350mg D5W 250mL 90min + leucovorin 400mg/m2 790mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-07-26 - + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 800mg NS 250mL 2hr + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg + granisetron 2mg + aprepitant 125mg PO + NS 250mL
  • 2022-12-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (docetaxel, Q3W)
  • 2022-11-21 - docetaxel 75mg/m2 140mg NS 250mL 1hr (docetaxel, Q3W)

==========

2023-09-18

The patient recently obtained a 28-day supply of Norvasc (amlodipine) and Diovan (valsartan) on 2023-09-12, to manage his primary hypertension. These drugs have been added to the active medication list, and there were no reconciliation issues identified.

700101071

231204

[diagnosis] - 2023-03-20 admission note

  • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
  • Peripheral T-cell lymphoma T3N3M1 stage4
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension
  • Mixed hyperlipidemia
  • Constipation, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Insomnia, unspecified

[past history] - 2023-03-20 admission note

  • Type 2 diabetes mellitus and hypertension for 20+ years under medications treatment.
  • Mixed hyperlipidemia for 5 years with medications control and cancle medications treatment recently
  • Past operation history: VATS exciosion of mediastinal nodules on 2022/12/06

[exam findings]

  • 2023-09-13 MRI - brain
    • Without-contrast multiplanar cerebral MRI revealed (Image quality: no gross motion artifacts)
      • moderate dilated intraventricular and extraventricular CSF spaces
      • punctate white amtter gliosis in the supratentorial brain; mild bilateral periventricular leukoaraiosis; old lacunar infarction in the bilateral basal ganglia.
      • unremarkable change in the skull base
    • IMP: brain atrophy; no evidence of brain tumors.
  • 2023-09-12 PET
    • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm. In comparison with the previous study on 2022/12/16, the glucose hypermetabolism in some neck lymph nodes, some axillary lymph nodes, mediastinal and bilateral pulmonary hilar lymph nodes and some inguinal lymph nodes are a little more evident. Lymphoma in a little more progression should be considered.
    • Inhomogenously and mildly increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Mildly increased FDG uptake in some focal areas in the lower lobes of bilateral lungs. Inflammation may show this picture.
  • 2023-09-11 CT - chest
    • Comparison was made with CT on 2023/06/16
      • interval increased size and number of multiple enlarged LNs at neck, bilateral axillary regions, mediastinum, retroperitoneum, mesentery and bil. inguinal regions as compared with previous CT on 6/16.
      • Lungs:a 6mm solid nodule at medial LLL and focal nodular septla thickening at RLL-superior segment.
        • mosaic attenuation changes in both lungs on inspiratory images.
      • extensive 3-vessls coronary arterial calcification
        • small anterior pericardial effusion.
      • Pleura: no effusion
      • moderate splenomegaly.
      • no abnormal density and size of the liver, GB, both adrenal glands, pancreas, and both kidneys.
    • Impression:
      • T-cell lymphoma involving both sides of diaphgram s/p C/T, in progression as compared with previous CT on 2023/06/16.
      • LLL and RLL lesions, secondary involvvement or infection.
  • 2023-06-16 CT - abdomen
    • History: T cell lymphoma
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
    • Findings: Comparison prior CT dated 2022/12/15.
      • Prior CT identified multiple enlarged LNs at neck, bil. axillary regions, mediastinum, gastrohepatic ligament, celiac trunk, para-aortic space, para-cava space, mesentery and bil. inguinal regions are noted again, marked decreasing in size that is c/w T-cell lymphoma S/P C/T with partial response.
      • Prior CT identified splenomegaly (the largest dimension: 15.5 cm) is noted again, stationary.
      • Prior CT identified some nodules (up to 7mm) at bil. lungs are noted again, mild decreasing in size.
    • IMP:
      • T-cell lymphoma S/P C/T show partial response.
  • 2023-06-10 Nasopharyngoscopy
    • Findings:
      • lump in throat and odynophagia for one month, patient has strong gap reflex, hard to assess NP and larynx by mirror
    • Diagnosis/conclusion
      • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
  • 2023-04-13 SONO - nephrology
    • right mild hydroureter
    • left renal cyst
  • 2023-04-12 KUB
    • increased air in nondistended loops of small bowel over LUQ and RUQ, could be paralytic ileus.
    • The size & contour of the kidneys, visualized portion of spleen and liver, and psoas shadows, properitoneal & pelvis fat lines, are unremarkable.
    • Rt L5-S1 facet joint osteoarthritis.
    • s/p foley catheter insertion in the urinary bladder.
  • 2023-02-27 CXR
    • Atherosclerotic change of aortic arch
    • Linear infiltration over both lung zone are noted. please correlate with clinical symptom to rule out inflammatory process.
    • Please correlate with CT.
  • 2023-02-27 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) absence of CMAP in left peroneal nerve, (2) prolonged distal motor latency in bilateral median, bilateral ulnar, and left tibial nerves, (3) reduced CMAP amplitude in all the sampled nerves, (4) decreased motor nerve conduction velocity in all the sampled nerves, (5) absence of SAP in left sural nerve, (6) reduced SAP amplitude in left median and ulnar nerves, (7) decreased sensory nerve conduction velocity in all the sampled nerves.
      • The F-wave study showed (1) absence of F-wave in left peroneal nerve, (2) prolonge minimal F-wave latency in all the sampled nerves.
      • The H-reflex study showed (1) absence of H-wave in left tibial nerve, (2) prolonged H-wave latency in right tibial nerve.
      • The EMG showed (1) poor recruitment of MUAP in right biceps brachii and right rectus femoris muscles, (2) fasciculation, fibrillation, and poor recruitment of MUAP in right tibialis anterior muscles.
    • Conclusion
      • The above findings suggest sensorimotor polyneuropathy with demyelinating pattern. Advise clinical correlation.
  • 2023-02-15 MRI - L-spine
    • diffuse high SI change on T2WI in the bilateral L-spine posterior perivertebral muslces and bilateral gluteal muscles.
    • herniated disc in the L4/5 idsc.
    • discitis in the L4/5 disc.
  • 2023-02-14 CXR
    • Atherosclerotic change of aortic arch
    • Linear infiltration over left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Few nodular opacities projecting at left lung are suspected.
    • Please correlate with CT.
  • 2023-02-13 SONO - abdomen
    • cholecystopathy
    • renal cyst, LK
    • small amouont ascites
  • 2022-12-20 ECG
    • Sinus tachycardia
    • poor wave progression
  • 2022-12-16 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm.
    • Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marow should be considered. Please correlate with other clinical findings for further evaluation.
  • 2022-12-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 25) / 75 = 66.67%
      • M-mode (Teichholz) = 66
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
  • 2022-12-15 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Positive for malignant T-cell lymphoma
    • Microscopically, it shows bone marrow tissue with presence of aggregations of T-cell lymphomatous cells.
    • Immunohistochemical stain reveals CD5(+), CD3(+), CD20(-), CD117(-), CD34(-), CD71(focal+), MPO(+),and CD138(-).
  • 2022-12-15 CT - abdomen
    • Findings
      • Enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions.
      • Splenomegaly.
      • Some nodules (up to 7mm) at bil. lungs.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP
      • Lymphoma as described.
  • 2022-12-08, -12-06 CXR
    • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
    • minimal right pneumothorax .
    • widening of Rt paratracheal stripe
    • Platelike lung atelectasis over Lt lower lung zone
  • 2022-12-06 Patho - lymph node region resection
    • Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma
    • Specimen submitted in formalin consists of 4 pieces of tan, irregular tissue measuring up to 5.0 x 2.0 x 1.5 cm. Several enlarged lymph nodes, measuring up to 3.5 x 2.0 x 1.5 cm, are founs and all for section in 3 cassettes A1-3 (A1-2: the same level).
    • Sections show lymph nodes with diffusely infiltration of medium-sized lymphocytes. Vascular proliferation and hyperplasia of follicular dendritic cells are seen.
    • The immunohistochemical stains reveal CK(-), CD3(+), CD5(+), CD4(+), CD8(+), CD20(-), CD56(-), Granzyme B(-), TdT(-), BCL2(+), CD30(-), CD10(-), BCL6(-), PD1(-), ICOS(-), and SAP(-).
    • The results are consistent with peripheral T-cell lymphoma, NOS. Please correlate with the clinical presentation and image study.
  • 2022-11-22 CT - chest
    • Findings
      • Lungs:
        • an oval-shaped LUL-S1/2 solid nodule adjacent to the najor fissure (7.6 mm srs).
        • an oval-shaped RML solid nodule(4mm srs).
        • favor intrapulmonary lymph node
        • normal pulmonary attenuation on inspiratory images, with mild patchy areas air-trapping in both lower lobes.
        • differential diagnosis include obstructive chronic airway disease, hypersensitive pneumonitis, and bronchiolitis obliterans,
      • Mediastinum and hila: enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces
      • Vessels:
        • calcified plaques of the coronary arteries, extensive in LAD artery
        • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: multiple enlarged LNs at supraclavicular fossae and both axillary regions.
      • Visible abdominal contents: moderate splenomegaly,
    • Impression:
      • lymphoma or other hematological disease or metastatic tumors in aforementioned regions.
      • suspected obstructive small airways disease in lowef lobes of lungs.
  • 2019-10-14 Thyroid Ultrasound
    • Suspected Autoimmune thyroid disease

[MedRec]

  • 2022-12-14 ~ 2022-12-23 POMR Hemato-Oncology Wan XiangLin
    • Discharge diagnosisw
      • Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites
      • Gout, unspecified
      • Hyponatremia
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Mixed hyperlipidemia
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
      • Insomnia, unspecified
    • CC
      • for lymphoma staging work-up
    • Present illness
      • This 59 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
      • According patient’s statement, he suffered from dry cough persist for 3 months. He denied has fever, chilliness, chest pain, chest tightness or hemoptysis noted occured. Chest CT revealed mediastinum and hila has enlarged LNs in the visceral space and small LNs in visceral and left anterior prevascular spaces; impression of lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs. The patient also told of appetite decrease and body weight loss about 10 kg in recent 6 months (abdout 70 kg decrease to 57 kg). Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly on 2022/12/06. Pathology oral presentation T cell lymphoma, waiting for formal report.
      • This time, he was admitted for staging work-up with whole body CT, bone marrow, PET-CT, Port-A insetion.
    • Course of inpatient treatment
      • After admission, bone marrow was done on 2022/12/15 and the report showed positive for malignant T-cell lymphoma.
      • Pathology showed Lymph node, right, paratracheal, excision — Malignant T-cell lymphoma, peripheral T-cell lymphoma, NOS on 2022/12/15.
      • ROMICON-A  20,20,90mg/cap 1# PO TID、Actein 66.7 mg/gm 1pk PO TID for cough.
      • Abdominal CT (from ABD to Chest) on 2022/12/15 showed enlarged LNs at neck, bil. axillary regions, mediastinum, retroperitoneum, peritoneal cavity and bil. inguinal regions; splenomegaly; some nodules (up to 7mm) at bil. lungs => IMP: Lymphoma as described, atherosclerosis of aorta, iliac arteries.
      • PET scan on 2022/12/16 showed 1. The FDG PET findings are compatible with lymphoma involving the nasopharynx, bilateral tonsils and multiple lymph nodes on both sides of the diaphragm; 2. Inhomogenously increased FDG uptake in the spleen and in the bone marow of the skeleton.
      • 2D echo on 2022/12/16 showed LVEF 66%, preserved LV and RV systolic function with normal wall motion, grade 1 LV diastolic dysfunction.
      • Port-A implantation on 2022/12/19, given Acetal 500 mg/tab 1# PO PRNQ6H if VAS>3.
      • Hyponatremia (Na 129 mmol/L) with N/S 1500ml hydration from 2022/12/14.
      • Type 2 diabetes mellitus with Glimet F.C 2mg & 500mg/tab 1# PO BIDCC, Dibose F.C. 100mg/tab 1# PO BIDCC and Soliqua 3mL/pre-filled pen 16 Unit SC QN, monitor blood sugar by one touch, due to Hypoglycemia was noted, adjust to 12 unit SC QN.
      • Hypertension with Aprovel 300mg/tab (Irbesartan) 1# PO QD and Aspirin 100 mg/cap 1# PO QD.
      • Mixed hyperlipidemia with Tulip F.C. 20mg/tab 1# PO QD.
      • Constipation with Through 12mg/tab 1# PO HS.
      • Chronic viral hepatitis B (Anti-HBc : reactive) with Vemlidy 25 mg/tab 1# PO QDCC.
      • Insomnia with Anxiedin 0.5mg/tab # PO PRNHS if insomnia.
      • Discussion with patient and family about disease condition and future treatment on 2022/12/19 and transfer service to Dr. Wan on 2022/12/20.
      • After transferring to Dr. Wan’s service, we checked HTLV-1,2 which showed nonreactive. After discussion with the patient and his family, they decided to undergo chemotherapy.
      • Chemotherapy (CHOP) prepare including blood test, normal saline 500ml + rolikan 40ml BID, Feburic 1# QD were arranged. We then arranged chemotherapy with CHOP on 2022/12/22.
      • Also, we checked finger sugar QIDAC, and adjusted insulin dosage to Tresiba 8 Unit HS + NovoRapid 4 Unit TIDAC with scale by meta doctor’s suggestion.
      • He had no significant discomfort after chemotherapy. Under stable condition, he discharged on 2022/12/23 and OPD follow up was arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Actein (acetylcysteine 200mg) 1# TID
      • Feburic (febuxostat 80mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Through (sennoside 12mg) 1# HS
      • Ulstop (famotidine 20mg) 1# QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
      • Compesolon (prednisolone 5mg) 9# QD
      • Compesolon (prednisolone 5mg) 9# QN
      • Alpraline (alprazolam 0.5mg) 1# PRNHS
  • 2022-12-05 ~ 2022-12-09 POMR Chest Surgery Xie MinXiao
    • Discharge diagnosis
      • Malignant T-cell lymphoma status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
      • Mediastinal lymphadenopathy status post video-assisted thoracoscopic surgery exciosion of mediastinal nodules on 2022-12-06
      • Type 2 diabetes mellitus without complications
      • Essential hypertension
      • Mixed hyperlipidemia
    • Course of Inpatient Treatment
      • After admission, pre-op assessment was done.
      • Operation of video-assisted thoracoscopic surgery exciosion of mediastinal nodules was performed smoothly at 2nd admission day. No complication was noted. Prophylactic antibiotics was prescribed for 1 day.
      • Dysuria was noted after removal foley and ICP U/O 350 ml ST at post op day 1, Bethanechol were prescribed and voiding smoothly by patient himself.
      • Right chest tube with LPS -18 cmH2O was done. Chest tube was removed at post-op 2nd day. He was discharged under stable hemodynamics at post-op 3rd day.
    • Prescription
      • Actein (acetylcysteine 66.7mg) 1# TID
      • MgO 250mg 1# TID
      • Wecoli (bethanechol 25mg) 1# TIDAC
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine (povidone iodine) QD EXT (for wound dressing change)
  • 2022-11-29 SOAP Chest Surgery
    • P
      • arrange admission on 12/5
      • VATS mediastinal nodule excision on 12/6.
  • 2022-11-28 SOAP Chest Medicine
    • S: dry cough persist for 3 months, no short of breath
    • O: 2022/11/22 CT: lymphoma or other hematological disease or metastatic tumors in aforementioned regions; r/o obstructive small airways disease in lowef lobes of lungs; calcified plaques of the coronary arteries, extensive in LAD artery
    • P
      • refer to chest surgeon for mediastinal lymphadenopathy suspected lymphoma
      • refer to oncologist for mediastinal lymphadenopathy suspected lymphoma
  • 2017-10-30 SOAP Metabolism
    • S: Drugs will be collected at our hospital in the future. referred to the PharmaCloud.
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Aprovel (irbesartan 300mg) 1# QD
      • Tulip (atorvastatin 20mg) 1# QOD
      • Bokey (aspirin 100mg) 1# QD
      • Forxiga (dapagliflozin 10mg) 1# QDCC
      • Glimet (glimepiride 2mg, metformin 500mg) 1# QDCC
  • 2017-10-23 SOAP Ophthalmology
    • Diagnosis
      • Vitreous hemorrhage, right eye [H43.11]
      • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema [E11.351]
  • 2017-10-18 SOAP Metabolism
    • S: type 2 DM since 2012 , hypertension , irregular Tx before , hyperlipidemia , hyperuricemia, poor control, family Hx of DM: (+)
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
  • 2017-10-17 SOAP Ophthalmology
    • S
      • refer from LMD vitrous hemorrha OD
      • Blurred visionBlurred vision
      • DM for fundus exam
      • DM+, HTN-, NKA
    • Diagnosis
      • Vitreous hemorrhage, right eye [H43.11]
    • Prescription
      • Trand (tranexamic acid 250mg) 1# BID

[consultation]

  • 2023-05-12 Ear Nose Throat
    • Q
      • for right ear pain & sorethroat R/O otitis media
      • He complained of right ear pain & sorethroat for days. We need expertise to evaluate his condition thanks!
    • A
      • Ear: bilateral cerumen impaction, after removal, bilateral ear drum intact without middle ear effusion.
      • Oral cavity and oropharynx: injected posterior pharyngeal wall.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx and hypopharynx. Patent airway.
      • Impression: Impending acute tonsillitis, bilateral cerumen impaction
      • Plan: Please give sulconazole solution Exelderm for bilateral ear, and please provide Curam for 5 days and analgesic agent if not contraindicated.
  • 2023-02-09 Dermatology
    • Q
      • This 60 year-old patient has past history of type II diabetes mellitus and hypertension for 20+ years under medications treatment; mixed hyperlipidemia for 5 years and cancle medications treatment recently; new diagnosis lymphoma in 2022/12.
      • He was under CHOP (cyclophosphenide + doxorubicin + vincrinstine + compesolon) chemotherpay with C1 on 2022/12/22 and C2 on 2023/01/13. This time, he was admitted for C3 CHOP chemotherapy.
      • We strongly need your expertise for lips rash and ulcer, suspected Herpes skin rash. Mucosa inside the mouth showed no ulcer, but there were ulcer noted at his lips. Due to immunosuppression state under chemotherapy, we strongly need your expertise for evaluation and management. Thank you very much.
    • A
      • The patient had sufferred from perioral scaling crust with erythematous macules (upper and lower lips and corners of the mouth) with mild stinging and itchy sensation.
      • Under the impression of exfoliative chelitis with secondary candidasis.
      • The following sugeetion:
        • Tetracycline onit 2 tube topical bid use first (First, apply it broadly, which can be used as a base for lip balm).
        • Mycomb cream 1 tube topical bid use over regional erythematous scaling lesions (use it locally on areas with surrounding redness and flaking skin).

[surgical operation]

  • 2022-12-06 - Op Method: VATS exciosion of mediastinal nodules
    • Finding: Multiple enlarged mediastinal LNs.

[chemoimmunotherapy]

  • 2023-06-16 - cyclophosphamide 750mg/m2 800mg NS 250mL 30min + doxorubicin 50mg/m2 40mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, 75% Endoxan for poor renal function, 60% Adriamycin for GPT 88)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug                       + NS 250mL
  • 2023-05-15 - cyclophosphamide 750mg/m2 790mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-03-24 - cyclophosphamide 750mg/m2 780mg NS 250mL 30min + doxorubicin 50mg/m2 70mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP, reduced Endoxan for poor renal function)
    •                 dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-02-14 - cyclophosphamide 750mg/m2 1000mg NS 250mL 30min + doxorubicin 50mg/m2 60mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2023-01-13 - cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 74mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL
  • 2022-12-22 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 80mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID D1-5 (CHOP)
    • betamethasone 4mg + dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL

==========

2023-07-17

It appears that there is a suspicion of AKI in this patient due to the decline in renal function.

  • 2023-07-16 Creatinine 4.13 mg/dL

  • 2023-07-03 Creatinine 1.68 mg/dL

  • 2023-07-16 eGFR 15.77

  • 2023-07-03 eGFR 44.52

  • 2023-07-16 BUN 71 mg/dL

  • 2023-07-03 BUN 29 mg/dL

Based on the patient’s current renal status, the dosage of drugs in the active formulary has been reviewed and no adjustment is required.

2023-06-26

  • According to the PharmaCloud database, our hospital has been the sole provider of all required medical services and medications for this patient for the past 3 months.

  • Our endocrinologist recently prescribed a refillable regimen of Tresiba Flex Touch (insulin degludec), Relinide (repaglinide), Trajenta (linagliptin), Aprovel (irbesartan), Tulip (atorvastatin), and Bokey (aspirin) on 2023-06-20. These drugs were added to the patient’s active medication list. As a result, no medication reconciliation issues were identified.

  • The most recent administration of CHOP was on 2023-06-16, and subsequent lab results indicate that leukopenia is still progressing. The use of G-CSF is covered by NHI when WBC < 1000/uL or ANC < 500/uL. Therefore, if the patient’s lab results meet these criteria, the use of G-CSF could be an appropriate management strategy. Please continue monitoring the patient’s WBC and ANC levels to make informed decisions about future treatment strategies.

    • 2023-06-26 WBC 1.24 x10^3/uL
    • 2023-06-25 WBC 1.43 x10^3/uL
    • 2023-06-14 WBC 4.84 x10^3/uL

2023-06-15

  • Upon review of the PharmaCloud database, it is observed that the patient has exclusively sought medical care at our hospital for the past three months. No issues related to medication reconciliation have been identified.

  • The patient’s renal function has remained insufficient over the past month, with an eGFR of 26 on 2023-06-15. The dose of cyclophosphamide in the CHOP regimen has been adjusted in response to this renal insufficiency. Please continue to monitor the patient’s renal function and consider whether further dose adjustments are necessary.

    • 2023-06-15 Creatinine 2.64 mg/dL
    • 2023-06-14 Creatinine 2.92 mg/dL
    • 2023-05-26 Creatinine 2.41 mg/dL
    • 2023-05-15 Creatinine 2.11 mg/dL
    • 2023-06-15 BUN 54 mg/dL
    • 2023-06-14 BUN 56 mg/dL
    • 2023-05-26 BUN 64 mg/dL
    • 2023-05-15 BUN 44 mg/dL
  • In addition, the LFT also demonstrated an increase in ALT. According to Folyd’s 2006 recommendations, when a patient’s transaminases are 2 to 3 times the ULN, the dose of doxorubicin should be reduced to 75% of the standard dose. (The manufacturers’ guidelines suggest adjusting doses based on serum bilirubin levels. However, the most recent test results show that this patient’s bilirubin level is within the normal range.)

    • 2023-06-14 S-GPT/ALT 88 U/L
    • 2023-05-26 S-GPT/ALT 27 U/L

2023-05-12

  • Based on the PharmaCloud database, the patient has only visited our hospital for medical needs in the past three months. After reviewing the database, no medication reconciliation issues were identified.

  • Lab results on 2023-05-11 indicate creatinine 3.26 mg/dL, eGFR 20.72, BUN 83 mg/dL, demonstrating the patient’s renal insufficiency. The rationale for dose adjustment in the CHOP regimen for patients with renal impairment is as follows:

    • cyclophosphamide
      • There are no dosage adjustments provided in the manufacturer’s labeling
      • Aronoff 2007
        • CrCl >=10 mL/minute: No dosage adjustment required.
        • CrCl <10 mL/minute: Administer 75% of normal dose.
      • KDIGO 2012: Lupus nephritis
        • CrCl 25 to 50 mL/minute: Administer 80% of normal dose.
        • CrCl 10 to <25 mL/minute: Administer 70% of normal dose.
    • doxorubicin
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, adjustments are likely not necessary given limited renal excretion.
    • vincristine
      • No dosage adjustment necessary
    • prednisolone
      • No dosage adjustment necessary
  • The cyclophosphamide dose has been reduced to 75% since the last administration on 2023-03-24 as indicated without an issue.

  • The other medications listed in the active prescription should be used with caution, considering the patient’s renal insufficiency (ref: UpToDate):

    • cimetidine
      • There are no dosage adjustments provided in the manufacturer’s labeling; use with caution. Severe kidney impairment: 300 mg every 12 hours; may increase frequency with caution. When hepatic impairment is also present, further reductions in dosage may be necessary.
      • Alternate recommendations (Aronoff 2007):
        • GFR >50 mL/minute: No dosage adjustment necessary.
        • GFR 10 to 50 mL/minute: Administer 50% of normal dose.
        • GFR <10 mL/minute: 300 mg every 8 to 12 hours.
    • silodosin
      • CrCl >50 mL/minute: No dosage adjustment necessary.
      • CrCl 30-50 mL/minute: 4 mg once daily.
      • CrCl <30 mL/minute: Use is contraindicated.
    • tenofovir alafenamide
      • Tenofovir is renally cleared, and exposures are increased in patients with CrCl <30 mL/minute and those receiving hemodialysis. Close monitoring for adverse effects in the advanced stages of kidney dysfunction is recommended.
      • Kidney impairment prior to treatment initiation:
        • CrCl >=15 mL/minute: No dosage adjustment necessary.
        • CrCl <15 mL/minute: Use is not recommended.
  • Please continue to monitor regularly and consider dose adjustments as needed based on patient renal function.

2023-03-21

  • The acute kidney injury (AKI) episode that occurred in late Feb 2023 appears to have subsided.
    • 2023-03-21 Creatinine 2.78 mg/dL
    • 2023-03-20 Creatinine 3.24 mg/dL
    • 2023-03-02 Creatinine 2.60 mg/dL
    • 2023-02-27 Creatinine 3.43 mg/dL
    • 2023-02-25 Creatinine 3.80 mg/dL
    • 2023-02-23 Creatinine 4.66 mg/dL
    • 2023-02-22 Creatinine 5.21 mg/dL
    • 2023-02-21 Creatinine 5.15 mg/dL
    • 2023-02-14 Creatinine 1.50 mg/dL
    • 2023-02-10 Creatinine 1.13 mg/dL
    • 2023-02-09 Creatinine 1.22 mg/dL
    • 2023-02-08 Creatinine 1.84 mg/dL
    • 2023-01-20 Creatinine 0.95 mg/dL
    • 2023-01-12 Creatinine 1.00 mg/dL
    • 2023-01-06 Creatinine 1.41 mg/dL
    • 2023-01-03 Creatinine 1.16 mg/dL
    • 2023-01-01 Creatinine 1.15 mg/dL
  • 2023-03-21 CrCl 19mL/min, eGFR 24.98.
    • Silodosin use is not recommended for patients with a CrCl below 30 mL/minute.
    • Metformin use is contraindicated for patients with an eGFR below 30 mL/minute/1.73m2.
    • For patients with an eGFR between 15 and 60 mL/min/1.73m2, glimepiride use may result in reduced renal clearance of active metabolites, increasing the risk of hypoglycemia.
    • Acarbose use is generally not advised for patients with a serum creatinine level above 2 mg/dL or a CrCl below 25 ml/minute/1.73m2, as the systemic area under the curve (AUC) may increase six-fold.

2023-01-13

  • Since around 2022/2023 new year’s eve, there has been no sign of neutropenia in the lab data.
    • 2023-01-12 WBC 9.41 x10^3/uL
    • 2023-01-06 WBC 51.96 x10^3/uL
    • 2023-01-03 WBC 1.66 x10^3/uL
    • 2023-01-01 WBC 0.16 x10^3/uL
    • 2022-12-30 WBC 0.30 x10^3/uL
    • 2022-12-22 WBC 6.75 x10^3/uL
    • 2022-12-14 WBC 9.13 x10^3/uL
    • 2022-12-05 WBC 7.96 x10^3/uL
    • 2022-11-29 WBC 10.69 x10^3/uL
  • A grade 4 neutropenia developed around new year’s eve, just about 10 days after the patient had received last chemotherapy on 2022-12-22. The date of this chemotherapy was 2023-01-12, approximately one to two weeks after that date, when the Chinese New Year holiday is approaching. In order to prevent potential neutropenia during the long holidays, it is recommended to take steps in advance.

701506934

231201

[lab data]

2023-11-30 HBsAg Nonreactive
2023-11-30 HBsAg (Value) 0.35 S/CO
2023-11-30 Anti-HBc Reactive
2023-11-30 Anti-HBc-Value 6.35 S/CO
2023-11-30 Anti-HCV Nonreactive
2023-11-30 Anti-HCV Value 0.12 S/CO

[exam findings]

  • 2023-11-29 CT - abdomen
    • Without and with contrast Abdomen CT showed
      • A fat containing tumor, about 82mm x 83mm x 79mm, in the right kidney was noted.
      • Partial calcified rim was noted in the lower pole of the right kidney.
      • High density fat stranding in the right perirenal space was noted.
      • Some air within the lesion was noted.
    • IMP:
      • r/o Angiomyolipoma in the right kidney with rupture and superimposed infectious process. Please correlate with U/A.

[consultation]

  • 2023-11-29 Urology
    • Q
      • CC: cough and fever (up to 39’C) on and off for a month
      • Phx: renal tumor s/p
      • 2023-11-10 CT: A 8.4-cm right renal angiomyolipoma with hydronephrosis, rupture, and presence of adjacent hematoma.
    • A
      • This 42 y/o female has intermittent for about 1 month.
        • According to her statement, low grade fever happened weeks ago.
        • In mid November, she suffered from sudden weakness and was sent to ER at Chang-hua where abdominal echo showed right renal mass.
        • She was then transferred to Chang-hua Christian Hospital for further evaluation.
        • Abdominal CT on 11/23 revealed a 8cm right renal tumor with hematoma formation.
        • TAE was done but fever persisted in the following days.
        • She received antibiotic treatment but the condition was not improved.
        • Therefore, the patient decided to came to our ER for personal reason.
        • At our ER, lab data showed abnormal differential count.
        • Mild leukocytosis with elevated CRP level were also noted.
        • Furthermore, thrombocytosis to 1055k/ul was revealed in hemogram.
        • Follow-up abdominal CT showed stable size of right renal tumor and hematoma.
      • Imp:
        • Right renal tumor rupture, status post TAE on 2023/11/23
        • Thrombocytosis and abnormal differential count, cause to be determined
      • Plan:
        • Pain control
        • Please do further survey for hematology problem that could cause thrombocytosis and abnormal differential count.
        • Since the patient just received TAE about 1 week ago, there might be inflammation or tissue reaction. Emergent surgery was not indicated if her vital sign is stable.
        • Follow-up abdominal image would be needed if there is possibility of renal abscess formation
        • Please contact us if there is any related problem

==========

2023-12-01

[thrombocytosis]

Thrombocytosis improves, cause remains unclear.

  • 2023-12-01 PLT 686 *10^3/uL
  • 2023-11-30 PLT 863 *10^3/uL
  • 2023-11-29 PLT 1055 *10^3/uL

Elevated D-dimer levels, in conjunction with elevated fibrinogen, can further indicate the increasing risk of thrombosis and cardiovascular complications. The combination of elevated fibrinogen and D-dimer levels is considered a stronger risk factor for thrombosis than either one alone. Close monitoring is essential.

  • 2023-11-30 Fibrinogen (quant) 581.5 mg/dL
  • 2023-11-30 D-dimer 5399.00 ng/mL(FEU)

701373652

231130

[diagnosis] - 2023-03-23 admission note

  • Adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 ~ 2023/02/21, plus Panitumumab from 2023/02/21, progression of LNs, bones and liver metastases s/p FOLFOX from 2023/03/09
  • Localized skin eruption due to drugs and medicaments taken internally
  • Chronic viral hepatitis B without delta-agent
  • Iron deficiency anemia, unspecified
  • Hypertension
  • Constipation, unspecified
  • Encounter for antineoplastic chemotherapy

[past history]

  • Hypertension for many years, regular medication with Norvasc                   

[allergy]

  • NKDA

[family history]

  • No known congenital disease was noted  
  • No cancer in his family  

[lab data]

  • 2022-11-18 Anti-HCV Nonreactive
  • 2022-11-18 Anti-HCV Value 0.07 S/CO
  • 2022-11-18 Anti-HBc Reactive
  • 2022-11-18 Anti-HBc-Value 6.67 S/CO
  • 2022-11-18 Anti-HBs 74.91 mIU/mL
  • 2022-11-02 HBsAg(nuclear medicine) Negative
  • 2022-11-02 HBsAg Value(nuclear medicine) 0.446

[exam findings]

  • 2023-09-07, -06-08 CT - abdomen
    • S/P colon operation. Mild regression of LNs and liver metastases. Stable condition of bony metastases.
  • 2023-03-09 CT - abdomen
    • History and indication: Adenocarcinoma of sigmoid colon with liver metastasis
    • IMP: S/P colon operation. Progression of LNs, bones and liver metastases.
  • 2023-02-03 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spot in the right rib cage and increased activity in the maxilla, mandible, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the L4-5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Some faint hot spot in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-12-15 All-RAS + BRAF mutation
    • Tissue block No. S2022-19716 A3
    • RESULTS
      • All-RAS:
        • There was no variant detect in the KRAS/NRAS gene.
      • BRAF
        • There was no variant detect in the BRAF gene.
  • 2022-12-15 KUB
    • There are Eqivocal osteoblastic change at L-spine and bilateral ilium that may be bony metastases? Please correlate with bone scan.
  • 2022-12-08 ECG
    • Left anterior fascicular block
    • Minimal voltage criteria for LVH, may be normal variant
    • Septal infarct, age undetermined
  • 2022-11-30 Patho - liver bipsy needle/wedge
    • Liver, CT guide biopsy — Metastatic adenocarcinoma, consistent with colorectal primary
    • The sections show moderately differentiated adenocarcinoma, composed of nests columnar neoplastic cells, arragned in glandular and cribrifrom patterns, in fibrous stroma. Dirty tumor necrosis is present.
    • IHC shows: CK7(-), CK20(focal +) and CDX2(+). The finding is consistent with metastatic colorectal adenocarcinoma.
  • 2022-11-29 Patho - peritoneum biopsy
    • Labeled as “LN at retroperitoneum”, CT guided biopsy — poorly differentiated carcinoma.
    • IHC stains: CK (+), Ki-67 (15%), trypsin (-), CK20 (-), S-100 (-), CD56 (-), LCA (-), CD3 (-), CD20 (-), chromogranin A(-), synaptophysin (-).
    • Section shows round blue cell tumor with pseudo-lumina or pseudo-rossette-like pattern.
  • 2022-11-10 - Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, laparoscopic sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection -
        • Negative for malignancy (0/24)
        • Four tumor deposits are seen
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1c(if cM0) or pStage IVB, pT3N1c(if cM1b(by CT finding)); please correlate with the clinical presentation.
    • Gross Description:
      • Operation procedure: laparoscopic sigmoid colectomy
      • Specimen site: sigmoid colon
      • Specimen size: 10.5 cm in length
      • Tumor size: 6.5 x 5.0 x 1.5 cm; annularly ulcerated
      • Tumor location: 2.6 cm and 1.5 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: a polyp measuring 0.7 x 0.5 x 0.4 cm is seen
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: colon, non-tumor; A2: polyp; A3-6: tumor; A7-10: lymph node, mesocolic; B: proximal cut end; C: distal cut end.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: very close, Distance of tumor from margin: < 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not available
      • Tumor Deposits: Present, Specify number of deposits: 4
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 0/24
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
        • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        • Distant Metastasis (pM): CT finding: if cM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
      • Additional Pathologic Findings
        • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
        • A tubulovillous adenoma is seen.
  • 2022-10-31 CT - abdomen
    • History and indication: Advanced sigmoid cancer (15-20AAV), s/p tattooed
    • Findings
      • Wall thickening of S-colon with adjacent fat stranding and regional LAP. Enlarged LNs at retroperitoneum.
      • Poor enhancing tumors in liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Collapse of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)

[MedRec]

  • 2022-11-17 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Arrange Port-A on 2022-11-22
      • After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
  • 2022-11-17 SOAP Colorectal Surgery Xiao GuangHong
    • A: Sigmoid cancer with obstruction, liver metastasis, Stage IV
    • P: Suggest colectomy first then target + chemotherapy due to partial obstruction then re-evaluation of liver resection
  • 2022-11-08 ~ 2022-11-22 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Advanced sigmoid cancer with nearly total obstruction with retroperitoneal lymph nodes and liver metastasis, cT4aN2bM1b, stage: IVB status post 3 dimensions Laparoscopic sigmoid colectomy on 2022/11/09
      • Malignant neoplasm of sigmoid colon
      • Hypertension
    • CC
      • Abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years
    • Present illness
      • This is a 74-year-old male with underlying disease of hypertension. This time, he suffered from abdominal fullness, frequent defecation, tarry stool and body weigh loss 2kg within 1 years. Tracing back to his history, he had been to LMD (Dr Chen ZiLiang) for medical help and advanced sigmoid cancer (15-20AAV), s/p tattooed was told. Thus, he came to our CRS Dr. Xiao’s OPD for second opinion and Abdominal CT survey. Blood test done on 10/31 revealed HB 7.2 g/dL and no other special finding. Abdominal CT done on 10/31 showed colonrectal cancer T4aN2bM1b, STAGE:IVB. Due to above finding he was admitted to our ward for further pre-operation survey.
    • Course of inpatient treatment
      • This 74-year-old male patient was a case of sigmoid colon cancer, T4aN2bM1b, STAGE:IVB. He admitted on 2022-11-08 and 3D Laparoscopic sigmoid colectomy was performed on the days of admission. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2022-11-12 and will follow up in our out-patient department next 2 week
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2022-11-03 SOAP Colorectal Surgery Xiao GuangHong
    • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[consultation]

  • 2023-03-23 Dermatology
    • Q
      • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab.
      • For paronychia and keloid with pus on the chest, sent culture on 2023/03/22, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • The patient had sufferred from paronychia with granulation formation over toenail and keloid with seocndary wound formation over chest.
      • Under the impression of paronychia with granulation, keloid with seocndary wound & bacterial infection.
      • The following sugeetion:
        • paronychia over fingernail, Tetracycline onit 1 tube topical bid use.
        • for limbs and hand xerosis, sinphraderm cream 1 tube topical QN use.(enahcne mositurization)
        • for keloid wound, keep wound CD and might consider Siliverzine cream 1 tube antibiotic use for wound occlusion effect.
  • 2023-03-09 Dermatology
    • Q
      • The 74 y/o man has adenocarcinoma of sigmoid colon with liver metastasis, pT3N1cM1b, Stage IVB, with nearly total obstruction s/p sigmoid colectomy on 2022/11/09, with EGFR RAS gene wildtype, s/p chemotherapy with FOLFIRI from 2022/12/12 plus Panitumumab from 2023/02/21. Red hot swelling sensation over face s/p target therapy with Panitumumab. follow up in your OPD on 2023/03/02.
      • For red hot swelling sensation over face, We need your consultation for evaluation. Thanks a lot!!!
    • A
      • The patient had sufferred from facial flush with scales and pruritus. Besides, dry xerosis was noted over lower legs.
      • Under the impression of seborrheic dermatitis and xerotic dermatitis
      • The following sugeetion:
        • for fisuriform wound protection, Tetracycline onit 1 tube topical bid use first.
        • for facial erythema, Free gel 1 tube topical bid use over erythematous rash over face (Can be used extensively on the face).
        • for itchy papules and sclaes, Mycomb cream 1 tube topical PRN bid use.

[MedRec]

  • 2023-03-30 SOAP Dermatology
    • S: refill medication use
    • Prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • Free Gel (metronidazole) BID TOPI
      • tetracycline BID EXT
  • 2023-03-22 SOAP Hemato-Oncology
    • O: Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (2023-03-22)
      • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
  • 2023-03-02 SOAP Dermatology
    • S: red hot swelling sensation over face, cancer target therapy.
    • O: Bilateral facial flush with tightness and burning sensation for weeks.
      • Impression: rosacea
    • P:
      • Education about drug side effec and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Allegra (fexofenadine 60mg) 1# BID
      • doxycycline 100mg 1# BID
      • Free Gel (metronidazole) BID TOPI
  • 2023-01-05 SOAP Hemato-Oncology
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-11-22
      • target + chemotherapy due to partial obstruction then re-evaluation of liver resection
  • 2022-11-17 SOAP Hemato-Oncology
    • O: Now on FOLFIRI +/- anti-EGFR
    • P: After SDM with patient for the selection of bevacizumab or cetuximab/panitumumab, patient choice cetuximab/panitumumab
  • 2022-11-03 SOAP Colorectal Surgery
    • A: Suggest colectomy first then target + chemotherapy due to partial obstruction

[surgical operation]

  • 2022-11-09
    • Surgery: 3D Laparoscopic sigmoid colectomy    
    • Finding: Sigmoid cancerwith nearly total obstruction, much stool in proximal colon and D-colon dilatation

[immunochemotherapy]

  • 2023-11-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-30 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2h4 + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-02 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-22 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-18 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-16 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-31 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 75)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 65mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX, Oxa 65)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-11 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-23 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - panitumumab 6mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - panitumumab 6mg/kg 500mg NS 250mL 1hr + irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-03 - irinotecan 150mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-16 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-26 - irinotecan 150mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[note]

Acneiform eruption secondary to epidermal growth factor receptor (EGFR) and MEK inhibitors 2023-04-12 https://www.uptodate.com/contents/acneiform-eruption-secondary-to-epidermal-growth-factor-receptor-egfr-and-mek-inhibitors

  • Acneiform eruption is the prototypical cutaneous adverse reaction associated with all epidermal growth factor receptor (EGFR) inhibitors, which include monoclonal antibodies and oral small molecules used for the treatment of certain advanced or metastatic cancers, such as non-small cell lung cancer (afatinib, erlotinib, gefitinib, osimertinib, mobocertinib, necitumumab, amivantamab), pancreatic cancer (erlotinib), breast cancer (lapatinib, neratinib), colon cancer (cetuximab, panitumumab), and head and neck cancer (cetuximab). Acneiform eruption is also one of the most frequent adverse effects of inhibitors of the EGFR downstream mitogen-activated protein kinase kinase (MEK) signaling pathways MEK1 and MEK2 (eg, trametinib, cobimetinib, binimetinib, selumetinib), especially when used as monotherapy.
  • Several studies have noted an association between acneiform eruption and increased overall response rate or survival.
  • Preemptive therapy
    • We suggest prophylactic oral antibiotics in conjunction with topical corticosteroids for patients initiating treatment with EGFR inhibitors. Treatment is started on the same day as EGFR inhibitor therapy and continued for six weeks. We typically use doxycycline 100 mg twice a day, minocycline 100 mg daily, or oxytetracycline 500 mg twice daily for six weeks. Alternative antibiotics include cephalosporins (eg, cefadroxil 500 mg twice daily) or trimethoprim-sulfamethoxazole (160 mg/800 mg twice daily).
    • A low-potency topical corticosteroid (eg, hydrocortisone 2.5%, alclometasone 0.05% cream) is applied twice daily to the face and chest.

==========

2023-10-31

CT scans from 2023-09-07 and 2023-06-08 both indicate mild regression of lymph nodes (LNs) and liver metastases, with a stable condition of bony metastases. This suggests that the Vectibix + FOLFOX regimen, initiated in Mar 2023, continues to be effective against the disease.

[potential folate-dependent anemia]

The patient has been on long-term iron supplementation, yet the MCV value is at the upper limit of the normal range (97.3 fL on 2023-10-30). While iron deficiency anemia typically presents with a low MCV, the observed decrease in HGB might be attributed to potential Vitamin B12 deficiency, folate deficiency, liver disease, or bone marrow dysfunction.

5-FU, a component of the FOLFOX regimen, disrupts DNA synthesis in cells. It acts by inhibiting the enzyme thymidylate synthase, which relies on folate for its activity. By inhibiting this enzyme, 5-FU can decrease the availability of active folate forms within cells. It’s plausible that the patient’s reduced HGB is related to folate deficiency.

2023-08-23

After reviewing HIS5 records, there are no medication reconciliation issues. PharmaCloud is not accessible currently.

2023-08-01

There are no medication reconciliation issues after review of PharmaCloud and HIS5 records.

2023-06-30

According to the PharmaCloud database, our hospital has been the only medical institution providing care and prescriptions for this patient over the past three months. The Hemato-Oncology department is solely responsible for the patient’s recent medications. Hence, no medication reconciliation issues were detected.

2023-05-04

  • An episode of leukopenia with a WBC count of less than 3K/uL (2.92K/uL on 2023-05-03) was observed for the first time since the patient started chemotherapy in mid-December 2022. It is important to closely monitor the patient’s WBC and check whether the leukopenia persists.
  • Over the past 7 months, the patient’s anemia has improved with the administration of Foliromin (ferrous sodium citrate). Given the expected decrease in marginal benefit of iron supplementation as the mean corpuscular volume (MCV) approaches 100 fL, it is recommended to either discontinue the medication or decrease the frequency from twice daily (BID) to once daily (QD) and/or assess body iron stores such as ferritin, transferrin to ensure that iron levels are adequate.
  • The patient’s rash, which is a side effect of the EGFR inhibitor panitumumab, is currently being managed with self-provided topical ointments without complications.

2023-04-12

  • Lab data on 2023-04-06 showed normal readings.

  • The patient’s anemia has improved with the use of Foliromin (ferrous sodium citrate) for the past 6 months. It is recommended to either discontinue or reduce the frequency of the medication from twice daily (BID) to once daily (QD) due to an expected decline in the marginal effect of iron supplementation, as the mean corpuscular volume (MCV) is approaches 100 fL.

    • 2023-04-06 HGB 12.0 g/dL
    • 2023-03-22 HGB 11.7 g/dL
    • 2023-03-07 HGB 11.8 g/dL
    • 2023-02-21 HGB 11.5 g/dL
    • 2023-02-02 HGB 11.3 g/dL
    • 2023-01-05 HGB 10.1 g/dL
    • 2022-12-22 HGB 9.9 g/dL
    • 2022-11-28 HGB 8.5 g/dL
    • 2022-10-31 HGB 7.2 g/dL
    • 2023-04-06 MCV 96.6 fL
    • 2023-03-22 MCV 94.2 fL
    • 2023-03-07 MCV 92.3 fL
    • 2023-02-21 MCV 93.8 fL
    • 2023-02-02 MCV 88.2 fL
    • 2023-01-05 MCV 82.4 fL
    • 2022-12-22 MCV 79.4 fL
    • 2022-11-30 MCV 76.7 fL
    • 2022-11-28 MCV 77.9 fL
    • 2022-10-31 MCV 71.7 fL
  • In late Feb/early Mar 2023, the patient developed a localized skin eruption secondary to the epidermal growth factor receptor (EGFR) inhibitor panitumumab. He is currently adequately being treated with a topical regimen of tetracycline, metronidazole, silver sulfadiazine, and urea.

2023-03-24

  • Although the CT scan on 2023-03-09 showed progression of lymph nodes, bone, and liver metastases, the CEA readings have been trending down towards normal. The two trends are not consistent with each other.
    • 2023-03-22 CEA 2.67 ng/mL
    • 2023-03-08 CEA 6.12 ng/mL
    • 2023-01-06 CEA 7.53 ng/mL
  • The chemotherapy regimen was changed from FOLFIRI to FOLFOX on 2023-03-09. The FOLFIRI regimen was used a total of five times prior to the change.
  • The patient has been experiencing continued dermatologic adverse reactions, and a dermatologist has been consulted on 2023-03-23. To alleviate these symptoms, the dermatologist has prescribed topical medication for the patient.
  • Other FOLFOX-related adverse events, in addition to the dermatologic adverse events caused by panitumumab, are not significant. Mild anemia, loss of appetite and constipation all have corresponding medications.

2023-03-08

  • 2022-11-10 a segment of colon was surgically removed due to a tumor that tested positive for EGFR.
  • 2022-12-15 no variants were detected in the KRAS/NRAS genes.
  • The patient is eligible for reimbursement for panitumumab and combination therapy with FOLFIRI or FOLFOX as a first-line treatment for metastatic colorectal cancer with EGFR RAS gene wildtype. The patient received his first dose of panitumumab during his previous hospitalization during 2023-02-21 ~ 23.
  • Panitumumab can cause various dermatologic adverse reactions. Skin or ocular toxicity from panitumumab typically develops after 12 days and resolves in about 14 weeks. The severity of dermatologic toxicity is predictive of response, with grades 2 to 4 skin toxicity correlating with improved progression-free survival and overall survival compared to grade 1 skin toxicity (Peeters 2009; Van Cutsem 2007). The patient developed a red, hot, and swollen sensation on his face and saw our dermatologist who prescribed oral fexofenadine, doxycycline, and topical metronidazole for one week on 2023-03-02. The prescription is only valid until 2023-03-09. It is recommended to check if the dermatologic symptoms have improved before deciding whether to refill the prescription.

2022-12-01

  • 2022-11-30 Hemoglobin 8.2 g/dL, MCV 76.7 fL, Ferritin 9.5 ng/mL, 2022-11-29 iron-bound Fe 36 ug/dL. Initialization of Foliromin (ferrous sodium citrate 50mg/tab) 1# QD is recommended.
  • 2022-11-30 the SBP remained around 170 ~ 190 mmHg under the single antihypertensive agent Norvasc (amlodipine 5mg/tab) 1# QD. An addition of Labtal (labetalol 200mg/tab) 1# BID might be an option to alleviate hypertension.

701496429

231130

{DLBCL}

[exam findings]

  • 2023-09-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (91 - 31.7) / 91 = 65.16%
      • M-mode (Teichholz) = 65.2
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial AR and MR, mild TR and PR
      • Impaired LV relaxation
      • Mildly thick IVS and LVPW
  • 2023-09-21 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of left costal-phrenic angle
    • Old fibrothorax at left CP angle.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-09-15 Patho - peritoneum biopsy
    • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type
    • Specimen submitted in formalin consists of 2 strips of tan, irregular tissue measuring up to 1.3 x 0.1 x 0.1 cm.
    • Section shows cores of atypical large lymphoid cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
  • 2023-09-13 PET
    • Glucose hypermetabolism lesions in bilateral lower neck regions, SCF, mediastinum, bilateral para-aortic space, common iliac chains, and pelvis, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose hypermetabolism lesions in the left pleural effusion, pleurae of the left upper, left lower and right upper lungs, and in skeleton including T11 spine, L5 spine and sacrum, highly suspected lymphoma with involvement of lungs and bone marrow.
    • Highly suspected lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-09-11 CT - abdomen
    • History and indication: Hydronephrosis with AKI, suspected Malignancy
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Enlarged LNs at retroperitoneum and pelvic cavity.
      • Wall thickening of rectum and S-colon.
      • Bil. pleural effusion with adjacent lung collapse.
      • Liver and renal cysts (up to 2.1cm).
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta.
      • S/P bilateral double J catheters insertion.
      • S/P foley catheter indwelling. Wall thickening of urinary bladder.
    • IMP:
      • Enlarged LNs at retroperitoneum and pelvic cavity.
      • Wall thickening of rectum and S-colon.
      • Bil. pleural effusion with adjacent lung collapse.
      • Wall thickening of urinary bladder.
  • 2023-09-06 Patho - colon biopsy
    • Colorectum, ascending colon and biopys removal — Tubular adenoma with low grade dysplasia.
  • 2023-09-01 CT - abdomen
    • CC: swelling all over the body for 3-4 days, decreased urination, dyspnea on exertion, abd. fullness +.
      • no fever, no vomiting, constipation +, dark color stool?
      • back pain noted for one week, no trauma.
    • PH: HTN under medical Tx
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status can not be determined without IV contrast.
    • Findings:
      • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
      • There are multiple enlarged nodes in the perirectal space, bilateral internal iliac chain, bilateral external iliac chain, and bilateral common iliac chain.
        • In addition, there are multiple enlarged nodes in para-aortic space and para-cava space, causing bilateral hydroureteronephrosis (obstructive uropathy). There are few small nodes in the mesentery.
      • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
      • There is a hypodense lesion 1.7 cm in S6 of the liver.
        • The differential diagnosis includes Metastasis and lymphoma.
      • There are bilateral Pleura effusion and old fibrothorax at left CP angle.
      • Both lobe thyroid show enlarged in size and few hypodense nodules.
        • Please correlate with sonography to R/O nodular goiter.
      • There is multiple enlarged nodes in left hilum and left anterior mediastinum.
      • There is fatty stranding at the subcutaneous fat layer of the lower pelvic wall.
      • There is minimal ascites in the Morison pouch.
    • IMP:
      • Lymphoma is highly suspected.
        • The differential diagnosis includes multiple metastatic nodes.
        • Please correlate with contrast enhanced dynamic CT.
      • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.

[MedRec]

  • 2023-09-01 ~ 2023-09-23 POMR Hemato-Oncology He JingLiang
    • Discharge diagnosis
      • Peritoneum, CT-guide biopsy — Diffuse large B-cell lymphoma, GCB type, immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
      • Hydronephrosis, status post double J (DJ) stent insertion, bilateral on 2023/09/08
      • Urinary tract infection with Urine culture: After 48 hours < 1000 CFU/ml on 2023/09/01
      • Gastric fungated ulcer, middle body, and Gastric ulcers, Forrest classification type III, antrum, and Reflux esophagitis LA Classification grade A (panendoscopy on 2023/09/05)
      • Colon polyp, ascending colon and Internal hemorrhoid (colonoscopy on 2023/09/05)
      • Hypertension
      • Paroxysmal atrial fibrillation
    • CC
      • edema in bilateral legs for 1 week, with dyspnea on exertion
    • Present illness
      • This patient is a 82-year-old male with underlying Af and hypertension. This time, he came with the complaint of edema in bilateral legs for 1 week, with dyspnea on exertion. According to the patient, he did not have a past history of kidney or liver diseases, and had never experienced similar symptoms before. Therefore he came to our ER for help.
      • At the ER, his vital signs were BP:143/65; PR:84; BT:35.2’C; RR:18; Con’s:E4V5M6; SpO2:97%. During physical examination, crackles were heard in bilateral lung fields.
      • Lab data revealed hyperkalemia, metabolic acidosis and elevated BUN and creatinine levels. Urinalysis showed nitrate (3+) and WBC (>100 HPF).
      • CT was performed which revealed
        • Lymphoma is highly suspected. The differential diagnosis includes multiple metastatic nodes. Please correlate with contrast enhanced dynamic CT.
        • Wall thickening at the rectosigmoid junction is suspected that may be normal variation and tumor. Please correlate with colonoscopy.
      • Urologist was consulted and suggested.
      • The CT showed multiple lymph node with compression effect of bilateral ureter ( right side beneath IVC, Aorta- IVC and left side lateral to Aorta) tumor stent may not pass.
      • PCND for acute renal failure may be more effective (right side seems better).
      • Foley for better record of urine output is recommended Under the impression of post-renal AKI and UTI, antibiotics were given, and a Foley catheter was inserted.
      • He was then admitted to our ward for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, Lasix was administered for AKI with edema in bilateral legs.
      • GU was also consulted for multiple lymph node with compression effect of bilateral ureter.
      • Empiric antibiotics with Rocephin was administered from 9/1(D5) due to right lower lung and left lung infiltration, pending culture.
      • Owing to still anemia susepct GI bleeding, EGD was performed on 2023/9/5 showed Gastric fungated ulcer, middle body, AW, s/p biopsy, r/o malignancy (B); Gastric ulcers, Forrest classification type III, antrum, GC, body, AW and PW, s/p biopsy (A) Reflux esophagitis LA Classification grade A.
      • Pathology showed
        • Stomach, body, AW, s/p biopsy (A), Chronic gastritis, H pylori NOT present.
        • Stomach, middle body, AW, s/p biopsy (B), Chronic gastritis, H pylori NOT present.
      • Colonscopy also done on 2023/09/05 showed Tubular adenoma with low grade dysplasia.
      • PPI with Nexium was prescribed.
      • As the renal function continued to deteriorate, the urology department was contacted, and a D-J catheter was implanted on 2023/9/08.
      • (selfpaid) PET was performed on 2023/09/13 for suspect lymphoma which revealed There was increased FDG uptake in lymph nodes in bilateral lower neck regions, SCF, mediastinum, in bilateral para-aortic space, common iliac chains, and pelvis. In addition, there was increased FDG uptake in the left pleural effusion and pleurae of the left upper, left lower and right upper lungs and in skeleton including T11 spine, L5 spine and sacrum.
      • CT guide biopsy was performed on 2023/9/15 and the pathology proved Diffuse large B-cell lymphoma, GCB type.
      • The immunohistochemical stains reveal CK(-), CD3(-), CD20(+), CD10(+), BCL2(+), BCL6(+), MUM1(+), c-MYC(+), Cyclin D1(-), CD30(-), CD56(-), and CD5(-). The Ki-67 is about 60%.
      • Bone marrow aspiration and biopsy was done on 2023/9/19 and report which showed negative for malignancy.
      • He was transferred to our ward for chemotherapy on 9/21 23.
      • C1 chemotherapy with R-COP was given on 9/22 23, smoothly without obviuous side effect.
      • He was discharged on 9/23 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 1# TID
      • Norvasc (amlodipine 5mg) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC (for 2023-09-05 EGD result)
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Compesolon (prednisolone 5mg) 9# BID 4D (9/22 ~ 9/26 18:00 end)

[chemotherapy]

  • 2023-12-21 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-11-29 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-11-02 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-10-11 - rituximab 375mg/m2 550mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 40mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO
  • 2023-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1200mg NS 250mL + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-COP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO

==========

2023-12-22

A review of PharmaCloud and HIS5 records revealed no medication discrepancies. However, the patient’s serum LDH level has shown a concerning upward trend this month. Previously, it remained stable following the initiation of the R-COP regimen on 2023-09-22. This recent rise warrants considering an update of the medical images to better assess the effectiveness of the treatment on the underlying disease.

  • 2023-12-21 LDH 348 U/L
  • 2023-12-19 LDH 285 U/L
  • 2023-12-11 LDH 156 U/L
  • 2023-12-04 LDH 181 U/L

2023-11-30

[hypoalbuminemia]

Hypoalbuminemia is emerging, and Plasbumin (human albumin) treatment was started on 2023-11-29.

  • 2023-11-28 Albumin(BCG) 2.8 g/dL
  • 2023-11-14 Albumin(BCG) 3.2 g/dL
  • 2023-11-07 Albumin(BCG) 3.5 g/dL

Given the patient’s recent lab results indicating normal liver and kidney function, the likelihood of hypoalbuminemia resulting from albumin loss in urine due to nephrotic syndrome or reduced hepatic albumin synthesis is lower. Please verify if the patient is experiencing malnutrition and/or edema.

2023-11-06

[leukopenia]

Episodes of leukopenia were noted approximately 1 to 2 weeks following the first cycle of R-COP on 2023-09-22 and the second cycle on 2023-10-11, specifically on 2023-10-04 and 2023-10-24. Granocyte (lenograstim) was appropriately administered for two periods of three consecutive days on these dates. Currently, there are no signs of leukopenia.

  • 2023-11-02 WBC 14.02 x10^3/uL
  • 2023-10-24 WBC 1.46 x10^3/uL **
  • 2023-10-11 WBC 9.39 x10^3/uL
  • 2023-10-09 WBC 6.92 x10^3/uL
  • 2023-10-06 WBC 11.69 x10^3/uL
  • 2023-10-05 WBC 3.04 x10^3/uL
  • 2023-10-04 WBC 0.87 x10^3/uL ***
  • 2023-09-27 WBC 9.86 x10^3/uL
  • 2023-09-20 WBC 7.14 x10^3/uL
  • 2023-09-18 WBC 6.52 x10^3/uL
  • 2023-09-11 WBC 9.71 x10^3/uL
  • 2023-09-07 WBC 8.61 x10^3/uL
  • 2023-09-04 WBC 8.06 x10^3/uL
  • 2023-09-02 WBC 7.49 x10^3/uL
  • 2023-09-01 WBC 6.92 x10^3/uL

According to the National Health Insurance medication reimbursement regulations, short-acting G-CSF injections, such as filgrastim and lenograstim, are indicated for use after intravenous chemotherapy for hematologic malignancies. This patient should meet the criteria for such coverage.

700360518

231129

[diagnosis] - 2023-05-01 admission note

  • Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
  • Other malaise
  • Malignant neoplasm of pyloric antrum
  • Cardiomegaly
  • Peritonitis, unspecified
  • Enterococcus as the cause of diseases classified elsewhere
  • Resistance to vancomycin
  • Type 2 diabetes mellitus with diabetic chronic kidney disease
  • Chronic kidney disease, stage 3 (moderate)
  • Heart failure, unspecified
  • Chronic atrial fibrillation
  • Alcoholic cirrhosis of liver with ascites
  • Hypo-osmolality and hyponatremia
  • Hypocalcemia
  • Other disorders of plasma-protein metabolism, not elsewhere classified
  • Pleural effusion in other conditions classified elsewhere
  • Chronic obstructive pulmonary disease, unspecified
  • Mixed hyperlipidemia
  • Enlarged prostate with lower urinary tract symptoms
  • Unspecified symptoms and signs involving the genitourinary system
  • Other ascites
  • Hyperkalemia

[past history]

  • HFmrEF
  • Af under edoxaban
  • DM
  • dyslipidemia
  • alcoholic liver cirrhosis.    

[allergy]

  • NKDA     

[family history]

  • Father: pancreatic cancer
  • Mother: hypertension

[exam findings]

  • 2023-10-05 ECG
    • Atrial fibrillation with rapid ventricular response
    • Low voltage QRS of limb leads
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2023-08-30 SONO - abdomen
    • Real-time sonographic evaluation of the abdomen findings:
      • The liver shows normal in size and echogenicity but mild irregular contour that may be cirrhosis.
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows enlarged in size (long axis: 15.81 cm) and echogenicity without focal lesion.
      • Abdominal aorta and IVC show unremarkable finding.
      • There is no evidence of para-aortic lymphadenopathy or ascites.
      • Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • No focal wall thickening or mass lesion in the gallbladder. Follow up is indicated.
      • Cirrhosis of the liver with portal hypertension is suspected.
  • 2023-08-30 Maximal Venous Outflow (MVO), Segmental Venous Capacitance (SVC)
    • Conclusion:
      • No evidence of DVT, bilateral upper arm
      • Bilateral upper arm MVO/SVC is normal
    • Suggestion:
      • keep anticoagulation as lixiana, because of history of atrial fibrillation if no contraindication.
  • 2023-08-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 98) / 186 = 47.31%
      • M-mode (Teichholz) = 47
    • Conclusion:
      • Dilated LV with global hypokinesis; impaired LV systolic function.
      • Mild RV hypertrophy with preserved RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
      • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
      • Mild aortic root calcification; mildly dilated proximal ascending aorta (35 mm).
      • Atrial fibrillation; severely dilated LA/RA.
      • No intracardiac vegetation was found by TTE study.
  • 2023-08-25 CT - abdomen
    • Indication: Double hit diffuse large B-cell lymphoma with stomach and intra-abdominal lymph nodes involvement, status post laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23, Lugano stage III
    • Findings:
      • S/P subtotal gastrectomy
      • There is splenomegaly and the greatest cranial-caudal dimension measuring 15 cm. The liver shows mild irregular contour that may be cirrhosis. please correlate with clinical condition.
      • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor.
      • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
      • There is mild bilateral Pleura effusion.
        • There is a calcification 7 mm in RUL of the lung that is c/w old granuloma. In addition, there are few enlarged nodes in paratracheal space. Follow up is indicated.
    • Impression:
      • Splenomegaly.
      • There is focal wall thickening at the gallbladder body, measuring 7 mm in wall thickness, that may be tumor. Follow up is indicated.
      • There are several enlarged nodes in para-aortic space and para-cava space that is c/w lymphoma. Follow up is indicated.
  • 2023-06-12 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Abnormal ECG
  • 2023-05-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Spondylosis of the T-spine
  • 2023-05-02 KUB
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation at left lateral aspect of L4-5.
    • Splenomegaly is highly suspected.
  • 2023-04-17 PET
    • Glucose hypermetabolism lesions in the gastric wall (Deauville score 5), in the celiac chain (Deauville score 5), in the left sub-diaphragm lymph nodes (Deauville score 5), in soft tissue in the RLQ of abdomen (Deauville score 5), and in lymph nodes of peritonium (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of stomach and intraabdominal lymph nodes.
    • Glucose hypermetabolism lesion in a peri-cardial lymph node (Deauville score 5), highly suspected diffuse large B-cell lymphoma with involvement of regional lymph node.
    • Diffuse large B-cell lymphoma, c-stage III or IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2023-03-30 KUB
    • Degeneration and spondylosis of L-S spine.
    • S/P operation with retention of surgical clips.
  • 2023-03-30 CXR
    • S/P operation with retention of surgical clips.
    • Degeneration of T-L spine.
    • Right catheterization to SVC in position.
    • Normal appearance of trachea and bil. main bronchus.
    • Left pleural effusion.
    • Cardiomegaly.
  • 2023-03-26 ECG
    • Atrial fibrillation with rapid ventricular response with premature ventricular or aberrantly conducted complexes
  • 2023-03-24 Patho - stomach subtotal/total (tumor)
    • Diagnosis
      • Stomach, antrum, laparoscopic subtotal gastrectomy (S2023-5511) with frozen section for margins (F2023-124) — Diffuse large B cell lymphoma, non-germinal center type.
        • IHC stains: CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), Bcl-6 (+), CD10 (-), MUM-1 (+, > 30%), c-myc (-), Ki-67: 95%, CK (-), CD23 (-) .
      • Margins, bilateral cut ends: free. radial surface postive for tumor.
      • Lymph node, perigastric, D2 dissection — free. CD3, CD20, Bcl-2, and Bcl-6 demonstrate a reactive pattern.
      • Omentum, omentectomy — Free
    • Microscopic Description:
      • Histologic Type - Diffuse large B cell lymphoma, non-germinal center type.
      • Histologic Grade - high grade, non-germinal center type.
      • Tumor Extension - Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved
        • Distal margin: uninvolved
        • Radial margin: involved
      • Lymphovascular Invasion: not identified
      • Perineural Invasion: not identified
      • Regional Lymph Nodes: free
        • S2023-5511A: LN1 (0/0); B1-3: LN3 (0/10); C1-4: LN4 (0/8); D1-2: LN5-6 (0/17); E1-2: LN7-8-9 (0/7); F1-2: LN12 (0/5); G1-4: omentum (0/1);
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) : Further work up is needed for staging.
  • 2023-03-22 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Abnormal ECG
  • 2023-03-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (186 - 106) / 186 = 43.01%
      • M-mode (Teichholz) = 43
    • Conclusion:
      • Dilated LV with global hypokinesis; impaired LV systolic function.
      • Mild RV hypertrophy with mild global hypokinesis and borderline RV systolic function.
      • Aortic valve sclerosis with mild AR; mild MR; mild to moderate TR.
      • Possible mild pulmonary hypertension (the estimated systolic PA pressure 46 mmHg).
      • Mild aortic root calcification.
      • Atrial fibrillation; severely dilated LA/RA.
  • 2023-03-06 Flow Volume Loop
    • Mild obstructive ventilatory impairment
  • 2023-03-04 Esophagogastroduodenoscopy, EGD
    • Superficial gastritis, s/p CLO test
    • Gastric ulcer, antrum, suspected malignancy, s/p biopsy
  • 2023-03-04 SONO - abdomen
    • Liver parenchymal disease (suboptimal exam of liver)
    • mild gallbladder wall thickening
    • splenomegaly
    • chronic renal parenchymal disease
    • bilateral pleural effusion
  • 2023-03-02 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/P NG tube placement.
    • Increased pulmonary vasculature is found.
    • Osteopenia of the bony structure is noted.
  • 2022-10-06 ECG
    • Atrial fibrillation
    • Low voltage QRS of limb leads
    • Abnormal ECG
  • 2022-10-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (190 - 102) / 190 = 46.32%
      • M-mode (Teichholz) = 46
      • 2D (M-simpson) = 48
    • Conclusion:
      • Dilated LA, LV, RA, RV and IVC; mildly abnormal LV systolic function with global hypokinesia
      • Moderate MR, mild AR, mild to moderate TR and trivial PR
      • Preserved RV systolic function
      • Atrial fibrillation with HR 62~83 bpm.
  • 2019-12-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (224 - 102) / 224 = 54.46%
      • M-mode (Teichholz) = 54
    • Conclusion:
      • Dilated LV with mild global hypokinesis and borderline LV systolic function.
      • Preserved RV systolic function.
      • Moderate MR and moderate TR (both due to chamber dilatation); mild AV sclerosis with trivial AR.
      • Possible mild to moderatre pulmonary hypertension (the estimated systolic PA pressure 50 mmHg).
      • Atrial fibrillation; severely dilated LA/RA.

[MedRec]

  • 2023-04-24 SOAP Hemato-Oncology
    • S
      • 3 daughters (the elderest daughter works in another hospital)
      • her daughter came to OPD for him
  • 2023-04-12 SOAP General and Digestive Surgery
    • A:
      • Gastric antrum lymphoma, cT4N0M0, stage II, ECOG:1, s/p laparoscopic subtotal gastrectomy and D2 lymph node dissection on 2023/03/23
      • Peritonitis, culture: VREfm (E.faecium)
      • Heart failure, New York Heart Association functional classification II
      • Chronic kidney disease, stage 3
      • Chronic atrial fibrillation
      • Alcoholic liver cirrhosis
      • Type 2 diabetes mellitus
      • Mixed hyperlipidemia
      • Hypocalcemia
      • Hypoalbuminemia
      • Hypo-osmolality and hyponatremia
      • Pleural effusion, bilateral sides
      • Massive ascites
      • Suspected Chronic Obstructive Pulmonary Disease
      • Enlarged prostate with lower urinary tract symptoms
    • P:
      • refer to ONC for further study and chemotherapy evaluation
      • PPI, vita B12, education, & OPD follow up
  • 2018-04-19 SOAP Cardiology
    • S: adjust carvedilol dose; add ARB for BP control
    • Prescription
      • Blopress (candesartan 8mg) 1# QD
      • Uretropic (furosemide 40mg) 1# Q3D
      • Lixiana (edoxaban 30mg) 1# QD
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Through (sennoside 12mg) 2# HS
      • Glucobay (acarbose 100mg) 1# BID
      • Syntrend (carvedilol 6.25mg) 1# QD
  • 2017-03-16 SOAP Cardiology
    • Diagnosis
      • Heart failure, unspecified [I50.9]
      • Atrial fibrillation [I48.2]
      • Cirrhosis of liver without mention of alcohol [K74.69]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Neuralgia and neuritis, unspecified [M79.2]
    • Prescription
      • Robestar (rosuvastatin 10mg) 0.5# QD
      • Through (sennosides 12mg) 2# HS
      • Glucobay (acarbose 100mg) 1# BID
      • Syntrend (carvedilol 6.25mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
      • Aldactin (spironolactone 25mg) 0.5# QD

[consultation]

  • 2023-03-06 General and Digestive Surgery
    • Q
      • for management of gastric cancer. Pending pathology.
      • This 70 y/o man with history of heart failure, Af, DM, hyperlipidemia, alcoholic liver cirrhosis with medication (Lixiana) control. This time, he suffered from passage tarry stool, vomiting blood, general weakness, dizziness since 20230227 morning. Abdominal CT showed gastric cancer T3N0M0. Under the impression of Gastrointestinal hemorrhage and suspected gastric cancer, he was admitted to MICU for further care on 2023-02-27.
      • After admitted MICU, the patient received anti with Sintrix (2/27~) for Infection prevention. kept NPO and high does PPI pump (2/27~3/2), then taper to Pantoloc 40mg IVD Q12H (3/2~), also disconnect Lixiana since 2/26. IV fluid for supply. Blood transfusion with LRBC for correct anemia (Hb: 7.9 => 9.2). There was no coffee ground or tarry stool was noted after try oral diet. However, dyspnea on exertion with breathing sound wheezing grade 1 was note, broncodilator with Butanyl plus Ipratran was prescribed. IV fluid and Const-K for correct imbalance electrolyte. The symptom got improvement after medical treatment, he will transfer to ward for further treatment and arrange 2nd PES (for supected gatric cancer biopsy).
      • At GI ward, his vital signs stable. Checked breathing sound: no wheezing. Try oral intaking but his care giver said easy choking.
      • Second look of EGD and the biopsy were all done, Now, we need your management of gastric cancer. Thanks a lot !!!
    • A
      • S:
        • Due to CT and panendoscopy highy suspected gastric antrm cancer, surgical treatment is consulted.
      • O: vital signs: stable, no fever
        • abdomen: soft, ovoid, normal bowel sound, no tenderness, no rebounding pain
        • lab data: see chart
      • A: Gastric antrum Ca, cT3N2M0, stage III, ECOG I
      • P:
        • I will take over this case for pre-op evaluation including heart echo and lung function test and nutritional support such as PPN
        • If heart & lung function is OK and the patietn is willing to receive operation, I will arrange laparoscopic resection later.

[surgical operation]

  • 2023-03-23
    • Surgery
      • Laparoscopic subtotal gastrectomy and D2 lymph node dissection
      • Post-OP Dx: gastric antrum Ca, cT3N2M0, stage III, ECOG 1       
    • Finding
      • An ulcerative tumor about 5x7 cm over antrum, lesser curvature site of antrum posterior wall with suspect serosal invasion.
      • Enlarged lymph nodes over area 3, 5, 7, 8, 9, 12 were noted.
      • Proximal cutting end 10 cm form tumor and distal cutting end 1 cm from tumor. Both cutting ends were margin free via frozen section.

[immunochemotherapy]

  • 2023-09-28 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-18 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-06-13 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-24 - rituximab 375mg/m2 693mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-mCHOP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-03 - rituximab 375mg/m2 660mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1300mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID D2-6 (R-COP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + NS 250mL D1-2

==========

2023-11-29

[proactive measures for leukopenia and renal function management]

After initiating the 5th cycle of R-COP/R-mCHOP on 2023-09-28, the patient experienced leukopenia in early Oct.

  • 2023-11-29 WBC 7.84 x10^3/uL
  • 2023-11-28 WBC 2.68 x10^3/uL *
  • 2023-11-10 WBC 4.23 x10^3/uL
  • 2023-10-23 WBC 4.01 x10^3/uL
  • 2023-10-16 WBC 5.72 x10^3/uL
  • 2023-10-13 WBC 5.46 x10^3/uL
  • 2023-10-10 WBC 0.76 x10^3/uL ***
  • 2023-10-09 WBC 0.72 x10^3/uL ***
  • 2023-10-05 WBC 2.64 x10^3/uL *
  • 2023-09-28 WBC 3.18 x10^3/uL

With a new session scheduled during this hospital stay, there’s a possibility of another leukopenia episode. Therefore, it may be advisable to have prophylactic G-CSF ready for use.

The patient has impaired renal function, but it is not severe enough to require dose adjustments for current medications. However, if the eGFR falls below 50 or creatinine exceeds 1.5, it’s important to consider adjusting the doses of Allegra (fexofenadine) and Lixiana (edoxaban).

  • 2023-11-28 BUN 28 mg/dL
  • 2023-11-28 Creatinine 1.36 mg/dL
  • 2023-11-28 eGFR 54.90 ml/min/1.73m^2

2023-07-07

[reconciliation]

  • According to the PharmaCloud database, besides our hospital, this patient has also visited a local dermatology clinic for problems related to skin and subcutaneous tissue infections on 2023-06-25, and for irritant contact dermatitis on 2023-06-04. Both times, he was prescribed medications for 7 days and 3 days respectively, which are now expired. No reconciliation issues were identified in this context.
  • Our cardiologist had prescribed Lixiana (edoxaban), Blopress (candesartan), Hexal (carvedilol), Dibose (acarbose), Glimet (glimepiride, metformin), and Galvus Met (vildagliptin, metformin) on 2023-06-15. All these drugs are included in the current active medication list without any identified reconciliation issues.

[to adjust Dibose (acarbose) from BID to BIDCC]

  • The optimal usage of Dibose (acarbose) involves taking it with the first bite of each main meal or immediately before starting a meal to ensure maximum effectiveness. Therefore, it is suggested that the patient’s current BID prescription should be adjusted to BIDCC. Ref: The effect of the timing and the administration of acarbose on postprandial hyperglycaemia. Diabet Med. 1995;12(11):979-984. doi:10.1111/j.1464-5491.1995.tb00409.x

2023-05-03

  • Given the patient’s history of heart failure, doxorubicin may not be an appropriate component of the treatment regimen. Instead of R-CHOP, R-COP was chosen as the treatment regimen to avoid the potential cardiotoxic effects of doxorubicin.

  • On 2023-05-03, the progress note indicated that the patient had increased frequency of vomiting and difficulty with oral intake due to NG tube cough. Metoclopramide, a dopamine (D2) receptor antagonist, is currently prescribed. If symptoms persist, the addition of serotonin (5-HT3) receptor antagonists (such as ondansetron, granisetron, or palonosetron) and/or neurokinin-1 (NK1) receptor antagonists (such as aprepitant, fosaprepitant, rolapitant, or netupitant) may be considered. These medications work through different mechanisms to control nausea and vomiting and may provide additional relief for the patient.

  • Dibose (acarbose) should be taken with the first bite of each main meal or just before starting a meal for best results. Acarbose works by slowing down the digestion of carbohydrates in the intestines, helping to control blood sugar levels. Taking it at the beginning of a meal ensures its optimal effect on carbohydrate digestion. It is recommended to change the medication from current BID to BIDCC.

700884793

231129

[exam finding]

  • 2023-10-04 SONO - abdomen
    • Parenchymal liver disease
    • Liver cyst, S6/7
    • post ERBD in CBD and left IHD
    • Pneumobilia, mild, left IHD
    • Renal cyst, left
    • Suspicious, focal dilated main pancreatic duct, pancreatic neck
    • Ascites, moderate
  • 2023-10-01 Abdomen - Standing (Diaphragm)
    • S/P metalic stent implantation at the bile duct and duodenum.
    • S/P plastic stent implantation at the left lobe IHD and duodenum.
    • Fecal material store in the colon.
    • There is ascites. Please correlate with sonography.
    • Disc space narrowing with marginal osteophyte formation of L4-5.
  • 2023-09-27 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: CBD stricture s/p metal stent placement, with obstruction
    • Symptoms: Jaundice
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: IV anesthesia
    • Equipment: TJF-260V
    • Management:
      • After C duct cannulation, retrieval balloon lithrotripsy was done before cholangiography and much sludge and pus were swept out from IHD and CBD. Selective cannulation of left IHD was done and mild dilated left IHD was found. One 14cm 7 Fr Gadelius Through The Mesh™ stent was performed at left IHD.
    • Diagnosis:
      • Malignant biliary stricture, s/p metal stent, with obstruction with much sludge and pus in IHD and CBD, s/p retrieval balloon lithrotripsy
      • Mild left IHD dilatation, s/p stenting with plastic stent
      • Chronic cholangitis
      • Duodenal swelling mucosa with luminal narrowing, 2nd portion
      • Reflux esophagitis, Gr. A
  • 2023-09-23 CT - abdomen
    • History and indication: Fever
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Some soft tissues in peritoneal cavity.
      • Liver and renal cysts (up to 3.9cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Invisible gallbladder. S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
      • Small caliber of extrahepatic portal vein.
      • Degeneration and spondylosis of L-S spine.
    • IMP:
      • Some soft tissues in peritoneal cavity.
      • S/P CBD stenting. Mild dilatation of biliary tree and p-duct.
      • Small caliber of extrahepatic portal vein.
  • 2023-09-23 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-08-02 CT - abdomen
    • Findings:
      • S/P metalic stent implantation at the CHD, CBD and duodenum.
      • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
      • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
      • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
      • S/P cholecystectomy.
      • There is no focal lesion in both lung and mediastinum.
      • A renal cyst measuring 3.9 cm in left upper pole is noted.
      • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
    • Impression:
      • S/P metalic stent implantation at the CHD, CBD and duodenum.
      • Prior CT identified dilatation of the IHDs on both hepatic lobes are noted again, mild decreasing in size.
      • Prior CT identified pancreatic duct dilatation is noted again, mild increasing in size.
      • The mesentery root shows fatty stranding and several enlarged nodes. please correlate with clinical condition.
  • 2023-06-05 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
      • The pancreatic duct is dilated.
      • Minimal pneumobilia is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Left renal cyst up to 4.02cm is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • The urinary bladder is well distended without soft tissue lesion.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • s/p biliary stent placement at CBD is found. Dilated IHDs and proximal CBD is found.
      • The pancreatic duct is dilated. No signficant soft tissue mass is found. But correlation with other finding is suggested.
  • 2023-03-07 MRI - MR Cholangiography, MRCP
    • History and indication: Malignant neoplasm of biliary tract
    • With and without contrast MRI of liver revealed:
      • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
      • Liver and renal cysts (up to 3.9cm).
    • IMP:
      • S/P CBD stenting with artifact. S/P cholecystectomy. Mild dilatation of IHD.
  • 2022-11-08 Abdomen - standing (diaphragm)
    • Degeneration and spondylosis of L-S spine.
    • Contrast medium retention in the bowel.
    • S/P CBD stenting.
  • 2022-11-07 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Indication: CBD stricture s/p metal stent placement
    • Symptoms: for pre-Op. evaluation
    • Premedication: Buscopan 20mg + Alfentanil 0.25mg IV
    • Anesthesia: IV anesthesia
    • Equipment: TJF-260V
    • Diagnosis:
      • Malignant biliary stricture s/p metal stent with no evidence of narrowing site
      • Chronic cholangitis
      • Juxta-papillary diverticulum
      • Reflux esophagitis, Gr. A
      • Gastric angioectasias, low body
  • 2022-11-08 SONO - abdomen
    • Indication: CBD cancer
    • Symptoms: fever
    • Diagnosis:
      • Asymmetric CBD wall thickening
      • Pneumobilia, both lobes
      • Metallic stent in the CBD
      • Prob. Parenchymal liver disease
  • 2022-08-08 CT - abdomen
    • History and indication
      • cholangiocarcinoma
    • Findings
      • A cystic lesion (4.3cm) at left kidney. Tiny liver and renal cysts.
      • Invisible gallbladder. S/P CBD stenting with pneumobilia.
    • IMP:
      • S/P CBD stenting with pneumobilia.
      • No interval change of peritoneal lesions.
  • 2022-07-06 CT - abdomen
    • History and indication
      • tea color urine for 10 days due to obstructive jaundice
      • SGOT: 103, SGPT: 141, HBsAG (-), antiHCV(-) (2022-01)
      • 20220114 CT: Cholangiocarcinoma at the CHD is noted.
        • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
        • cT2N2M1, cStage:IV
      • 20220214 CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
    • Findings:
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
      • Prior CT identified several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) are noted again, mild decreasing in size.
      • S/P metalic stent implantation from CHD to duodenum.
      • S/P cholecystectomy.
      • Pneumobilia on left lobe IHD is noted.
      • There is no evidence of IHD dilatation.
      • A renal cyst measuring 4 cm in left upper pole is noted.
      • Abdominal aorta shows atherosclerosis and ectasia 2.2 cm.
      • There is no focal lesion in both lung and mediastinum.
      • Prior CT identified few hepatic cysts in both lobes are noted again, stable in size. The largest one 0.8 cm in S8.
    • Impression
      • Prior CT identified soft tissue lesions in the omentum at LUQ abdomen are noted again, stationary.
  • 2022-05-24 KUB
    • S/P clips projecting at the liver hilum.
    • S/P metalic stent implantation at CHD, CBD and duodenum.
    • Pneumobilia on left lobe IHDs.
    • Fecal material store in the colon.
  • 2022-05-23 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Malignant biliary stricture s/p FCSEMS (Kaffes stent, 5 cm and 8 mm ) (FCSEMS = Fully Covered, Self Expanding Metal Stent)
      • Chronic cholangitis
      • Juxta-papillary diverticulum
      • Reflux esophagitis, Gr. A
    • suggestion
      • f/u amylase & lipase
  • 2022-05-22 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-05-12 SONO - abdomen
    • Liver cyst, right lobe
    • Post cholecystectomy
    • Mild left IHD dilatation
    • Pneumobilia, left
    • Post CBD stenting
    • Renal cyst, left kidney
  • 2022-05-04 CT - abdomen
    • Pneumobilia on left lobe IHD is noted.
    • Carcinomatosis is suspected. Please correlate with ascites cytology.
  • 2022-04-20 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter and stent.
      • S/P operation with retention of surgical clips.
  • 2022-04-18 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2022-04-18 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p plastic stent exchange
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-03-12 Percutaneous transhepatic cholangio drain, PTCD (drainage)
    • The necessarity and risks of the procedure was well explanined to patient family before the PTCD. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
    • Dilatation of the biliary tree (by CT images). S/P CBD stenting.
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree via left IHD smoothly.
    • No procedure-related complication during the whole procedure.
  • 2022-03-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-03-09 CT - abdomen
    • Cholangiocarcinoma at the CHD and metastatic nodes show stationary.
    • Mild ascites is noted.
  • 2022-02-15 Patho - duodenum biopsy
    • PATHOLOGIC DIAGNOSIS
      • CBD tumor, serosa, laparotomy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Gallbladder, open cholecystectomy — Chronic cholecystitis and free from tumor
      • Lymph nodes, post-pancreatic region (LN 16), frozen section — Free from tumor metastasis (0/11)
    • MICROSCOPIC EXAMINATION
      • CBD tumor, serosa: poorly cohesive carcinoma characterized by tumor cells arranged in linear or individual pattern with signet-ring cell differentiation.
        • Immunohistochemistry of CK(+), CK7(+), CK20(+, focal) and CDX2(+) for tumor.
      • Gallbladder: chronic cholecystitis with serosal hemorrhage and free from tumor invasion
      • Lymph nodes, post-pancreatic region (LN 16): free from tumor metastasis (0/11)
  • 2022-02-14 CXR
    • S/P operation with retention of surgical clips.
    • S/P Port-A infusion catheter insertion.
    • S/P CBD stenting.
    • Right CVP inserted to SVC in position.
    • Ground glass opacity in RLL.
  • 2022-01-26 SONO - abdomen
    • CBD wall thickening with upstram ductal dilatation
    • pneumobilia, both lobes
    • stent in the CBD
    • pancreatic cystic lesion
    • Prob. Parenchymal liver disease
  • 2022-01-25 Body fluid cytology
    • Bile duct brushing: atypia
  • 2022-01-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 26) / 87 = 70.11%
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild MR, TR
  • 2022-01-24 Endoscopic Retrograde CholangioPancreatography, ERCP
    • diagnosis
      • Biliary stricture s/p brushing cytology & plastic stent placement
      • Chronic cholangitis
      • Reflux esophagitis Gr.A
    • suggestion
      • f/u amylase & lipase
  • 2022-01-14 CT - abdomen
    • Cholangiocarcinoma at the CHD is highly suspected.
      • Please correlate with CEA, CA199, ERCP and biopsy.
      • Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected.
      • According to American Joint Committee on Cancer(AJCC)staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
    • Mild wall thickening at the gastric antrum and duodenum is noted. Please correlate with gastroscopy.
  • 2022-01-14 SONO - abdomen
    • Parenchyaml liver disease
    • Hepatic cyst
    • Bilateral IHD dilatation
    • Bilateral renal cysts
    • Pancreatic cyst
  • 2019-11-17 ECG
    • Sinus bradycardia
    • Left anterior fascicular block
    • Nonspecific ST abnormality
  • 2018-08-06 CT - abdomen
    • Distention of urinary bladder with irregular wall. Enlargement of prostate.
    • A cystic lesion (4.0cm) at left kidney.

[consultation]

  • 2023-11-15 Infectious Disease

    • A
      • The is a case of cholangiocarcinoma at common hepatic duct. Cholangitis is suspected.
      • Agree with your use with finibax.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-09-25 Gastroenterology (not completed)

  • 2023-09-25 Infectious Disease

    • Q
      • Empiric antibiotics with Cefotaxime was administered.
      • Under the impression of Cholangiocarcinoma, cT2N2M1, stage IV suspect cholangitis. He was admitted for further management.
      • Due to B/C: GNB, so we need your help for antibiotic evaluation, thanks a lot!!
    • A
      • B/C: GNB, E. coli.
      • Agree with your use of brosym for the GNB sepsis.
      • Please keep IV antibiotics for 7~10 days.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2022-04-20 Radiation Oncology

    • Q
      • This is a 71 year-old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
        • Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB.
        • Unresectable Bile duct tumor status post open cholecystectomy and port-A insertion on 2022/02/14.
        • Cholangitis with dilatation of the biliary tree. S/P CBD stenting.Percutaneous Transhepatic Cholangiography and Drainage on 2022/03/12.
        • He was regular follow up at our GI OPD.
        • Due to ERCP revealed Biliary stricture s/p plastic stent exchange on 20220418, we need arrange cholangiography, thank you~
    • A
      • According to the clinical condition and imaging findings, cholangiography is indicated.
  • 2022-03-12 Radiation Oncology

    • Q
      • This 71-year-old male,a case of Common bile duct poorly cohesive carcinoma with signet-ring cell differentiation, pT4N0M0, stage IIIB under XRT since 20220301, chemotherapy with 5-FU (200mg/m2) on 20220307~20220311. Spiking fever was noted on 20220311 morning, laboratory test revealed hyperbilirubinemia. Empiric antibiotics with Flumarin was administered. We need your expertise for further management, thanks.
    • A
      • According to the clinical condition and imaging findings, PTCD is indicated.
  • 2022-02-15 Radiation Oncology

    • Q
      • He was admitted for CBD tumor resection.
      • Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • Pathology report was pending.
      • After explanation, he preferred neoadjuvant CCRT
      • After CCRT surgery will be asssessed in the future.
      • Therefore, we need your expertise to evaluate, manage his current condition.
    • A
      • Subjective:
        • History: This is a 71 years old male suffered from obstructive jaundice s/p ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24. He was admitted for CBD tumor resection. Because of unresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein was noted during OP. The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14. Pathology report was pending. Neoadjuvant CCRT was suggested by Tumor Board.
          • Previous RT: denied.
          • Other disease: BPH s/p RaSP+bilateral TAPP on 2018/12/05. Polyp status post polypectomy on 2019/11/12.
          • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Widower. Caregiver: his only son. Job: retired business. Mild economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion:
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2022/02/15: No SCF LAPs.
        • Pathology, 2022/2/14, pending.
        • OP finding: distended GB and dilated proximal CBD; an indurated hard tumor at distal CBD with serosa, right hepatic artery and portal vein invasion, tumor extended to pancreatic head; multiple LN at para-aorta and hepatoduodenal ligament and common hepatic artery.
        • Images:
          • CT, 2021/12/17: There is mild wall thickening (8 mm in wall thickness) and abrupt narrowing at the CHD, causing marked dilatation of proximal CHD and both lobe IHDs. Cholangiocarcinoma at the CBD is highly suspected. There are several enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, and para-aortic space (non-regional nodes) that may be metastatic nodes. Imp: 1. Cholangiocarcinoma at the CHD is highly suspected. Metastatic lymphadenopathy at gastrohepatic ligament, hepatoduodenal ligament and para-aortic space are suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for bile duct cancer: T2 N2 M1, Stage:IV
          • CXR, 2022/01/17: No metastasis.
        • CA199: 103.38 (2022/1/15).
      • Diagnosis:
        • Cholangiocarcinoma, distal CBD with serosa, right hepatic artery and portal vein invasion with gastrohepatic ligament, hepatoduodenal ligament and para-aortic space s/p brushing cytology & plastic stent placement on 2022/01/24, s/p open cholecystectomy and port-A insertion on 2022/02/14; ECOG: 1.
      • Suggest: Radiotherapy.
        • Goal: Curative (Preoperative).
        • RT Plan:
          • Target & Volume: CBD tumor and LAPs.
          • Technique: VMAT & IGRT.
          • Dose & Fractionation: 4500cGy/25 fractions.
        • Plan: CCRT is suggested for locoregional control. CT simulation is arranged on Feb 22 09:30 am. Possible treatment toxicity (radiation gastritis and enteritis) is told. Diet education & psychological support is given.
  • 2022-02-14 Gastroenterology

    • Q
      • For changing of biliary tract metallic stent evaluation and management.
      • This is a 71 years old male had past histories of
        • BPH s/p RaSP + bil TAPP on 2018/12/05.
        • Polyp status post polypectomy on 2019/11/12.
      • ERCP with Biliary stricture s/p brushing cytology & plastic stent placement on 2022/01/24.
      • He was admitted for CBD tumor resection.
      • Because of nonresectable CBD tumor, invasion to panceratic head, right hepatic artery and portal vein.
      • The procedure changed to open cholecystectomy and port-A insertion on 2022/02/14.
      • After explanation, he preferred neoadjuvant chemotherapy, and for biliary tract management, metallic stent was suggested.
      • Therefore, we need your help to performed the procedure (ERCP)
    • A
      • Please confirm if he needs Radiation therapy or not before metalic stenting.
  • 2022-01-25 General and Gastrointestinal Surgery

    • Q
      • Suspected cholangiocarcinoma for further management
      • This is a 71 years old male had past histories of 1.) BPH s/p RaSP + bil TAPP on 20181205. 2.) Polyp status post polypectomy on 20191112.
      • This time, due to he suffered from jaundice and tea color urine for 10+ days. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastirc pain, no tarry/bloody stool, no TOCC found. He visited to our GI OPD for help. At GI OPD, follow up blood test that showed hyperbilirubinemia, no leukocystosis nor PT prolong found. Abdominal sonography wsa done revealed parenchyaml liver disease; hepatic cyst; bilateral IHD dilatation; bilateral renal cysts and pancreatic cyst. Abdominal CT with contrast was also done for further survey which revealed cholangiocarcinoma at the CHD is highly suspected. ERCP was arrnged and showed 1. Biliary stricture s/p brushing cytology & plastic stent placement 2. Chronic cholangitis 3. Reflux esophagitis Gr.A. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • Assessment
        • A case impressed of CBD tumor with obstruction suspected malignancy
      • Suggestion
        • arrange f/u cardiopulmonary function
        • check tumor marker of CEA, CA199
        • triflow training (self-paid)
        • arrange GS OPD on 20220208
        • planing for further operation with total CBD resection after TBI < 6

[surgical operation]

  • 2022-02-14
    • Surgery
      • open cholecystectomy
      • port-A insertion
    • Finding
      • distended GB and dilated proximal CBD
      • an induration hard tumor at distal CBD with serosa, right hepatic atery and portal vein invasion, tumor extended to pancreashead
      • multiple LN at pararota and hepatoduodenal ligament adn common hepatic artery
  • 2022-12-05 Suprapubic prostatectomy
    • pre-op, post-op diagnosis: BPH
    • PCS code: 79404C
    • findings: adenoma 51 gm was resected, bilateral mixed type.

[radiotherapy]

  • 2022-03-01 ~ 2022-04-08 - 5000cGy/25 fractions (15 MV photon).

[chemoimmunotherapy]

  • 2023-11-08 - gemcitabine 1000mg/m2 1200mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-10-18 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-10-11 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-12 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-05 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-22 - pembrolizumab 100mg NS 100mL 30min + gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (Keytruda + gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-15 - gemcitabine 1000mg/m2 1600mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 1hr + NS 500mL 1hr (after CDDP) (gemcitabine + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-12-26 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-11-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-11-17 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3980mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-09-29 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3960mg NS 500mL 46hr (neoadjuvant FOLFIRINOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + aprepitant 125mg PO + atropine 1mg + NS 250mL
  • 2022-09-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 660mg 2hr + fluorouracil 2400mg 3970mg 46hr (neoadjuvant FOLFIRINOX, Q2W)
  • 2022-08-31 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3950mg 46hr
  • 2022-08-17 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-29 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-07-14 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 3900mg 46hr
  • 2022-06-28 - oxaliplatin 80mg/m2 130mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 640mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-06-14 - oxaliplatin 70mg/m2 100mg 2hr + irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-19 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3800mg 46hr
  • 2022-05-03 - oxaliplatin 60mg/m2 90mg 2hr + irinotecan 140mg/m2 200mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3700mg 46hr
  • 2022-03-28 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-21 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-17 - fluorouracil 200mg/m2 300mg 24hr D1-2
  • 2022-03-07 - fluorouracil 200mg/m2 300mg 24hr D1-2

==========

2023-11-29

[Brosym dosage assessment for the patient with jaundice and poor renal function]

This patient has severe jaundice and poor kidney function, and is currently being treated with Brosym (cefoperazone, sulbactam) 4g IVD Q12H.

  • 2023-11-27 AST 90 U/L
  • 2023-11-27 ALT 54 U/L
  • 2023-11-27 BUN 36 mg/dL
  • 2023-11-27 Creatinine 1.32 mg/dL
  • 2023-11-27 eGFR 56.51 ml/min/1.73m^2
  • 2023-11-27 Bilirubin total 13.76 mg/dL
  • 2023-11-27 Bilirubin direct 7.85 mg/dL
  • 2023-11-27 Alkaline phosphatase 208 U/L
  • 2023-11-27 r-GT 181 U/L

Sanford Guide:

  • Cefoperazone is extensively excreted in bile and the serum half-life is usually prolonged with urinary excretion of the drug increased in patients with hepatic diseases and/or biliary obstruction. Even with severe hepatic dysfunction, therapeutic concentrations of Cefoperazone are obtained in bile and only a 2- to 4-fold increase in half-life is seen.
  • Dose modification may be necessary in cases of severe biliary obstruction, severe hepatic disease or in cases of renal dysfunction associated with either of those conditions.
  • In patients with hepatic dysfunction and concomitant renal impairment, dosage should not exceed 2 g/day of Cefoperazone without close monitoring of serum concentrations.

The current dosage of Brosym is twice the recommended amount according to the Sanford Guide. Please consider reducing the dosage based on the clinical situation.

2023-11-16

[biweekly gemcitabine-cisplatin and monthly pembrolizumab demonstrate sustained response]

The current treatment regimen, which includes biweekly administrations of gemcitabine and cisplatin, along with monthly pembrolizumab, initiated on 2023-08-15, seems to remain effective. This effectiveness is indicated by the decreasing trend in CA-199 levels and the stable readings of CEA.

  • 2023-11-14 CA-199 (NM) 79.720 U/ml

  • 2023-11-07 CA-199 (NM) 78.021 U/ml

  • 2023-10-24 CA-199 (NM) 190.180 U/ml

  • 2023-10-17 CA-199 (NM) 208.840 U/ml

  • 2023-09-19 CA-199 (NM) 210.380 U/ml

  • 2023-09-08 CA-199 (NM) 148.890 U/ml

  • 2023-08-25 CA-199 (NM) 593.460 U/ml

  • 2023-08-22 CA-199 (NM) 850.900 U/ml

  • 2023-07-28 CA-199 (NM) 1253.210 U/ml

  • 2023-05-26 CA-199 (NM) 23.184 U/ml

  • 2023-03-10 CA-199 (NM) 11.934 U/ml

  • 2022-11-18 CA-199 (NM) 11.891 U/ml

  • 2022-11-07 CA-199 10.940 U/mL

  • 2022-10-07 CA-199 (NM) 8.593 U/ml

  • 2022-08-10 CA-199 (NM) 9.805 U/ml

  • 2022-05-05 CA-199 (NM) 8.925 U/ml

  • 2022-04-29 CA-199 (NM) 18.368 U/ml

  • 2022-03-09 CA-199 (NM) 21.032 U/ml

  • 2022-01-15 CA-199 103.380 U/mL

  • 2023-11-14 CEA (NM) 7.340 ng/ml

  • 2023-11-07 CEA (NM) 6.487 ng/ml

  • 2023-10-24 CEA (NM) 7.002 ng/ml

  • 2023-10-17 CEA (NM) 8.315 ng/ml

  • 2023-09-19 CEA (NM) 5.347 ng/ml

  • 2023-09-08 CEA (NM) 6.293 ng/ml

  • 2023-08-25 CEA (NM) 7.052 ng/ml

  • 2023-08-22 CEA (NM) 7.820 ng/ml

  • 2023-07-28 CEA (NM) 6.275 ng/ml

  • 2023-05-26 CEA (NM) 3.872 ng/ml

  • 2023-03-10 CEA (NM) 4.042 ng/ml

  • 2022-11-18 CEA (NM) 3.139 ng/ml

  • 2022-11-07 CEA 3.090 ng/mL

  • 2022-10-07 CEA (NM) 3.624 ng/ml

  • 2022-08-10 CEA (NM) 2.325 ng/ml

  • 2022-05-05 CEA (NM) 2.259 ng/ml

  • 2022-04-29 CEA (NM) 3.142 ng/ml

  • 2022-03-09 CEA (NM) 1.678 ng/ml

  • 2022-01-15 CEA 3.380 ng/mL

[assessing the risk of edema in the context of increasing hypoalbuminemia]

The patient is exhibiting a trend of worsening hypoalbuminemia. Factors such as impaired liver function, suspected cholangitis, and infection could be contributing to this condition. It is advisable to check for the presence of edema, as indicated by the weight increase from 56.4 kg on 2023-11-08 to 60.8 kg on 2023-11-15.

  • 2023-11-15 Albumin (BCG) 2.5 g/dL
  • 2023-11-08 Albumin (BCG) 2.5 g/dL
  • 2023-11-01 Albumin (BCG) 2.8 g/dL
  • 2023-10-18 Albumin (BCG) 3.3 g/dL
  • 2023-10-11 Albumin (BCG) 2.9 g/dL
  • 2023-10-04 Albumin (BCG) 2.8 g/dL
  • 2023-10-02 Albumin (BCG) 2.8 g/dL
  • 2023-09-28 Albumin (BCG) 2.7 g/dL
  • 2023-09-26 Albumin (BCG) 2.6 g/dL
  • 2023-09-12 Albumin 3.1 g/dL
  • 2023-09-05 Albumin 3.0 g/dL
  • 2023-08-22 Albumin 3.2 g/dL
  • 2023-08-15 Albumin 3.0 g/dL
  • 2023-07-25 Albumin 3.0 g/dL
  • 2023-01-16 Albumin 3.9 g/dL
  • 2023-01-09 Albumin 3.6 g/dL
  • 2022-12-26 Albumin 4.0 g/dL

701470461

231129

[MedRec]

  • 2023-02-06 ~ 2023-02-21 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Multiple myeloma not having achieved remission
      • Multiple myeloma, IgG type, ISS stage II
      • Spondylosis without myelopathy or radiculopathy, lumbar region
      • Low back pain
    • CC
      • back pain for 5 month
    • Present illness
      • This is a 66-year-old male with history of Hypertension, hyperlipidemia and Gout for 20 years, BPH s/p for 3 years, Colon polyps s/p for 10 years with regular medication control, he was admitted due to back pain since Oct 2022.
      • This time, he suffered from fall down in Oct 2022 and took analgesic agent for one month ago but in vain and visited to YiLan YangMing Hospital for aid and was admitted at that hospital in Dec 2022 due to L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 111/12/24 & BPH S/P LASER.
      • Two months later follow-up spine x-ray showed compression fracture and bone cement was done on 2023-02-02. Owing to difficulty urinating was noted and foley cather was inserted on 2023-02-04. Poor appetite, body weight loss about 5 kg and both lower legs weakness and massive yellowish sputum were also since 2023-01-21. Will arranged spine biopsy on 2023-02-06 at YiLan YangMing hospital but the patient was refused and transferred to our ER for treatmetn.
      • Under the impression of back pain for 5 month, R/O spine tumor, R/O prostate cancer with multiple bone mets, R/O multiple myeloma and increase infilitration over both lungs R/O aspiration pneumonia. He was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • After admission, pain control with Tramacet 37.5 & 325mg/tab 1# PO Q6H.
      • Consult NS for evaluation and management, persue tumor marker report; on brace prn; May consult radiologist for CT guide biosy (left T11 vertebrae body?); or bone marrow biopsy as your expertise.
      • R/O aspiration pneumonia, antibiotic with Cefuroxime 1500mg IVD Q8H from 2023/02/06~2023/02/13, tapper to oral form with Cinolone 250mg/tab 3# PO Q12H* 7days.
      • Bome marrow on 2023/02/08, pathology showed myeloma. IHC stains: CD138: 20-25%, kappa and lambda: a predominant kappa sub-population;  CD117: %; CD34: <1 %; MPO: 20 % (of the nucleated cells).
      • Consult dental for Xgeva use, no deep caries were noticed. no pathological findings could be obtained due to lack of dental panoramic film and mild periodontitis of full mouth was noticed. Xgeva 120mg/1.7mL/vial 1vial was give on 2023/02/14.
      • VTD regimen for MM, Bortezomib is applied, Thado 50mg/cap 2# PO HS since 2023/02/14, Limeson 4mg/tab 10# PO QW3 since 2023/02/15.
      • Patient tolerated the treatment of multiple myeloma. With the stable condition, he was discharged on 2023/02/21 and OPD followed up later.  
  • 2023-02-06 SOAP Medical Emergency Hu YuHui
    • S
      • Admitted at National Yang Ming Chiao Tung University Hospital in 2022/12:
        • L 4/5 listhesis s/p Bil MIS Rt L 4/5 transforaminal laminectomy + discectomy for nerve root decompression + i-TLIF cage implantation + Bil L 4-5 TPS fixation + Lt L4/5 laminotomy on 2022/12/24 BPH S/P LASER
      • 2023-02-02 chest/abdomen CT:
        • Multiple osteolytic lesions at thoracic vertebra and suspicious bilateral ribs.
        • D/Dx: metastasis, multiple myeloma, metabolic bone disorder.
        • Suggest further clinical evaluation.
    • A
      • Preliminary impression:
        • M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region

[chemotherapy]

  • 2023-11-19 - melphalan 100mg/m2 160mg NS 500mL 1hr D1-2 (D-2,-1 conditioning regimen prior to APBSCT D0 2023-11-21)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-09-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-07-07 - cyclophosphamide 3000mg/m2 4800mg NS 500mL 2hr (for PBSC harvest)

  • 2023-06-16 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-06-09 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-06-02 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-26 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-19 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-12 - bortezomib 1.3mg/m2 2.2mg SC (VTd)

  • 2023-05-05 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-28 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-21 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-14 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-04-07 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-31 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-24 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-17 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

  • 2023-03-09 - bortezomib 1.3mg/m2 2.1mg SC (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma - 2023-11-29 - https://www.uptodate.com/contents/image?imageKey=ONC%2F101205

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth.
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22

==========

2023-11-29

[APBSCT day 8: minor WBC rise, no PLT improvement]

Today is Day 8 post-APBSCT, and there is a slight increase in the WBC level observed. However, the PLT remains low and has not shown any signs of rising.

  • 2023-11-29 WBC 0.73 x10^3/uL D08

  • 2023-11-27 WBC 0.03 x10^3/uL D06

  • 2023-11-26 WBC 0.02 x10^3/uL D05 nadir

  • 2023-11-25 WBC 0.53 x10^3/uL D04

  • 2023-11-24 WBC 4.25 x10^3/uL D03

  • 2023-11-23 WBC 11.14 x10^3/uL D02

  • 2023-11-22 WBC 3.81 x10^3/uL D01

  • 2023-11-20 WBC 5.23 x10^3/uL D-1

  • 2023-11-29 PLT 18 *10^3/uL D08

  • 2023-11-27 PLT 53 *10^3/uL D06

  • 2023-11-26 PLT 78 *10^3/uL D05

  • 2023-11-25 PLT 28 *10^3/uL D04

  • 2023-11-24 PLT 51 *10^3/uL D03

  • 2023-11-23 PLT 75 *10^3/uL D02

  • 2023-11-22 PLT 98 *10^3/uL D01

  • 2023-11-20 PLT 143 *10^3/uL D-1

Based on the lab results from 2023-11-29, the patient’s liver and kidney functions are normal, indicating no need for dosage adjustments due to liver or renal concerns.

[tube feeding]

Concor 5mg - For administration, employ the Simple Suspension Method (SSM). This involves dissolving the tablet in warm drinking water, leaving it for 5-10 minutes, and occasionally stirring or gently shaking the container until the tablet fully dissolves. Once dissolved, it can be administered through a feeding tube. This technique is particularly useful for dissolving tablets and capsules in warm water, making them suitable for suspension and feeding tube administration.

Harnalidge 0.4mg - Since Harnalidge (tamsulosin 0.4mg) is not appropriate for tube feeding, it is advised to transition to Urief (silodosin 8mg) as a suitable alternative to meet the patient’s requirements.

2023-11-16

[minutes of interprofessional practice and family meeting]

Today, at 11:00 on 2023-11-16, an interprofessional practice and family meeting was convened by the attending physician, Dr. Gao, in the conference room of Ward 11A. The patient, along with his wife and only son, attended the meeting.

Dr. Gao provided the patient and his family with a comprehensive explanation about the current status of the disease, prognosis, the expected outcomes and risks associated with autologous PBSCT, and asked several questions to assess whether the family fully understood the situation.

Before the meeting, I visited the family and informed that the patient’s bilirubin levels were slightly elevated, but renal function was normal, and there was currently no need to adjust dosages due to liver or kidney function status.

As the patient’s hearing has been gradually declining, I suggested during the post-meeting casual conversation that, once the transplantation procedure is completed and the patient is in a stable condition, he should consider consulting an otolaryngologist to explore further corrective measures, such as getting a hearing aid.

701456176

231127

[exam findings]

[MedRec]

  • 2023-09-21 SOAP Hemato-Oncology Xia HeXiong
    • S: NGS BRCA2 C9515G (Leu3172A) > Uncertain Significance
    • P: Due to aberrant BRCA2 -> The follow-up CY will include the ovarian site.
  • 2023-08-30 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
    • Admission diagnosis
      • Left breast invasive carcinoma, cT1cM0N0, stage IA.ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left breast invasive carcinoma, cT1cM0N0, stage IA, ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%, s/p chemotherapy with Liposome Doxorubicin/Cyclophosphamide from 2023/08/31~
      • Chronic viral hepatitis B without delta-agent
      • Hyperlipidemia, unspecified
    • CC
      • for prepare chemotherapy        
    • Present illness
      • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
      • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
      • Breast sono on 2023/06/15 showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described. Left breast core needle biopsy was done on 2023/06/20 showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
      • Chest CT on 2023/06/30 showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Bone scan on 2023/07/03 showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • She received left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023/07/26.
      • This time, she was admitted for prepare chemotherapy.        
    • Course of inpatient treatment
      • After admission, arrange echocardiography for survey before chemotherapy, was done on 2023/08/31 showed LVEF: 75.6%, atypical mitral valve and tricuspid valve proplapse, adequate LV and RV performance with normal wall motion at resting state, mild MR, TR, normal LV and RV relaxation, then she receive Liposome Doxorubicin (30mg/m2, self paid) + Cyclophosphamide (600mg/m2) on 2023/08/31 smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Strocain 5mg/tab 1# PO TIDAC for stomach discomfort.
      • Chronic viral hepatitis B with Baraclude 0.5mg/tab 1# PO QDAC.
      • Hyperlipidemia wity Tulip F.C 20mg/tab 1.5# PO QOD.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, she was discharged on 2023/09/01 and OPD followed up later.
    • Discharge prescription
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Sinpharderm Cream (urea) BID TOPI
      • Emend (aprepitant 125mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# QOD (QN)
  • 2023-08-16 SOAP Hemato-Oncology Xia HeXiong
    • S: For further management
      • HBsAg (+), Anti-HBc (+), Anti-HBs (-), AHCV (-)
      • Mitral valve prolapse
      • Hyperlipidemia (+)
    • A
      • left breast cancer, TNBC, Ki-67: 10%, pT1cN0M0
    • P
      • Arrange admission for heart echo. Liopo-Dox / Cyclophoasmide x 4 followed by docetaxel x 4
      • Genetic test BRCA1/2
  • 2023-07-26 ~ 2023-07-29 POMR General and Gastrointestinal Surgery Chen YenZhi
    • Discharge diagnosis
      • Left breast invasive carcinoma status post simple mastectomy+sentinel lymph node biopsy on 2023/07/26. cT1cM0N0, stage IA. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. ECOG:0.
      • Right breast fibroadenoma status post partial mastectomy on 2023/07/26.
    • CC
      • noted a mass at left bresat on 2023/05 by health examination.
    • Present illness
      • This 46-year-old female patient had 1). Mitral Valve prolape without follow up it for many years ago; 2). HBV with follow up it for many years ago; 3). Hyperlipidemia with medicine control for many years. She denied any TOCC histories in recent 3 months.
      • She noted a mass at left bresat on 2023/05 by health examination. She came to our outpatient department for help.
      • Breast sono showed Left subareolar, size: 1.10x0.76 cm and 1.45x1.29 cm, ill-defined irregular shape lesion, suggested biopsy. Right 2/1.20 cm , size: 1.06x1.90 cm, fibroadenomas as described.
      • Left breast core needle biopsy showed invasive carcinoma. ER: Negative, PR : Negative, HER-2/Neu: Equivocal (2+), DISH: negative, Ki-67: 10%. CEA: 0.744 ng/ml, CA-153 :10.386 U/ml.
      • Chest CT showed 1). nodular lesion with enhancement at left breast measuring 1.91cm in largest dimension is found; 2). There is no evidence of mediastinal LAP. 3). No evidence of bilateral pleural effusion. 4). The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • Bone scan showed a hot area in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss.
      • Physical examination: symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 2x2 and 2x2 cm without discharge. The left nipple without dimping, exudative nor bloody discharge and no retraction. The left breast skin had no cellulite change. a hard, nontender, movable mass and irregular margin at right breast around 2x2 cm without discharge. The right nipple without dimping, exudative nor bloody discharge and no retraction. The right breast skin had no cellulite change.
      • Under the impression of left breast invasive carcinoma and right breast tumor, she was admitted for surgery of 1). left simple mastectomy + sentinel lymph node biopsy; 2) right partial mastectomy.
    • Course of inpatient treatment
      • After admission, left breast simple mastectomy + sentinel lymph node biopsy and right breast partial mastectomy were performed on 2023-07-26.
      • The post-operative course was relatively smooth without complication. The wounds are clean and dry.
      • Under the stable condition, she was discharged today and the final report will be follow up at outpatient department.
    • Discharge diagnosis
      • Acetal (acetaminophen 500mg) 1# QID
      • MgO 250mg 1# QID
      • Gaslan (dimehylpolysiloxane 40mg) 1# TID
      • Through (sennoside 12mg) 1# HS

[surgical operation]

[chemotherapy]

  • 2023-11-25 - docetaxel 75mg/m2 100mg NS 250mL 1hr (D, Q3W)
    • dexamethasone 4mg + metoclopramide 10mg + NS 250mL
  • 2023-11-02 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-10-12 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-09-21 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2
  • 2023-08-31 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL (AC(Lipo) Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-2

701499763

231127

[exam findings]

  • 2023-10-30 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 18.9) / 101 = 81.29%
      • M-mode (Teichholz) = 81.3
    • Conclusion:
      • Dilated aortic root, normal AV with mild AR
      • Normal MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
  • 2023-10-30 Miniprobe Endoscopic Ultrasound
    • Diagnosis:
      • Esophageal cancer, middle to lower esophagus, multifocal: T3Nx at least (lesion C), T1b (lesion B), unspecified T stage at lesion A
      • Hypopharyngeal cancer
      • Suboptimal study of EUS (related to difficulty in water immersion and suboptimal patient’s tolerance due to frequent coughing)
    • Suggestion:
      • Correlate with other imaging
  • 2023-10-28 MRI - brain
    • Large area of old infarction over left anterior amd middle MCA territories.
    • Passive dilatation of left lateral ventricle.
  • 2023-10-27 PET
    • Glucose hypermetabolism involving the right hypopharynx and posterior pharyngeal wall, compatible with primary hypopharyngeal malignancy.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes, bilateral neck level III and IV and left supraclavicular lymph nodes, suggesging metastatic lymph nodes.
    • Glucose hypermetabolism in the L5 spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
    • Glucose hypermetabolism in some focal areas in the middle and lower portions of the esophagus and in multiple lymph nodes around the EG junction. Synchronous esophageal malignancy with multiple regional lymph node metastases may show this picture.
    • Mild glucose hypermetabolism in the right shoulder and in bilateral pulmonary hilar lymph nodes. Inflammatory process may show this picture.
  • 2023-10-26 CT - chest
    • Indication: suspect esophageal cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • Lymphadenopathy at bilateral thoaracic inlet is found. Compatible with hypopharyngeal cancer meta.
      • Wall thickening at lower esophagus with extension into gastric cardiac portion is found measuring 8.5cm in largest dimension. Esophageal cancer is considered. Regional lymph nodes are found at perigatric region (n=5)
      • Mild to moderate Emphysematous change over both lungs is found.
      • Calcified coronary arteries is found.
      • Dilatation of the infrarenal aorta measuring 2.4cm is found.
      • Wall thickening at cardiac portion of the stomach. Suggest correlate with endoscopy to exclude synchronous gastric cancer.
      • Diffuse wall thickening at hypophrynx with regional lymphadenopathy. Extensive hypopharyngeal cancer is considered.
    • Imp:
      • Esophageal cancer with gastric cardiac extension and regional lymphadenopathy.
      • Synchronous esophageal cancer.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-10-25 Tc-99m MDP bone scan
    • Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in some T-spine, right shoulder, right elbow, and left S-I joint.
  • 2023-10-25 Patho - esophageal biopsy
    • Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident. Tumor necrosis is present.
  • 2023-10-24 MRI - larynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A large right hypopharyngeal tumor, extending to left site, highly suspect with right carotid space invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Enlarged right retropharyngeal LN and bil. neck LNs. Highly with ENE (+) at left low neck, supraclavicular fossa.
    • IMP:
      • Right hypopharyngeal CA, T4bN3Mx stage IVB
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 4b(T_value) N: 3b(N_value) M: 0(M_value) STAGE: IVB (Stage_value)
  • 2023-10-24 EGD
    • Diagnosis:
      • Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion
      • C/W hypopharyngeal cancer
    • Suggestion:
      • Pursue pathology report
  • 2023-10-24 SONO - abdomen
    • Findings
      • Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction.
    • Diagnosis:
      • Suspect lymph node metastasis
    • Suggestion:
      • EGD and CT study
  • 2023-10-12 Patho - larynx biopsy
    • Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stains: Ki-67: 70%, p16 (-).
  • 2023-10-02 Nasopharyngoscopy
    • smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??

[MedRec]

  • 2023-10-02 SOAP Ear Nose Throat Huang YunCheng
    • S:
      • lump in throat, dysphagia and easy choking for3 months
      • patient has strong gap reflex, hard to assess NP and larynx by mirror
    • O:
      • Nasopharyngoscope findings: Smooth NP, right posterior pharyngeal wall bulging tumor, also right vocal plasy??
      • breathing smooth
    • P:
      • suggest LMS biopsy

[consultation]

  • 2023-11-02 Oral and Maxillofacial Surgery
    • Q
      • This 56-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • He admitted for cancer workup, after the examination done, hypopharyngeal cancer and esophageal cancer were diagnosed. CCRT was indicated.
      • We had consult your expertise on 10/24. You suggest that extraction of all hopeless teeth (12,17,23,27,38 and 44) .
      • The patient has shceduled port-A implant and juojenostomy on 2023/11/03.
      • The patients to have a tooth extraction during the thoracic surgery, but after reconfirming with the thoracic department, the surgery might only start around noon. The patient won’t be discharged in the short term, so we can arrange for the tooth extraction to be done in separate sessions
    • A
      • Dear doctor, we will arrange the surgery.
  • 2023-10-26 Gastroenterology
    • Q
      • For arrange miniprobe EUS
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
      • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
      • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
      • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
      • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
      • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which suggest arrange miniprobe EUS. We need your help, thank you very much!!
    • A
      • This is a 55-year-old male who was admitted due to newly found right hypopharyngeal cancer.
        • EGD showed a few polypoid and nodularity lesions noted 30cm below incisors to EC junction, suspect metastasis, r/o second primary cancer.
        • We are consulted for EUS.
      • S
        • dysphagia, solid and liquid food
        • smoking and betelnut before, quit
      • O
        • E4V5M6, cons clear
        • Conjunctiva: not pale
        • Sclera: anicteric
        • Abdomen: soft and flat, no tenderness
      • Impression
        • Right hypopharyngeal cancer, T4bN3Mx
        • Suspected esopharyngeal malignancy, suspect second primary cancer
      • Suggestions
        • EUS may be arranged.
  • 2023-10-26 Radiation Oncology
    • A: The patient’s history was reviewed and patient was examined.
      • S: For CCRT due to hypopharyngeal carcinoma and esophageal carcinoma.
        • PI: The patient suffered from right MCA infarct on 2023/06. He complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor. He recevied laryngomicrosurgery on 2023/10/11.
          • Pathology showed squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-). The diagnosis was right hypopharyngeal carcinoma, stage cT4bN3M0, stage IVB. In addition, PES showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. Referred for CCRT.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM (-); HTN (-)
        • Previous RT Hx: (-)
      • O: ECOG: 2
        • PE: neck and bil SCF: a palpable nodal lesion over right middle neck. CVA with right upper limb weakness.
        • CXR (2023-10-11): Tortuosity of the aorta with atherosclerotic change.
        • Pathology (S2023-20303, 2023-10-16): Labeled as “Right arytenoid papillary tumor”, LMS biopsy — squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
        • Abd sono (2023-10-24): Hypoechoic leison up to 2.8cm was noted near the S3 and EC junction. Diagnosis: Suspect lymph node metastasis.
        • UGI panendoscopy (2023-10-24): Tumor, lower esophagus, s/p biopsy, suspect metastasis, r/o primary lesion. C/W hypopharyngeal cancer.
        • MRI of larynx (2023-10-24): Right hypopharyngeal CA, T4bN3Mx stage IVB
        • Bone scan (2023-10-25): Faint hot spots in the posterolateral aspect of the right 10th rib and right scapula, respectively, and increased activity in the lower C-spine and right S-I joint, the nature is to be determined (post-traumatic change or other nature?)
        • Pathology (S2023-21165, 2023-10-26): Esophagus, lower, biopsy — Squamous cell carcinoma, moderately differentiated
      • A:
        • Squamous cell carcinoma, p16 (-), of the right hypopharynx, stage cT4bN3M0 (stage IVB).
        • Squamous cell carcinoma of the low third esophagus.
      • P:
        • CCRT is indicated for this patient with the following indicators: hypopharyngeal carcinoma, stage cT4bN3M0 (stage IVB); esophageal carcinoma.
        • Goal: palliation
        • Treatment target and volume: 1. hypopharyngeal tumor to bilateral neck; 2. low third esophageal carcinoma and peripheral area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor bed and involved nodal lesion. 5040cGy/28 fractions of the esophageal tumor (if surgery no tplanned).
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0900, 2023-11-2.
        • Please consult Dental department for pre-RT dental evaluation and management.
  • 2023-10-25 Hamato-Oncology
    • Q
      • For CCRT further evaluation
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06.
      • This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01.
      • Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. IHC stains: Ki-67: 70%, p16 (-).
      • Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up.
      • Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB.
      • Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis.
      • PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion.
      • Bone scan was done on 10/25 and pending result. We consulted CS for suspect eshopharygeal cancer evalution, which arrange staging for eshopharygeal cancer, neoadjuvant CCRT will be first considered.
      • We need your help for CCRT further evaluation. Thank you very much!!
    • A
      • This 55 year old man had inderline disease of right MCA infarction on 2023/06. We are consulted CCRT for 1. Hypopharygear cancer, cT4bN3Mx, stage IVB and 2. Suspect esophageal cancer, pending pathology result.
      • Suggestion:
        • We will discuss with patient about CCRT.
        • Pending esophageal cancer biopsy result and complete esophageal cancer staging (chest CT+/-contrast, PET/CT scan…).
        • Additionally, Please check HBsAg, Anti HBc, Anti HBs, Anti HCV before chemotherapy.
        • And arrange port A and jejunostomy before chemotherapy.
  • 2023-10-24 Thoracic Surgery
    • Q
      • For suspect esophageal caner
      • This 55-year-old man had Right MCA infarct on 2023/06. Operation histiory of left scalp laceration status post repair on 2023/06. This time, he complained about cough with blood-tingled sputum, lump in throat, dysphagia and easy choking since 2023/01. Then, he went to our ENT OPD for help, where nasopharyngoscope was done and showed right posterior pharyngeal wall bulging tumor.
      • He recevied laryngomicrosurgery on 2023/10/11. Pathology result squamous cell carcinoma. Under the impression of hypopharyngeal cancer. This time, the patient was admitted for cancer work-up. Laryngeal MRI was arranged and showed right hypopharyngeal CA, T4bN3Mx, stage IVB. Abd echo arranged and showed hypoechoic leison up to 2.8cm was noted near the S3 and EC junction, suspect lymph node metastasis. PES arrange and showed a few polypoid and nodularity lesions were noted from 30cm below incisors to EC junction, suspect metastasis, r/o primary lesion. We need your help for further evaluation. Thank you very much!!
    • A
      • I will arrange staging for eso. ca. After staging, I will explain the following management with him and his family.
      • Neoadjuvant CCRT will be first considered. Feeding jejunostomy and port-A insertion will be arranged before treatment.
  • 2023-10-24 Oral and Maxillofacial Surgery
    • Q
      • For tooth evaluation
      • This time, the patient was admitted for cancer work-up. We will arrange CCRT for him. We need your help for tooth evaluation. Thank`s a lot
    • A
      • After examing the intraoral condition.
      • Possible treatment plan
        • Treatment option A
          • extraction of all hopeless teeth (12,17,23,27,38 and 44) to prevent RT-related osteonecrosis and risk of cellulitis
          • Possible risk: relative contraindication due to recent right MCA infarction this June.
        • Treatment option B
          • conservative treatment (toothbrushing)
          • Possible risk: osteonecrosis and risk of cellulitis
      • patient’s father and his wife understands and will consider about it. thank you for your consultation

[radiotherapy]

[chemotherapy]

  • 2023-11-21 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-11-06 - NS 500mL 1hr (before CDDP) + cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 500mL 1hr (after CDDP) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-27

[Akynzeo use for prolonged nausea control post-chemotherapy]

On 2023-11-21, the patient was administered cisplatin at 40mg/m2, with premedication including dexamethasone, diphenhydramine 30mg, palonosetron 250ug, and NS hydration.

Post-treatment, the patient experienced nausea and vomiting for an additional three days, leading to the prescription of metoclopramide.

For subsequent chemotherapy sessions, it may be beneficial to consider Akynzeo, available in this hospital. Akynzeo, containing netupitant, an NK-1 receptor antagonist with a 96-hour half-life, could provide prolonged anti-emetic effects.

[hypomagnesemia and hypokalemia]

Cisplatin is a common cause of hypomagnesemia and hypokalemia due to renal magnesium (Mg) and potassium (K) losses.

  • 2023-11-27 K (Potassium) 3.1 mmol/L

  • 2023-11-24 K (Potassium) 3.8 mmol/L

  • 2023-11-23 K (Potassium) 4.9 mmol/L

  • 2023-11-27 Mg (Magnesium) 1.8 mg/dL

  • 2023-11-06 Mg (Magnesium) 1.9 mg/dL

Magnesium (MgO) and potassium (Const-K) supplements are currently in use. There is no problem with the supplementation.

[mild hyponatremia]

Based on the laboratory data, mild hyponatremia has been consistently observed for the past month and a half, and it may be considered to investigate the possible underlying causes.

  • 2023-11-27 Na (Sodium) 133 mmol/L
  • 2023-11-24 Na (Sodium) 134 mmol/L
  • 2023-11-23 Na (Sodium) 133 mmol/L
  • 2023-11-06 Na (Sodium) 133 mmol/L
  • 2023-10-11 Na (Sodium) 134 mmol/L

[elevated BUN]

Cisplatin primarily injures the S3 segment of the proximal tubule. Urea undergoes a more complex process involving reabsorption and secretion in different parts of the tubules, while creatinine is not significantly reabsorbed after filtration. The elevated BUN may be a vague indication of cisplatin nephrotoxicity.

  • 2023-11-27 BUN 35 mg/dL
  • 2023-11-23 BUN 21 mg/dL
  • 2023-11-14 BUN 15 mg/dL

2023-11-06

Every oral medication listed as currently active is suitable for administration via a feeding tube.

700032025

231124

[MedRec]

  • 2023-11-14 SOAP Heamto-Oncology He JingLiang
    • S: ca of stomach with liver mets
    • P: arrange C/T with FOLFOX
  • 2023-11-14 SOAP Gastroenterology Gong ZiXiang
    • S
      • Gastric cancer with liver metastasis, r/o HCC or cholangiocarcinoma (r/o double cancer) -> refer to GS, Oncology, keep PPI
        • GS suggest: tissue aquitition is needed for liver tumor
    • O
      • 2023/11/03 CT: ABD — whole abdomen, pelvis - Impression (Imaging stage): T4aN2M1, stage: IVB
        • There is a huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size
      • 2023/10/30 PATHO - Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
        • IHC stain— Her2/neu: negative (0)
    • Prescription
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Pariet (rabeprazole 20mg) 1# QDAC
  • 2017-01-26 SOAP Cardiology Xu ShunYi
    • Diagnosis
      • Pure hyperglyceridemia [E78.1]
      • Essential hypertention, unspecified [I10]
      • Chronic airway obstruction (COPD) ,NEC [J44.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type [E11.9]
    • Prescription x3
      • Diovan (valsartan 160mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD

[consultation]

  • 2023-11-20 Radiation Oncology
    • Q
      • for liver mass for R/T
      • This is a 71-year-old male with past history of HTN and hyperlipidemia, Type 2 DM, Ankylosing Spondylitis and Gastric adenocarcinoma, cT4aM1N2, stage IVB status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size.
      • He used to smoking 1 packs per week for about 20-30 year and had tea, coffee ocasionally.
      • According to patient statement and his medical record, he had burning sensation at night, poor digestion progressive for a half year, more severe on October. He went to our GI OPD for help.
      • EsophagoGastroDuodenoscopy was arranged on 10/30 and showed gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy.
      • Abdominal CT was arranged on 11/03 and revealed Adenocarcinoma of the stomach and HCC 9 cm in S4-7-8 of the liver is highly suspected, imaging stage: T4aN2M1,stage:IVB.
      • Panendoscopy biopsy pathological report revealed poorly differentiated adenocarcinoma. CT guide of liver was arranged for R/O HCC huge central type.
      • Liver, CT-guided biopsy showed Adenocarcinoma. This time, he was admitted for on port-A and chemotherapy.
      • We sincerely need your professional assistance!!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy of the metastatic liver tumor.
        • PI: The patient was a case of gastric adenocarcinoma, stage cT4aN2M1 (IVB), status with metastatic nodes with huge heterogeneous poor enhancing mass in S4-7-8 of the liver, measuring 9 cm in size. Pathology (S2023-22725, 2023-11-15) showed liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma. Referred for radiotherapy of the metastatic liver tumor.
        • Family history: (father: hepatoma)
        • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
        • Personal Hx: DM (-); HTN (+); HBV (+); ankylosing spondylitis
        • RT Hx: (-)
      • O: ECOG: 1
        • PE: neck and bil SCF: neg; abdomen: mild induration of the upper abdomen.
        • UGI panendoscopy (2023-10-30): Reflux esophagitis LA Classification grade A. Superficial gastritis, s/p CLO test. Gastric ulcer, cardia, AW-LC, suspected malignancy, s/p biopsy. CLO test: Negative.
        • Pathology (S2023-21538, 2023-11-1): ADDENDUM: IHC stain — Her2/neu: negative (0). DIAGNOSIS: Stomach, cardia, biopsy — poorly differentiated adenocarcinoma
        • CT scan of abdomen (2023-11-14): 1. Adenocarcinoma of the stomach. 2. HCC 9 cm in S4-7-8 of the liver is highly suspected. The differential diagnosis includes Metastasis. Please correlate with dynamic MRI. 3. Detailed findings, please see description.
        • Pathology (S2023-22725, 2023-11-15): Liver, CT-guided biopsy — Adenocarcinoma, moderately differentiated, compatible with metastatic gastric adenocarcinoma
      • A: Poorly differentiated adenocarcinoma of the stomach, stage cT4aN2M1(IVB) with liver metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: large metastatic liver tumor
        • Goal: palliation
        • Treatment target and volume: metastatic liver tumor
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the metastatic liver tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-11-22.

[radiotherapy]

[chemotherapy]

  • 2023-11-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

700617345

231124

[lab data]

2023-04-07 Anti-HBs 64.07 mIU/mL
2023-04-07 Anti-HBc Nonreactive
2023-04-07 Anti-HBc Value 0.08 S/CO
2023-04-07 Anti-HCV Nonreactive
2023-04-07 Anti-HCV Value 0.06 S/CO
2023-04-07 HBsAg Nonreactive
2023-04-07 HBsAg (Value) 0.47 S/CO

[exam findings]

  • 2023-10-03 CT - abdomen
    • S/P hysterectomy.
    • Liver cyst, 0.4cm in S2-3.
    • R/O left renal cyst, 0.5cm.
  • 2023-07-17 EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, antrum
  • 2023-03-29 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Uterus, endometrium, total hysterectomy with frozen section — endometrioid adenocarcinoma grade 2.
      • Uterus, myometrium, total hysterectomy — tumor invasion, 1 mm; <1/2 thichness of the thickness of the myometrium; one myoma present.
      • Uterus, cervix, total hysterectomy — free
      • Ovaries and fallopian tubes, bilateral, BSO — No malignancy. Endometriosis and corpora lutea present.
      • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      • Omentum, partial omentectomy — Free
      • pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA
    • Gross description:
      • Procedure (select all that apply) - staging surgery: Total hysterectomy and bilateral salpingo-oophorectomy, partial Omentectomy: uterus: 10 x 8 x 5 cm with polypoid endometrial tumor at fundus. Left ovary: 3.5 x 2.5 x 1.5 cm. Left tube: 5.5 x 1 x 1 cm; right ovary: 3.5 x 2.5 x 1.5 cm; right tube: 5 x 1 x 1 cm. Omentum: 6 x 3.5 x 1.5 cm
        • For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Tumor Site (select all that apply)- Endometrium, fundus, > 4.5 cm from cervical margin.
      • Tumor Size:
        • Greatest dimension: 5 cm
          • Additional dimensions (centimeters): 3.5 x 0.5 cm
      • Sections are taken and labeled as:
        • Tissue for section: A: left external iliac lymph nodes; B: left obturator lymph nodes; C: right external iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: right para-aortic lymph nodes; G1: left ovary; G2: left tube; G3: right ovary; G4: right tube; G5-8: endometrial tumor; G9: non-tumrous endometrium and uterine corpus and myoma; H1-3: omentum.
    • Microscopic Description:
      • Histologic Type: Endometrioid carcinoma
      • Histologic Grade: FIGO grade 2 (low-grade)
      • Myometrial Invasion: present, 1 mm in depth; < 1/2 thichness of the thickness of the myometrium
      • Uterine Serosa Involvement - Not identified
      • Cervical Stromal Involvement - Not identified
      • Other Tissue / Organ Involvement: Not identified
      • Bilateral ovaries: free
      • Omentum: free
      • Margins (required only if cervix and/or parametrium/paracervix is involved by carcinoma)
        • Ectocervical/Vaginal Cuff Margin: ree
        • Parametrial/Paracervical Margin: Free
      • Lymphovascular Invasion: Absent
      • Regional Lymph Nodes: free= 0/48= A: left external iliac lymph nodes (0/10); B: left obturator lymph nodes (0/10); C: right external iliac lymph nodes (0/11); D: right obturator lymph nodes (0/11); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/3).
        • Right Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free 0/22
        • Left Pelvic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): 0/20
        • Para-aortic Node: (Number of lymph nodes with metastasis) / (Number of total lymph nodes examined): free (0/6)
      • Additional Pathologic Findings - myoma
  • 2023-03-23 CT - abdomen
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE: IA_(Stage_value)
  • 2023-03-16 Patho - endometrium curretage / biopsy
    • Uterus, endometrium, D&C — endometrioid carcinoma with focal clear cell carcinoma
    • Sections show atypical crowded and cribriform endometrioid carcinoma (grade 1) with focal clear cell carcinoma.
    • Immunohistochemically, the endometrioid carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(-), and PR(+).
    • Immunohistochemically, the clear cell carcinoma shows PAX8(+), WT-1(-), p53(No aberrant expression), Napsin A(+), and PR(-).

[MedRec]

  • 2023-04-11 SOAP Radiation Oncology Huang JingMin
    • A: Endometrioid carcinoma with focal clear cell carcinoma of the uterine endometrium, stage pT1a pN0 (cM0); AJCC 8th edition Pathology stage: IA, s/p staging surgery.
    • P: Radiotherapy is indicated for this patient with the following indicators: invasive clear cell carcinoma, stage IA.
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-25.
  • 2023-04-11 SOAP Hemato-Oncology Xia HeXiong
    • S: This 36 year old woman is a case of Endometrioid adenocarcinoma grade 2. pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
    • Plan:
      • Arrange CCRT with CDDP and then C/T with TP
      • Simulation on 2023/04/25
      • May start weekly CDDP on 2023-05-02
  • 2023-03-28 ~ 2023-04-07 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Endometrioid adenocarcinoma grade 2.pT1a pN0 (if cM0); AJCC 8th edition Pathology stage: IA  post Staging surgery on 2023/03/29
      • Abnormal vaginal bleeding
      • Epilepsy
    • CC
      • Abnormal intermittent uterine bleeding for 1 year
    • Present illness
      • This is a 36 y/o woman who had no sexual history, G0P0, LMP 2023/03/26, menstral cycle irregular with duration/interval of 7/28-30 days.
      • She had past history of (1) epilepsy s/p epilepsy surgery twice (2013, 2014) and vagus nerve stimulation therapy (2021.08.25), currently on anticonvulsant drugs, (2) Mixed hemorrhoids. She is allergic to carbamezepine. She denied oral contraceptives or hormone use.
      • According to the patient, she noticed abnormal intermittent uterine bleeding for 1 year. During menstration, heavy menstrual bleeding was noticed which she must use night sanitary pads and change at least 3 times a day, blood clots could be found, with fresh red color. She denied dysmenorrhea. Intermenstrual spotting with scanty, brownish discgarge was noted during the past 6 months. Epileptic seizures were triggered by menstration, and during menstration the frequency and duration of seizure increase. She denied abdominal pain, nausea, vomiting, tarry or bloody stool, constipation, unintentional body weight loss, or disuria or urinary frequency.
      • She turned to our GYN OPD for help, and some examination was done. The transvaginal sono on 2023.03.07 revealed endometrial polyp in size of 13*12mm. Hysteroscopy was performed on 2023.03.08 and multiple endometrial polyps with abberant vessels were found. D&C on 2023.3.16 revealed endometrioid carcinoma with focal clear cell carcinoma and chronic cervicitis. Abdominal CT was also done on 2023.03.23 and revealed soft tissue in the uterine cavity, r/o endometrial malignancy, stage T1aN0M0. Tumor marker showd CA125 = 34.5 U/mL; CEA = 2.16 ng/mL. And Hb level was 7.6 g/dL. Under the impression of endometrial clear cell carcinoma, she was admitted on 2023.03.28 for staging operation.        
    • Course of inpatient treatment
      • The patient was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day.
      • The surgical pathology revealed, The surgical pathology frozen section, endometrioid adenocarcinoma grade 2. Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition.
      • The Gyn tumor conference suggest further chemotherapy and radiotherapy for her after operation. Arrange port-A for checmotherapy and removed JP drain on 04/06. The vital sign was stable after surgery. She is discharged on 04/07/2023 and her followup appointment is scheduled on next week.
    • Discharge prescription
      • cephalexin 500mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 2# TID
      • Through (sennoside 12mg) 2# HS

[consultation]

  • 2023-04-06 Neurology
    • Q
      • For evaluation of epilepsy therapy during chemo/radiotherapy.
      • The 36-year-old female patient with underlying of epilepsy under medication and s/p vagal nerve stimulator in 2021 was admitted on 03/29/2023 and underwent laparoscopic GYN cancer staging surgery (bil salpingo-oophoretomy + BPLND + partial omentectomy) and laparoscopic adhesiolysis the next day. The surgical pathology revealed: endometrioid adenocarcinoma grade 2; Pathology stage: IA , pT1a pN0 (if cM0); AJCC 8th edition. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. The Gyn tumor conference was arranged and chemo/radiotherapy will be arranged.
      • Due to her underlying of epilepsy with medication and vagal nerve stimulator, we need your expertise for evaluation of treatment.
      • Current medication: Lacosamide, Lamotrigine, Clobazam, Topiramate, Perampanel, Rufinamide.
    • A
      • This 36 year fenalt P’t is a case of Epilsy since 10+ years old and persis poor control even under 6 ASMs within therapy range and lesionnectomy. VNS was placed last year but still under titration of stimulation amplitudes and frequent.
      • She admitted to our GYN ward for sndometrioid adenccarcinoma and received bil salpingo-oophoretomy + BPLND + partial omentectomy on 3/29. Now, due to need further chemo/radiotherapy, we were consulted for evaluation the condition and further suggestion.
      • Imp:
        • Drug resistent epilepsy under ASMs and VNS
        • endometrioid adenocarcinoma s/p bil salpingo-oophoretomy + BPLND + partial omentectomy
      • Suggestion:
        • Due to all ASM within therapeutic dosage and no obvious drug-drug interation, we suggested keep present treatment.
        • Keep VNS therapy, needn’t adjust during chemo/radiotherapy
        • We had explained to patient and family that seizure rate may elevated during chemo/radiotherapy. But treatment plan of epilepsy needn’t adjust right now.
        • We also explained the possibility of status epiepticus and promised Neuroogist will help as soon as possible.
        • If seizure attack and persist over 5 minutes, give ativan iv 2 amp st, and depakine iv 30mg/kg quickly loading within 5~10 minutes. Consult Neuro emergency for further management of status epilepticus.

[surgical operation]

  • 2023-04-06
    • Surgery
      • Operation
        • Port-A (47080B)
        • Fluoroscopy (32026C)        
    • Finding
      • Insertion via right subclavian vein.
      • Port: Polysite, 3007, 7Fr,
      • Fluorosopy: catheter tip in SVC above RA
  • 2023-03-29
    • Surgery
      • Diagnosis: Endometrial cancer
      • Surgery: Staging surgery
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Bilateral adnexa: grossly normal
      • CDS: mild adhesion (+), ascites (+)
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal
      • Estimated blood loss: 300 mL
      • Blood transfusion: nil
      • Complication: nil
    • Procedure
      • Put the patient on the lithotomy position
      • Vaginal douching, insert Foley catheter, skin disinfection with beta-iodine, and skin draping.
      • Make midline vertical skin incision and open the abdominal wall layer by layer.
      • Serous ascites, send for cytology
      • Apply auto-retractor and pack up the intestine to expose the uterus.
      • Clamp, ligate and cut left round ligament
      • Clamp, cut andligate left infundibulo-pelvic ligament
      • Repeat step 6-7 at the right side.
      • Dissect the densely adherent posterior leaf of broad ligaments overlying the uterosacral ligaments bilaterally.
      • Dissect and reflect the bladder downwards and off the uterus.
      • Clamp, cut andligate the ascending branches of uterine arteries bilaterally at the level of isthmus of cervix.
      • Clamp, cut and ligate the paracervical vessels along lateral borders of cervix step by step downwards bilaterally till the level of lateral vaginal fornix.
      • Cut the uterus and grasp the vaginal stump
      • Suture the bilateral angles of vaginal stump with 1-0 Vicryl
      • Suture the vaginal stump with 1-0 Vicryl
      • Step by step clamp, cut and ligate the omentum.
      • Irrigate the pelvic cavity with normal salin.
      • Check bleeding and hemostasis.
      • Insert J-VAC X 2 at the cul-de-sac.
      • Close the abdomen layer by layer.
      • Skin approximation.
  • 2023-03-16
    • Surgery
      • Diagnosis: R/O endometrial hyperplasia
      • Surgery: Fractional dilatation and curettage        
    • Finding
      • Uterus: Anteversion, 7 cm.
      • Scanty endocervical and some endometrial tissue were curetted out.
      • Mild laceration wound at 4 o’clock of the hymen.
      • Estimated blood loss:5 mL, Blood transfusion: nil, complication: nil.        
    • Procedure
      • Put the patient on lithotomy position.
      • Douching, skin disinfection and skin draping as usual.
      • Sounding: Anteversion, 7 cm.
      • Cervical dilatation to Hegar No. 7.
      • Curette the endocervical canal and uterine cavity.
      • Check bleeding.
      • Pack one piece of Bosmin gauze in the vagina to compress the hymen laceration wound.

[radiotherapy]

  • 2023-05-04 ~ 2023-06-16 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.

[chemotherapy]

  • 2023-11-23 - paclitaxel 105mg/m2 160mg NS 500mL 3hr + cisplatin 45mg/m2 70mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-10-30 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-10-04 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3 + lorazepam 2mg IVD Q12H D1-3
  • 2023-09-12 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-03 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-14 - paclitaxel 175mg/m2 240mg NS 500mL 3hr + cisplatin 75mg/m2 100mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) (Q3W)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-08 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-01 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-25 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-18 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-11 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-04 - cisplatin 40mg/m2 60mg NS 500mL 2hr + NS 1000mL (Y-sited CDDP) (weekly CDDP, CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-24

[reduced chemotherapy dosage in this hospitalization]

The dosage of the paclitaxel-cisplatin regimen given during this hospital stay was decreased to 60% of the previous amount, taking into account the patient’s ability to tolerate the treatment.

While the CEA and CA125 markers are within normal limits, the rising CA199 levels may indicate underlying conditions that are yet to be identified and warrant further investigation.

  • 2023-11-14 CA199 1260.46 U/mL
  • 2023-10-17 CA199 1545.37 U/mL
  • 2023-09-06 CA199 633.28 U/mL
  • 2023-08-22 CA199 351.27 U/mL
  • 2023-07-26 CA199 3.92 U/mL
  • 2023-05-02 CA199 3.90 U/mL

2023-10-31

The drugs prescribed by VGHTPE on 2023-10-16 are currently in use, no medication discrepancy is found.

2023-10-03

The drugs rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam refilled on 2023-09-08 to treat the patient’s “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus” are currently in use with no discrepancy found.

2023-09-12

No medication discrepancy has been found.

2023-08-04

[reconciliation]

This patient recently refilled a 30-day prescription on 2023-07-24, provided by Taipei Veterans General Hospital, for rufinamide, lamotrigine, topiramate, lacosamide, perampanel, and clobazam to manage her “localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, with status epilepticus.” However, these medications are not currently in use. Please verify if there is no longer a need for these drugs.

2023-07-14

[leukopenia]

The organization of WBC level changes is as follows, where * represents WBC < 3K/uL, ** represents WBC < 2K/uL. Leukopenia, which occurred in late May and worsened in mid-June, is more likely the result of the cumulative effects of multiple CCRTs when considering the treatment timeline. After each dose of Granocyte (lenograstim 250ug) administered on 2023-06-29 and 2023-07-01, leukopenia is currently no longer present.

2023-07-13 WBC 5.96 x10^3/uL 2023-07-06 WBC 4.03 x10^3/uL
2023-06-29 WBC 1.64 x10^3/uL ** Granocyte (lenograstim 250ug) 06/29, 07/01 2023-06-15 WBC 1.59 x10^3/uL ** concurrent CDDP 06/08 2023-06-07 WBC 2.05 x10^3/uL * concurrent CDDP 06/01 2023-05-31 WBC 2.02 x10^3/uL *
2023-05-24 WBC 2.22 x10^3/uL * concurrent CDDP 05/18, 05/25 2023-05-17 WBC 3.21 x10^3/uL concurrent CDDP 05/11 2023-05-10 WBC 3.47 x10^3/uL concurrent CDDP 05/04 2023-05-02 WBC 5.00 x10^3/uL
2023-03-30 WBC 10.44 x10^3/uL
2023-03-28 WBC 3.01 x10^3/uL
2023-03-08 WBC 3.31 x10^3/uL
2021-07-12 WBC 3.97 x10^3/uL

[paclitaxel administered, leukopenia needs to be monitored in the coming weeks]

  • It is worth noting for the future that the paclitaxel, which we started administering today on 2023-07-14, is also expected to cause bone marrow suppression. Among these, neutropenia is the main dose-limiting hematologic toxicity of paclitaxel. Severe, grade 4 neutropenia and febrile neutropenia have been reported. Neutrophil nadir is generally rapidly reversible. The onset is intermediate, with neutrophil nadir typically occurring at a median of 11 days. Risk factors include higher doses, longer duration of infusion, and extent of prior cytotoxic chemotherapy.
  • In addition to paclitaxel, cisplatin is also being used simultaneously. The latter causes leukopenia (25% to 30%; nadir: Day 18 to 23; recovery: By day 39; dose-related).
  • Therefore, it is suggested to closely monitor the patient over the next few weeks.

700648329

231124

[lab data]

2023-08-04 Anti-HBc Reactive
2023-08-04 Anti-HBc-Value 7.10 S/CO
2023-08-04 Anti-HBs 205.76 mIU/mL
2023-08-04 HBsAg Nonreactive
2023-08-04 HBsAg (Value) 0.27 S/CO
2023-08-04 Anti-HCV Nonreactive
2023-08-04 Anti-HCV Value 0.10 S/CO

[exam findings]

  • 2023-08-25 Venous Ultrasound
    • Report: Thrombus None
      • Right side:
        • SVC: 3.3 mmHg ; 3.9 mmHg ;
        • MVO/SVC: 100 % ; 100 % ;
        • Average MVO/SVC: 100 %
      • Left side:
        • SVC: 11.0 mmHg ; 11.4 mmHg ;
        • MVO/SVC: 78 % ; 82 % ;
        • Average MVO/SVC: 80 %
    • Conclusion:
      • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
      • Right lower limb soft tissue edema; mild right long saphenous vein engorgement
  • 2023-08-23 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider anterior ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2023-08-21 Peripheral Vascular Test - Artery. lower limbs
    • Atherosclerosis: Minimal
    • Doppler : Normal
    • Conclusions:
      • Patent bilateral CFA, SFA, PFA and popliteal arteries.
        • Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs.
      • Tissue edema at right leg.
  • 2023-08-18 Cell block
    • 50 cc brown turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and some atypical epithelial cells which immunocytochemistry shows GATA-3(+), TTF-1(-), and P40(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic breast carcinoma.
  • 2023-08-17 CXR (erect)
    • Bilateral pleural effusion.
    • Multiple nodules at bil. lungs.
  • 2023-08-12, -08-11 CXR (erect)
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-08-11 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy
      • Superficial gastritis
      • Gastric polyps, body
    • Suggestion:
      • pursue pathology
      • PPI and sucralfate therapy
  • 2023-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (77 - 39) / 77 = 49.35%
      • M-mode (Teichholz) = 70
    • Conclusion
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2023-08-08 Tc-99m MDP bone scan
    • Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2023-08-07 PET
    • Increased FDG uptake in the left breast, compatible with the primary breast cancer.
    • Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases.
    • Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases.
    • Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-04 Patho - breast biopsy
    • DIAGNOSIS: Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade
    • Microscopically, section shows intermediate-grade ductal carcinoma in situ characterized by a proliferation of atypical ductal epithelial cells with central necrosis of comedo-type. The tumor cells exhibit round to oval nuclei, nuclear pleomorphism, hyperchromasia and increased N/C ratio.
    • Immunohistochemical stain reveals
      • ER: negative
      • PR: negative
      • Her2/neu: positive(3+)
      • CK5/6: negative
      • p63: positive for myoepithelium.
  • 2023-08-04 SONO - breast
    • Left breast malignancy with axillary lymph nodes metastasis.
    • BI-RADS: Category 5: highly suggestive of malignancy-appropriate action should be taken.
  • 2023-08-03 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-06-20 CT - abdomen
    • History and indication: abdominal pain
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Left breast tumor (5.4cm).
      • Multiple lung and liver tumors.
      • Right renal stone (3mm).
    • IMP:
      • Left breast cancer with lung and liver metastases.

[MedRec]

  • 2023-09-28 SOAP Hemato-Oncology Xia HeXiong
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-08-11
      • Use TCHP first, and then add R/T if needed based on the effectiveness.
  • 2023-08-03 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Left breast ductal carcinoma in situ, intermediate-grade with left mid- and high-axillary lymph nodes, bilateral lungs and in both lobes of the liver, cTxN3aM1, stage IV, ER(-), PR(-), Her/neu(3+)
      • Malignant neoplasm of unspecified site of unspecified female breast
      • Intraductal carcinoma in situ of left breast
      • Abnormal results of liver function studies
      • Chronic viral hepatitis B without delta-agent, Anti-HBc (+)
      • Anemia, unspecified
      • Fever, unspecified
      • Agranulocytosis secondary to cancer chemotherapy
      • Abnormality of albumin
      • Hypokalemia
      • Hypomagnesemia
    • CC
      • breast ca is considered, admission for biopsy of left side breast
    • Present illness
      • The 57 years-old woman deny any past medical history. Initial symptoms with left side breast mass redness and swelling was found since 2018, no treatment. Since 2021, she return to taiwan received Chinese medicine treatment until now, but progression in 2023/04.
      • She visted to LMD, free echo showed much tumor in abdominal then referral to our ER. She suffered from shortness of breathing off and on, bilateral low leg edema and poor appetite for least two months. body weight loss 14 kg more than a year. Denied TOCC history in recent three months.
      • Accroding to the abdominal CT image on 2023/06/20, report showed Left breast cancer with lung and liver metastases.
      • This time, she was admitted, the PE showed left side breast mass, bilateral low leg edema 3-4+.
      • Under the impression of Left breast cancer with lung and liver metastases, so she admitted to our ONC ward for biopsy.
    • Course of inpatient treatment
      • After admission, left side breast mass 6x6 cm was found, highly suspected malignancy, 2023/06/20 CT image showed Left breast cancer with lung and liver metastases. Check lab and tumor marker and viral hepatitis. Consult Diagnostic Radiology and arrange breast sono and biopsy of breast on 2023/08/04.
      • Breast sono showed Left breast malignancy with axillary lymph nodes metastasis, biopsy was done, pathology showed Breast, left, biopsy — ductal carcinoma in situ, intermediate-grade, ER:negative, PR:negative, Her/neu:positive(3+), CK5/6:negative, p63:positive for myoepithelium, and sent Major Illness (+).
      • Cancer survey was arranged: PET on 2023/08/07 showed 1. Increased FDG uptake in the left breast, compatible with the primary breast cancer, 2. Increased FDG uptake in the left mid- and high-axillary lymph nodes, highly suspected breast cancer with regional lymph nodes metastases, 3. Increased FDG uptake in multiple lobes of bilateral lungs and in both lobes of the liver, highly suspected cancer with distant metastases, 4. Left breast cancer, cTxN3aM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan;
      • Bone scan on 2023/08/08 showed 1. Increased activity in the lower T-spines and L3-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation, 2. Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation, 3. Increased activity in biateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
      • Cardiac echo on 2023/08/09 showed LVEF:70%, 1. Adequate LV systolic function with normal resting wall motion, 2 .Septal hypertrophy, 3. Trivial MR and trivial TR, 4. Preserved RV systolic function. Tramacet 37.5 & 325mg/tab 1# PO QD and 1# PO Q6HPRN for painn control.
      • Malignant fungating wound was noted, no acute bleeding, consult wound care practitioner for woun care, wound CD with Biomycin ointment 40gm/tube and Framycin Gause Dressing 18mg/patch cover.
      • Bao-gan 150mg/cap 1# PO TID was given for Abnormal results of liver function studies.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for AntiHBc (+).
      • Family meeting on 2023/08/09, discussion with patient and daughter ablut disaease condition and treatment plan, and consult CS for Port-A implantation on 2023/08/11.
      • Anemia was noted, blood transfusion to correct with LRBC 2unit for 2days (8/10, 8/11).
      • Collect stool/routine for check showed OB:3+, add ULSTOP F.C 20mg/tab 1# PO BID and arrange PES on 2023/08/11 showed Reflux esophagitis LA Classification grade B with ulcer, suspect Mallory-Weiss syndrome, s/p biopsy, Superficial gastritis, Gastric polyps, body. Then shift to Nexium 40mg/tab 1# PO QDAC. PES sent pathology for survey, report ulcer.
      • Add Plasbumin-20, 20% 10g/50mL/bt 1bot self paid mix lasix 1amp IVD QD *3day for low leg edema and suspect lung edema and bil. leg edema, add Plasbumin-20, 20% 10g/50mL/bt 1bot (self paid) mix lasix 1amp IVD BID.
      • She receive chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Dorison 1# po BID and Famotidine 1# po BID x3 day for prevention chemotherapy allergy from 2023/08/11~2023/08/13.
      • Shortness of breathing off and on, follow up D-dimer showed high, arrange Doppler for survey on 2023/08/21 showed 1. Patent bilateral CFA, SFA, PFA and popliteal arteries, Mild atherosclerosis with mild stenosis at bilateral PTAs, ATAs and DPAs, 2. Tissue edema at right leg, Venous Duplex was arrange on 2023/08/25 no DVT.
      • Consult hospice care for lymphatic massage for low leg edema relief on 2023/08/25.
      • Arranged chest echo for chest tapping on 2023/08/15, hepatomegaly was noted; minimal amount pleural effusion; thoracocentesis was not performed due to high risk of complications. Left thorax: no pleural effusion.
      • Progression shortness of breathing, arranged chest echo for chest tapping again on 2023/08/18 showed right side minimal amount of pleural effusion, 600cc serosangious fluid was aspirated for analysis.
      • Fever was noted, CRP: 9.9 mg/dL, Cravit 250mg/50mL/bot 750mg IVD QD from 2023/08/16~2023/08/20.
      • After chemotherapy with Docetaxel (35mg/m2) on 2023/08/12, Neutropenia was noted on 2023/08/21, Granocyte 250mcg/vial 250 mcg SC QD was given from 2023/08/21~2023/08/23 and Tapimycin 4.5g/vial 4.5 gm IVD Q6H from 2023/08/21~2023/08/24, due to Blood culture showed no growth and no fever, stop use.
      • Family meeting on 2023/08/19, discussion with patient and daughter about disaease condition and treatment plan again.
      • No infection status, she received chemotherapy with Liposome Doxorubicin (20mg/m2) + Cyclophosphamide (300mg/m2) on 2023/08/28(C1), received 2nd chemotherapy on 2023/09/11 (C2).
      • Fever was noted, empirical antibiotic with Tapimycin 4.5g/vial 4.5g IVD Q6H for infection control from 2023/09/01~2023/09/08, due to Blood culture showed no growth and no fever, stop use.
      • Acetal 500 mg/tab 1# PO Q6H for suspect tumor fever. Left eye redness and itch was noted, diagnosis was Allergic conjunctivitis, os. Emedastine 1gtt BID os, Inform red flags, come back earlier if s/s worsen and OPD f/u. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.  
    • Discharge prescription
      • BaoGan (silymarin 150mg) 1# TID
      • Baraclude (entecavir 0.5mg) 1# HS
      • Cough Mixture (platycodon) 5mL TID
      • MgO 250mg 1# TID
      • Nexium (esomeprazole 40mg) 1# QODAC
      • Spironolactone 25mg) 1# BID
      • Through (senosside 12mg) 1# HS hold if diarrhea
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# QD
      • Transamin (tanexamic acid 250mg) 1# PRNQD SKIN for wound bleeding
      • Biomycin Ointment (neomycin, tyrothricin) 1# QD TOPI
      • Framycin Gause Dressing (fradiomycin 18mg/patch) 1# PRNQD EXT for wound care use
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H if VAS > 3
  • 2023-08-02 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange admission for biops. Consult GS for breast biopsy or sono-guided biopsy and lab.
  • 2023-06-23 SOAP Hemato-Oncology He JingLiang
    • S
      • multiple liver and lung mets
      • ca of breast is considered
      • suggest breast biopsy

[chemotherapy]

  • 2023-11-07 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-10-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 400mg/m2 600mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-10-04 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-09-11 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-08-28 - liposome doxorubicin 20mg/m2 20mg D5W 250mL 2hr + cyclophosphamide 300mg/m2 500mg NS 500mL 1hr (AC(Lipo))
    • dexamethasone 4mg + granisetron 3mg + NS 250mL
  • 2023-08-12 - docetaxel 35mg/m2 60mg NS 250mL 1hr (DHP(SC/loading))
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

[abnormal liver function test results point to possible liver damage]

Laboratory findings indicate elevated liver function test (LFT) values, suggesting possible liver damage.

  • 2023-11-23 AST 79 U/L
  • 2023-11-23 ALT 48 U/L
  • 2023-11-23 Bilirubin total 1.08 mg/dL
  • 2023-11-23 Bilirubin direct 0.39 mg/dL
  • 2023-11-23 DBI/TBI 36.11 %

The patient has been receiving Baraclude (entecavir) and BaoGan (silymarin), and is prescribed Nexium (esomeprazole 40mg), taken as 1# QOD, no medication problem identified.

[dosing adjustments in hepatic impairment: guidelines for AC(Lipo) components]

The AC(Lipo) regimen being administered to this patient includes pegylated liposomal doxorubicin and cyclophosphamide.

  • Liposomal Doxorubicin Dosing for Hepatic Impairment (Adults):
    • General Note: No specific dosage adjustments in the U.S. manufacturer’s labeling. However, reduction is advised for serum bilirubin >= 1.2 mg/dL.
    • Dosage Adjustments:
      • Krens 2019 Recommendations:
        • Bilirubin >1.2 to <3 mg/dL: Reduce to 75% of original dose.
        • Bilirubin 3 to 5 mg/dL: Reduce to 50% of original dose.
        • Bilirubin >5 mg/dL: Not recommended.
      • Canadian Labeling (Caelyx) Recommendations:
        • Bilirubin 1.2 to 3 mg/dL:
          • Breast/Ovarian Cancer: Start with 75% of normal dose; may increase to full dose in cycle 2 if tolerated.
          • AIDS-related Kaposi Sarcoma: Start with 50% of normal dose.
        • Bilirubin >3 mg/dL:
          • Breast/Ovarian Cancer: Start with 50% of normal dose; may increase to 75% in cycle 2, then to full dose in subsequent cycles if tolerated.
          • AIDS-related Kaposi Sarcoma: Start with 25% of normal dose.
  • Cyclophosphamide Dosing for Hepatic Impairment (Adults):
    • General Note: No specific dosage adjustments in the manufacturer’s labeling. Efficacy may be reduced in severe hepatic impairment.
    • Dosage Adjustments:
      • Floyd 2006 Recommendations:
        • Serum bilirubin 3.1 to 5 mg/dL or transaminases >3 times ULN: Administer 75% of dose.
        • Serum bilirubin >5 mg/dL: Avoid use.
      • Krens 2019 Recommendations:
        • Mild/Moderate Impairment: Likely no adjustment needed.
        • Severe Impairment: Not recommended due to reduced efficacy risk.

2023-11-07

Medication not found to be mismatched.

2023-10-05

No discrepancy in the medication is found.

The AST to ALT ratio has been greater than 1 since the earliest available data from 2023-08-03. Please exclude the possibility of alcohol abuse in this patient. In addition, the subsequent initiation of cyclophosphamide from 2023-08-28 may also lead to hepatotoxicity.

2023-08-30

[leukopenia]

A single dose of docetaxel (35mg/m2) was administered on 2023-08-12 before an episode of leukopenia was observed on 2023-08-21. Following a single injection of Granocyte (lenograstim 250ug), no further episodes of leukopenia have been observed to date.

2023-08-28 WBC 15.29 x10^3/uL
2023-08-23 WBC 19.11 x10^3/uL
2023-08-21 WBC 1.84 x10^3/uL 2023-08-16 WBC 6.88 x10^3/uL
2023-08-14 WBC 12.40 x10^3/uL
2023-08-12 WBC 7.95 x10^3/uL
2023-08-10 WBC 10.92 x10^3/uL
2023-08-03 WBC 9.67 x10^3/uL
2023-06-19 WBC 11.37 x10^3/uL
2023-08-28 Neutrophil 82.5 %
2023-08-25 Neutrophil 77.4 %
2023-08-23 Neutrophil 55.7 %
2023-08-21 Neutrophil 7.6 %
2023-08-16 Neutrophil 77.2 %
2023-08-14 Neutrophil 94.2 %
2023-08-10 Neutrophil 68.9 %
2023-08-03 Neutrophil 74.5 %
2023-06-19 Neutrophil 76.0 %

[monitor cardiac function going forward]

While 2D transthoracic echocardiography on 2023-08-09 showed preserved right ventricular systolic function, ECG on 2023-08-23 showed T-wave abnormalities consistent with anterior ischemia and prolonged QT interval. Since anthracyclines such as doxorubicin may prolong the QT interval, it would be prudent to monitor the condition after administration of (liposomal) doxorubicin (on 2023-08-28).

2023-08-09

2023-08-04 breast biopsy pathology IHC revealed: ER (-), PR (-), Her2/neu (3+), CK5/6 (-), p63 (+ for myoepithelium).

NHI coverage for pertuzumab is applicable under the following conditions: 1. Pertuzumab, in combination with trastuzumab and docetaxel, is used to treat patients with HER2-positive (IHC3+ or FISH+) metastatic breast cancer who have not previously received treatment with anti-HER2 therapy or chemotherapy for metastasis. 2. Prior approval is required for usage, and after approval, efficacy assessment data must be provided every 18 weeks for re-application. If the disease worsens, re-application should not be pursued. The maximum coverage duration for each patient is limited to 18 months.

If doxorubicin is intended for use, it is advisable to conduct a pre-treatment 2D transthoracic echocardiography to establish the baseline heart function.

701502017

231124

[MedRec]

  • 2023-10-19 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Hx of breast cancer, ER 1% (weak) PR (-), Her-2 1+, Ki67 78%
        • Neoadjuvant TC x 4 followed by EC x 4 -> SD
        • R/T to primary
        • maintain with xeloda x 6 months
        • Follow up
      • Now recurrence over brain, lung, liver, bone, completed with lower limbs weakness
    • O
      • Anti-HCV (-), AntiHBs (+), AntiHBs (-), AntiHBc (-)
      • 2023-10-19: BP:105/76; HR:91;
      • 2023-10-09 CT of abeomen
        • Multiple liver mets
        • R/O bilateral renal mets
        • R/O bone mets with pathological fracture at L2 vertebra
      • 2023-10-09 CT of chest
        • Compatible with right breast cancer, smaller
        • Multiple metastases at bilateral lungs and left pleura
      • 2023-10-09 CT of Brain
        • Multiple metastases at brain and left cerebellum
        • A prominent right partoid LN
    • A/P
      • Suggest Enhertu
      • Suggest R/T to brain and bone and Arrange Port-A insertion

[consultation]

  • 2023-10-20 Radiation Oncology
    • Q
      • This 45-year-old woman had past history of Right breast cancer, ER (1%, weak), PR (-), Her-2 (1+), status post
        • Neoadjuvant chemotherapy with TC (Docetaxel + Cyclophosphamide) x 4 followed by EC (Epirubicin + Cyclophosphamide) x 4 –> stable disease
        • Partial mastectomy and sentinel lymph node dissection in 2022/6
        • Radiotherapy to primary tumor
        • Maintain with Xeloda (Capecitabine) x 6 months
      • She used to follow up at NTUH.
      • CT on 2023/10/9 showed (1) multiple metastases at brain and left cerebellum (2) multiple metastases at bilateral lungs and left pleura (3) multiple liver metastases, r/o bilateral renal metastases, r/o bone metastases with pathological fracture at L2 vertebra. Oral Dexamethasone was prescribed for brain metastases.
      • She went to our Oncology OPD for help on 2023/10/19. Under the impression of right breast cancer, with recurrence and metastasis over brain, lung, liver, and bone, she was admitted to our ward for further evaluation and management.  
      • We need your expertise for evaluation and management of radiotherapy for brain and bone metastases, thank you!
    • A
      • She is now sufferred from brain swelling sensation and lower back pain. Suggest bone scan and brain MRI (previous MRI at NTUH on 2023/7/29 showed no metastasis).
      • CT-simulation will be arranged on 10/24.
      • Plan to devlier 30 Gy/ 10 fx to the whole brain first, around 10/25 or 26.
      • RT for the lower back bone metastatses will wait for bone scan result for better treatment field design.
      • Thank you very much.

[MultiTeam]

  • 2023-11-24 Multi-Team Recommendations - Palliative Care
    • Referral Date: 2023-11-24
    • Response Content:
      • The co-care nurse and Dr. Xia from the family medicine department visited together.
      • Outside the ward, they explained the concept of palliative care to the patient’s husband, who expressed a wish for home-based palliative care (residing in XinZhuang).
      • The co-care nurse explained that the patient, being conscious, needs to fill out an advance directive for palliative care.
      • During the visit, the patient was observed with closed eyes and a furrowed brow, using nasal cannula, and breathing with slight difficulty.
      • The patient reported headaches, coughing, pain from a bedsore on the buttocks, and aching in the hips and legs.
      • The main complaint was a desire to go home and “die at home,” expressing a wish not to be resuscitated and to be comfortable without suffering.
      • The advance directive for palliative care was completed.
      • The co-care nurse suggested preparing an oxygen concentrator and an electric bed at home, and to return home once pain management is under control.
      • The co-care nurse will assist in inquiring about local home-based palliative care resources and will provide the information to the family next Monday.
      • The co-care nurse’s contact number was left for further inquiries about palliative care.
    • Conclusion and Recommendations: Joint Palliative Care
    • Responder: Chen Hui
    • Response Date: 2023-11-24 18:20
  • 2023-11-01 Multidisciplinary Team Recommendations - Psycho-Oncology
    • Referral Date: 2023-10-19
    • Reason for Referral: Other: Cancer Inpatient Brief Health Scale Score >= 10 points
    • Conclusion:
        • On 10/20, the patient was visited with her husband present. She was holding her forehead, indicating a headache. Pain medication had been prescribed, but she was still unaware of the treatment plan.
        • On 10/26, during another visit when a friend was visiting and her husband was working outside the ward, she mentioned her headache had lessened. She expressed that her husband was having a hard time as he was taking care of everything. As a couple, they wanted to know how the treatment would proceed. She advised ’not to think, but to be optimistic (tears fell), and wondered what to do with negative thoughts.
        • She had difficulty reading due to loss of vision in her left eye. Her friend mentioned reading three pages a day and recording it to send to her, which made her smile and said she would assign this task to her husband too.
        1. Breast cancer diagnosis in October 110, post-CCRT surgery in June 111, brain metastasis in July 112, and bone, liver, and lung metastases in October. She was admitted to our hospital on 10/19 seeking a second opinion, with a BSRS score of 12 points (moderate).
        1. Focused on caring for the patient’s emotional adjustment, encouraging self-dialogue methods as suggested in the book “The Healing Power Within.”
      • (AP) The patient’s family is inclined towards active cooperation with the current possible treatment methods. The team is requested to continue assisting with symptom relief, discussing the treatment plan, and being mindful of the timing for palliative co-care.
    • Counseling Psychologist Huang XiaoFang
    • Responder: Huang XiaoFang
    • Response Date: 2023-10-27 17:50
  • 2023-10-23 Multidisciplinary Team Recommendations - Social Services
    • Referral Date: 2023-10-19
    • Reason for Referral: Other: Inpatient Brief Health Scale Score >= 10 points
    • Case Status: No case opened
    • Reason for Not Opening Case: Consultation with the patient and her husband on 2023-10-20
    • Family Situation:
      • The patient is 45 years old and married. Her husband accompanied her during the hospital stay.
    • Assessment and Treatment:
      • During the ward visit, the patient appeared somewhat indifferent, only mentioning that she had slept better the previous night, without elaborating further. Her husband also noted that she had slept better the previous night and during the conversation, it was understood that the patient did not use sleeping pills. It was mainly the relief of pain and other discomforts that improved her sleep. The patient and her husband were informed that if they need to talk to a social worker in the future, they can proactively notify the team, and they were receptive to this.
      • This consultation assessed that the patient’s family support is adequate, with no emerging issues at present. If there is a need for social worker assistance in the future, a referral can be made again. Thank you.
    • Responder: Luo Yuquan”
    • Response Date: 2023-10-20

[immunochemotherapy]

  • 2023-11-20 - trastuzumab deruxtecan 5.4mg/m2 100mg D5W 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-11-24

Enhertu (trastuzumab deruxtecan) dosing

  • Kidney Impairment
    • CrCl >=30 mL/minute: No dosage adjustment necessary. Monitor more frequently for interstitial lung disease in patients with moderate impairment.
    • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).
  • Hepatic Impairment
    • Mild (total bilirubin ≤ ULN and any AST > ULN or total bilirubin >1 to 1.5 times ULN and any AST) or moderate (total bilirubin >1.5 to 3 times ULN and any AST) impairment: No dosage adjustment necessary. Monitor closely for toxicities in patients with moderate impairment.
    • Severe impairment (total bilirubin >3 to 10 times ULN and any AST): There are no dosage adjustments provided in the manufacturer’s labeling (a recommended dose has not been established).

Lab data

  • 2023-11-23 AST 136 U/L
  • 2023-11-23 Bilirubin total 0.64 mg/dL
  • 2023-11-23 Creatinine 0.23 mg/dL
  • 2023-11-23 eGFR 347.44 ml/min/1.73m^2

Although the suggested dosage of the medication is 5.4mg/m2, the dose actually given was only around 40% of this recommendation. This significant reduction in dosage may lead to less than optimal treatment outcomes. (Enhertu is currently not covered by the NHI).

Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms. Permanently discontinue fam-trastuzumab deruxtecan in all patients with >= grade 2 ILD/pneumonitis. Advise the patient of the risk and the need to immediately report symptoms.

701279426

231123

[exam findings]

  • 2023-09-27 CT - abdomen
    • History
      • 20210428 CT: rectal cancer, T3N0M1a, STAGE: IVA
      • 20211124 S/P LAR: Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA
    • FINDINGS: Comparison: prior CT dated 2023/06/27.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size that are c/w multiple liver metastases S/P C/T with progressive disease.
      • There is soft tissue nodule 8 mm at RLL of the lung that is c/w lung metastasis.
      • S/P LAR with autosuture retention over the rectum.
      • There are several hepatic cysts in both lobes and the largest one is measured about 4.1cm in size at S6.
      • In addition, there are several soft tissue masses in the uterus that are compatible with myomas.
    • Impression:
      • Multiple liver metastases S/P C/T show progressive disease.
      • Lung metastasis 8 mm at RLL is noted.
      • Follow up CT of the abdomen (include lung) 3 months later is indicated.
  • 2023-06-27 CT - abdomen
    • History and indication:
      • Adenocarcinoma of rectum with liver metastasis, ypT2N1M1a, ypStage IVA status post closure of loop ileostomy on 2021/11/24, liver metastasis in progression on 2023/03/04
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Progression of liver metastases.
      • A nodule (4mm) at RLL.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Rectal cancer s/p operation.
      • Progression of liver metastases.
      • A nodule (4mm) at RLL.
  • 2023-03-04 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • Colon cancer, s/p operation.
      • Progression of liver metastasis.
      • Presence of uterine myomas.
    • Impression
      • Colon cancer, s/p operation
      • Multiple liver metastasis, in progression
  • 2022-11-28 CT - abdomen
    • Indication
      • Malignant neoplasm of rectum
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Abdominal and Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at left brachiocephalic vein.
      • s/p LAR.
      • Low density lesions are found at both lobes of liver up to 4.38cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-08-02, the lesions are stationary.
    • Imp:
      • Colon cancer s/p LAR.
      • Diffuse liver meta. stationary.
  • 2022-08-02 CT - abdomen
    • Clinical history: 57 y/o female patient with Rectal cancer, T3NoM1a status post laparoscopic low anterior resection, ileostomy on 2021/09/01.
    • With and without contrast enhancement CT of abdomen–whole:
      • Post-op at the colon.
      • There are multiple liver tumors in both lobes of liver, could be due to liver metastasis, stationary.
      • There are uterine tumors, could be due to uterine myomas.
      • Right anterior chest wall tumor, 1.2cm, stationary.
    • Impression:
      • Psot-op at the colon.
      • Liver tumors, r/o metastasis, stationary.
      • Right anterior chest wall tumor, 1.2cm, stationary.
      • Uterine tumors, r/o myomas.
  • 2022-04-16 CT - abdomen
    • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver and spine metastases.
  • 2021-11-04 Tc-99m MDP bone scan
    • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, elbows, hips and knees, compatible with benign joint lesions.
  • 2021-10-28 CT - abdomen
    • History and indication: 56 y/o female, a pt of rectal CA wt liver mets
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
      • Enlargement of uterus with nodules r/o myomas.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Rectal cancer s/p operation with adjacent fatstranding.
      • Stable condition of liver metastases.
      • Some osteolytic lesions in spine r/o metastases.
  • 2021-09-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, rectum, laparoscopic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p chemotherapy
      • Ovary, right, oophorectomy —- Consistent with endometrioma
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      • Uterus, myometrium, myomectomy —- Leiomyoma
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/14) —- A tumor deposit is found
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: ypStage IVA, ypT2N1c(if cM1a)
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic low anterior resection, bilateral salpingo-oophorectomy, myomectomy
      • Specimen site: rectum
      • Specimen size: Rectum: 9.5 cm in length; right ovary:5.8 x 4.3 x 2.6 cm; right fallopian tube: 4.8 cm in length and 0.4 cm in diameter; left ovary: 2.7 x 2.0 x 1.0 cm; left fallopian tube: 5.5 cm in length and 0.4 cm in diameter; myoma: 2.8 x 2.8 x 2.0cm
      • Tumor size: 1.6 x 1.4 cm
      • Tumor location: 6.5 cm and 0.9 cm away from the two resection margins, respectively
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: congestion
      • The right ovary is cystic and containing chocholate material.
      • The left ovary and bilateral fallopian tubes are unremarkable. The cut surfaces of the leiomyoma show whorls of bundles without hemorrhage, or necrosis.
      • Representative sections are taken and labeled as: A1-4: tumor; A5:colon, non-tumor; A6: circumferential resection margin; A7-12: lymph nodes, mesocolic; B: proximal resection margin; C: distal resection margin; D1: right fallopian tube; D2-4: right ovary; E1: left fallopian tube; E2: left ovary; F: myoma.
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 15 mm from the margin,
      • Lymph node metastasis, mesocolic:0/14
      • Lymph node metastasis, IMA / SMA: not received
      • Extranodal involvement: Not identified.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): pN1c: No regional lymph nodes are positive, but there are tumor deposits in the subserosa, mesentery, or nonperitonealized pericolic, or perirectal/mesorectal tissues.
        • Distant Metastasis (pM): if cM1a
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings:
        • S2021-07002: ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
        • A tumor deposit is found in mesorectal tissues.
        • Tumor Budding: Low score (0-4)
        • The right cystic ovarian tissue reveals aggregation of hemosiderin ladened histiocytes. No resiual epithelium is seen. The morphology is consistent with a endometrioma.
        • The left ovary and bilateral fallopian tubes are unremarkable and free of malignancy.
        • The leiomyoma reveals whorls of bland smooth muscle bundles without hypercellularity, nuclear atypia or mitosis.
      • TNM descriptors: y (Post-treatment).
      • Tumor regression grading S/P CCRT: Modified Ryan scheme for tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
  • 2021-07-27 CT - abdomen
    • Indication: Colon cancer, S/P neoadjuvant C/T
    • Abdominal CT with and without enhancement revealed:
      • Several low density lesions (n>10) are found at both lobes of liver up to 1.93cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2021-04-28, these lesions decreased in size.
      • Increased intestinal gas is found.
      • Swelling of the rectum is found up to 2.01cm in largest dimension. In regression.
      • Several uterine myomas are found.
      • Right ovarian cyst up to 5.3cm in largest dimension.
    • Imp:
      • Rectal cancer with liver meta. The primary tumor and metastatic lesions regressed.
  • 2021-05-11 PET
    • Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum.
    • Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?). Please also correlate with other clinical findings for further evaluation.
  • 2021-05-10 CT - chest
    • Indication: stage W/U to exclude lung mets.
    • Impression:
      • no evidence of lung metastasis.
      • hepatic metastatic tumors and simple cysts.
  • 2021-05-04 Patho - colorectal polyp
    • Rectal cancer s/p biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).

[MedRec]

  • 2021-05-21 ~ 2021-05-23 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of rectum
      • Rectum cancer with liver metastasis
    • CC
      • for #1 chemotherapy with FOLFIRI
    • Present illness
      • This 56-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas. Several poor enhancing lesions on both hepatic lobes, R/I mets. D/D: cysts with old hemorrhage or atypical hemangioma? The largest one (2.6 cm) in S6. several hepatic cysts in both lobes, the largest one (2.9 cm) in size at S6. soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Imp: T3N0M1a stage IVA.
      • She came to referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong due to rectal cancer with suspected liver mets.
      • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op.
      • HBsAg, anti-HBc, anti-HCV (5/11 21) showed negative.
      • K-RAS / N-RAS mutation test was done and report was pending.
      • Port-A was inserted on 5/12 21.
      • XRT started since 5/20 21 by Dr Huang JingMin for rectal tumor.
      • We explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op.
      • The chest CT (5/10 21) showd no evidence of lung metastasis; hepatic metastatic tumors and simple cysts.
      • The PET scan (5/12 21) revealed Prominent glucose hypermetabolism in the rectum, compatible with primary malignancy of the rectum. Multiple glucose hypermetabolic lesions in both lobes of the liver. Multiple liver metastases may show this picture. Please correlate with other clinical findings for further evaluation. Mild glucose hypermetabolism in both lobes of the thyroid gland. The nature is to be determied (thyroiditis? hyperthyroidism?).
      • Today. she was admitted for #1 palliative chemotherapy with FOLFIRI on 5/21 21.
    • Course of inpatient treatment
      • After admission, chemotherapy with Campto (160mg/m2) plus Leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 5/21-5/23 21, smoothly without obvious side effect. She was discharged on 5/23 21 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • loperamide 2mg 1# PRNQ6H if watery diarrhea > 3 times
  • 2021-05-11 SOAP Radiation Oncology Huang JingMin
    • S:
      • For radiotherapy due to rectal cancer.
      • PI: The patient is a case of rectal CA with suspectde liver mets Dx in May 2021. She suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage wks later.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
      • Personal Hx: DM (-); HTN (-)
      • Previous RT Hx: (-)
    • O:
      • ECOG: 0
      • PE: neck and bil SCF: neg.
      • CT scan of abdomen (2021-04-28): 1. There is a cystic lesion measuring 5 x 4.7 cm in right adnexa without contrast enhancement that may be endometrioma or cystic tumor. Please correlate with CA125. In addition, there are several soft tissue masses in the uterus that are compatible with myomas. 2. There are several poor enhancing lesions on both hepatic lobes that may be metastases. The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
      • The largest one measuring about 2.6 cm in S6 (Srs:4 Img:34). 3. There are several hepatic cysts in both lobes and the largest one is measured about 2.9 cm in size at S6. 4. A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum. Stage cT3N0M1a.
      • Colonoscopy (2021-05-04):One mass was noted in the rectum 8 cm from AV. Diagnosis: Rectal cancer s/p biopsy
      • Pathology (S2021-07002, 2021-05-05): ADDENDUM: IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+). DIAGNOSIS: Rectal cancer s/p biopsy — Adenocarcinoma. An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
      • CT cscan of lung (2021-05-10): no evidence of lung metastasis. hepatic metastatic tumors and simple cysts.
      • Lab:
        • 2021/04/27 CA125 = 11.9 U/mL
        • 2021/04/27 CA199 = 188.31 U/mL
        • 2021/04/27 CEA = 13.18 ng/mL
    • A:
      • Adenocarcinoma of the rectum, stage cT3N0M1a, with liver metastases.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: stage cT3N0M1a.
      • Goal: palliation.
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her sister. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-05-12.
  • 2021-05-08 SOAP Hemato-Oncology Zhang ShouYi
    • S
      • referred to our hemato-oncologic clinic on 5/8 21 for pre-Op neoadjuvant C/T by Dr Xiao GuangHong
        • rectal CA wt suspected liver mets.
      • Dr Xiao GuangHong suggested to do pre-Op neoadjuvant C/T first then wlll do abd CT then Op (5/8 21).
    • P
      • will do HBsAg, anti-HBc, anti-HCV (5/8 21).
      • will do K-RAS / N-RAS mutation test (5/8 21).
      • will consult Dr Chen YanZhi for Port-A installation (5/8 21).
      • will consult Dr Huang JingMin for R/T to rectal tumor.
      • will do PET scan to evaluate liver tumor & pelvic tumor (5/8 21).
      • will do chest CT to exclude lung mets (5/8 21).
      • explain to pt & her sister about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRI / Avastin IV Q2W x 4~6 then do abd CT & Op. (5/8 21).
      • will give post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt PF ( 2 days ) IV Q2W x 4~6 mo.
      • Adm on 5/6 16 for #1 palliative C/T wt Oxaliplatin + PF ( 2 days ) IV Q2W.
      • RTC 1 wk later on 5/4 20 for CBC & DC, CXR, abd no report.
  • 2021-05-06 SOAP Colerectal Surgery Xiao GuangHong
    • S
      • Rectal cancer
      • Liver metastasis; Ovarian tumor
    • O
      • 2021/05/04 Colonoscopy: Rectal cancer s/p biopsy
        • Pathology: Rectal cancer s/p biopsy — Adenocarcinoma.
          • An addendum report of the result of IHC stains of EGFR, PMS2, MSH6, MSH2, and MLH1 will be followed.
    • P
      • Suggest chemotherapy + target therapy then evaluation of resection
  • 2021-04-29 SOAP Colorectal Surgery Xiao GuangHong
    • S:
      • First visit, ovarian tumor, liver metastasis
    • O:
      • 2021/04/27 CA199 = 188.31
      • 2021/04/27 CEA = 13.18
      • 2021/04/27 HGB = 10.5
      • 2021/04/28 CT: ABD — whole abdomen, pelvis
        • Metastases on both hepatic lobes are suspected.
          • The differential diagnosis include cysts with old hemorrhage or atypical hemangioma? Please correlate with sonography and MRI.
        • Right adnexa lesion, nature?
          • The differential diagnosis include endometrioma or cystic tumor.
          • Please correlate with CA125.
        • A soft tissue mass-like lesion or fecoloma 2.8 cm in the rectum is suspected. Please correlate with physical examination.
    • P:
      • Arrange colonoscopy and inform the risk of complication including bleeding and perforation

[consultation]

  • 2023-03-22 Dermatology
    • Q
      • for skin rash, itchy for 10 days
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later. She came to our Pro Huang SiCheng arranged abd CT & colonscopy in May 2021.
      • This time, she is admitted for chemotherapy, then she complaints the skin rash, and itchy for 10days when after chemotherapy, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from reddish papules on the neckalce and grouped pigmented macules over buttock (previous erythematous papules with fine vesicles)
      • Under the impression of intertrigo eczmea over neck, favor post-herpes simplex infection over buttock.
      • The following suggetion:
        • Mycomb cream 1 tube as a good choice for neck lesions.
        • for pigmentation macules over buttock, consider Sinphraderm 1 tube topical QN use over the residual pigmentation lesions of the buttock.
        • enhane body mositurization after body clean to prevent furtehr xerosis skin texture.
  • 2023-03-04 Obstetrics and Gynecology
    • Q
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
      • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
      • We would like to consult you for your expertise, thank you.
    • A
      • This is a 57-year-old female patient with rectal cancer with liver metastasis in May 2021, s/p CCRT, currently admitted for #16 Avastin (self-paid)/FOLFOX.
        • She received concurrent laparoscopic bilateral salpingo-oophorectomy on 2021-09-01 for right ovarian tumor, and pathology showed right ovarian endometrioma, with left ovary and bilateral tubes all negative for malignancy.
        • According to the patient, she noted blood while wiping after defecation 2 days ago.
      • O
        • G0, sex(-), menopause around 52-53 y/o
        • PV: narrowing atrophic vagina (suspect radiotherpy related), no active bleeding nor blood clots noted.
        • TVS: AVF uterus 66x39mm, endometrium 4.7mm, subserosal and intramural myomas (15x11, 16x13, 15x10), pelvis free of other GYN lesion, no ascites.
      • Imp: bleeding point not favored GYN origin due to thin endometrium (<5mm) and no endometrial lesions (eg, polyp or submucosal myoma) noted
        • Suggest survey other origin of the bleeding
        • Educated the patient to receive pap smear at OPD f/u
      • Contact us if any problems!!
  • 2023-03-03 Colorectal Surgery
    • Q
      • This 57-year-old female, a pt of rectal cancer with liver mets Dx in May 2021, suffered from initial presentation of abnormal vaginal bleeding in April 2021 & bloody stool passage weeks later.
      • Surgical pathology with rectal cancer s/p biopsy (5/4 21) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1(+). Stomach, fundus, s/p biopsy (5/4 21): Hyperplastic polyp.
      • Image study with abd CT (4/28 21) showed a cystic lesion, 5 x 4.7 cm in R adnexa, R/I endometrioma or cystic tumor. several soft tissue masses in the uterus that are compatible with myomas.
      • She was admitted for #16 chemotherapy with Avastin (self-paid)/FOLFOX today, however, blood was noted after wiping.     
      • We would like to consult you for your expertise, thank you.
    • A
      • This is a 57-year old woman with anal bleeding after defecation for 2 days
      • DRE:
        • mild internal hemorrhoids, acute anal fissure over 6 o’clock region
        • yellowish stool
      • A/P:
        • add alcos anal onitment bid and prn topic use
        • add laxative drugs, such as MgO 2# Bid
        • if s/s persisted than sigmoidoscopy should be considered

[radiotherapy]

[chemotherapy]

  • 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4120mg NS 500mL 46hr (Avastin + FOLFOXIRI; Q2W)

  • 2023-05-18

  • 2023-04-20

  • 2023-03-21

  • 2023-03-03 - (Avastin + FOLFOX; Q2W)

  • 2023-02-01 - (Avastin + FOLFOX; Q2W)

  • 2022-12-23 - (Avastin + FOLFOX; Q2W)

  • 2022-12-02 - (Avastin + FOLFOX; Q2W)

  • 2022-11-15 - (Avastin + FOLFOX; Q2W)

  • 2022-10-20 - (Avastin + FOLFOX; Q2W)

  • 2022-09-16 - (Avastin + FOLFOX; Q2W)

  • 2022-08-18 - (Avastin + FOLFOX; Q2W)

  • 2022-08-01 - (Avastin + FOLFOX; Q2W)

  • 2022-07-08 - (Avastin + FOLFOX; Q2W)

  • 2022-06-17 - (Avastin + FOLFOX; Q2W)

  • 2022-04-26 - (Avastin + FOLFOX; Q2W)

  • 2022-04-08 - (Avastin + FOLFOX; Q2W)

  • 2022-03-08 - (Avastin + FOLFOX; Q2W)

  • 2022-02-10 - (Avastin + FOLFOX; Q2W)

  • 2022-01-07 - (Avastin + FOLFOX; Q2W)

  • 2021-12-21 - (Erbitux + FOLFOX; Q2W)

  • 2021-11-03 - (Erbitux + FOLFOX; Q2W)

  • 2021-10-18 - (Avastin + FOLFIRI; Q2W)

  • 2021-09-29 - (Avastin + FOLFIRI; Q2W)

  • 2021-07-29 - (Avastin + FOLFIRI; Q2W)

  • 2021-07-09 - (Avastin + FOLFIRI; Q2W)

  • 2021-06-25 - (Avastin + FOLFIRI; Q2W)

  • 2021-06-07 - (Avastin + FOLFIRI; Q2W)

  • 2021-05-21 - (Avastin + FOLFIRI; Q2W)

FOLFOXIRI chemotherapy for metastatic colorectal cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F70559

  • Cycle length: 14 days.
  • Regimen
    • Irinotecan
      • 165 mg/m2 IV
      • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • LEVOleucovorin
      • 200 mg/m2 IV
      • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2400 to 3200 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
      • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

Modified FOLFIRINOX chemotherapy for pancreatic cancer - 2023-11-23 - https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-11-23

[rising tumor markers and progressive disease]

This patient has a history of multiple lines of treatment for her cancer, including:

  • Avastin + FOLFOXIRI (since March 2023 and undergoing)
  • Avastin + FOLFOX (January 2022 to March 2023)
  • Erbitux + FOLFOX (November 2021 to December 2021)
  • Avastin + FOLFIRI (May 2021 to October 2021)

Both CEA and CA199 have been rising for the past two months, consistent with the progressive disease seen on the CT scan on 2023-09-27.

  • 2023-11-21 CEA (NM) 382.930 ng/ml

  • 2023-10-24 CEA (NM) 130.315 ng/ml

  • 2023-09-26 CEA (NM) 95.670 ng/ml

  • 2023-11-21 CA-199 (NM) 4220.750 U/ml

  • 2023-10-24 CA-199 (NM) 2298.450 U/ml

  • 2023-09-26 CA-199 (NM) 1177.830 U/ml

As the liver metastases are more severe, more intensive monitoring of liver function might be advisable.

[mixed acid-base disorder?]

Here’s a breakdown of the results of the venous blood gas (VBG - 2023-11-22) values:

  • pH: 7.451
    • This is higher than the normal venous pH range (7.31-7.41), indicating mild alkalemia (increased alkalinity in the blood).
  • HCO3 (Bicarbonate): 28.1 mmol/L
    • This is elevated. Normal venous HCO3 levels are typically around 22-26 mmol/L.
  • ctCO2 (Total Carbon Dioxide): 29.4 mmol/L (23-27 mmol/L).
  • Base Excess (BE) and BEecf: 3.6 mmol/L and 4.1 mmol/L, respectively
    • These values are slightly elevated, indicating a mild excess of base in the blood.
  • SBC (Standard Bicarbonate): 27.4 mmol/L (22-26 mmol/L).
  • O2 Saturation: 73.5%
    • The oxygen saturation might be a concern, depending on the clinical context.

The results suggest a mild metabolic alkalosis, as indicated by the slightly elevated pH and bicarbonate levels, along with a positive base excess.

Meanwhile, lactic acid was elevated (2023-11-22 2.5 mmol/L), this could indicate lactic acidosis, a condition where there is an accumulation of lactic acid in the body, often due to inadequate oxygen delivery to tissues (hypoxia), shock, or other metabolic issues.

In the context of the mild metabolic alkalosis suggested by the vein blood gas results, elevated lactic acid could point towards a mixed acid-base disorder. This is where more than one acid-base imbalance is occurring simultaneously.

O2 cannula 3L/min has been ordered and the updated SpO2 is 95% (2023-11-23).

700324847

231122

[exam findings]

  • 2023-05-27 MRI - brain
    • No brain nodule or metastasis.
  • 2023-05-15 KUB
    • Bilateral pleural effusion.
    • Presence of ileus.
    • Intact bony structure(s).
  • 2023-05-15 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-05-12 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Loculated bilateral pleural effusion at bilateral interlobular fissure and lower hemithorax is found.
        • Consolidation over right lower lobe and left lower lobe is found.
        • Enlarged lymph nodes are found at bilateral paratracheal region.
        • Patent airway is found.
      • Visible abdomen:
        • Moderate ascites formation is found.
        • Increased intestinal gas is found.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • IMp:
      • Pneumonic patch at both lungs with bilateral massive pleural effusion.
      • Moderate ascites formation.
  • 2023-05-12 CXR
    • Bilateral Pleura effusion.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Enlargement of cardiac silhouette.
  • 2023-05-05 SONO - CXR
    • Echo diagnosis:
      • right side minimal amount of pleural effusion
      • left side small amuont of pleural effusion, 600cc serosangious fluid was drained out for symptom relief.
  • 2023-04-24 SONO - breast
    • Suggestion and Plan
      • Calcifications in right breast.
      • R/O enlarged lymph nodes in left axillary region, suggest biopsy.
    • BI-RADS: Category 4a: low suspicious abnormality-biopsy should be considered.
  • 2023-04-22 MRI - pelvis
    • With and without contrast enhancement MRI:
      • Cystic tumor, 8.6cm in right adnexa, with mural soft tissue, r/o right ovarian malignancy.
      • Another cystic tumor, with internal hemorrhage, 2.8cm in left adnexa, r/o ovarian malignancy with hemorrhage.
      • There are enlarged lymph nodes in bilateral obturator regions and right common iliac region, r/o lymph nodes metastasis.
      • Presence of ascites.
      • There are soft tissue tumors in the mesentery, r/o peritoneal carcinomatosis.
      • Left pleural effusion.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T: T3c_(T_value) N: N1b(N_value) M: M1(M_value) STAGE: IV (Stage_value)
    • Impression:
      • Ovarian cystic tumor with carcinomatosis and lymph nodes, left pleural effusion, r/o ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1.
  • 2023-04-20 Gynecologic ultrasonography
    • R/O Pelvis mass: 101 x 78mm (Multuple papillary, solid mass: 26 x 25mm)
    • R/O LT Ovarian mass
  • 2023-04-19 CT - abdomen
    • Findings:
      • There is ascites and soft tissue nodules in the omentum. Carcinomatosis is suspected. Please correlate with ascites cytology.
      • There is a mild hyperdense lesion in the pelvis at pre-contrast CT, measuring 9.1 x 10.4 x 8.5 cm (width x depth x cranial-caudal length) in size, and poor enhancement in portal venous phase images except suspicious few ill-defined enhancing mural nodules.
        • The uterus shows posterior displacement by the upper described mass.
        • Cystic adenocarcinoma of the ovary is highly suspected.
        • Please correlate with GYN. sonograph, MRI and CA125.
      • There is a mild hyperdense lesion in left adnexa at non-enhanced CT, measuring 3.4 cm in size, and it shows poor enhancement in portal venous phase images except a mural nodule shows enhancement.
        • Cystic tumor of left ovary is highly suspected.
        • The differential diagnosis includes left ovarian cyst with hemorrhage.
      • S/P pigtail catheter implantation at right CP angle.
        • There is massive left side Pleura effusion.
    • Impression:
      • Carcinomatosis is suspected. Please correlate with ascites cytology.
      • Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
  • 2023-04-18 CT - chest
    • Findings
      • moderate Lt pleural effusion and residual minimal Rt pleural effusion s/p pigtail drain placement.
      • lungs:extensive, patchy and centrilobular ground-glass opacities with interbular septal thickening, at both lower lobes.
        • minimal patchy ground-glass opacities at LUL.
        • dependent relaxation subsegmental atelectasis at LLL.
      • Mediastinum and hila: many enlarged LNs in the visceral space and left anterior prevascular space.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • mild ascitic fluid and dirty omentum.
      • Visualized bones: unremarkable.
    • Impression:
      • bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease?
      • abdominal ascites, cause? due to lesion in pelvic cavity?
  • 2023-04-18 Cell block - pleural effusion
    • Cytological diagnosis: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. Metastatic carcinoma is favored. Please correlate with the clinical presentation.
  • 2023-04-17 Cell block - pleural effusion
    • Cytological diagnosis: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK7(+), CK20(-), PAX8(+), WT-1(+), TTF-1(-), Napsin A(-), p40(-), GATA3(-), Calretinin(-), and CD56(-). The results are consistent with metastatic carcinoma from ovary. Please correlate with the clinical presentation.
  • 2023-04-15 SONO - chest
    • Echo diagnosis:
      • Pleural effusion, massive amount, right, s/p pig-tail insertion
      • Pleural effusion, massive amount, left, s/p thoracentasis (1100ml)
  • 2023-04-14 ECG
    • Sinus tachycardia
    • Anteroseptal infarct, age undetermined
    • Abnormal ECG
  • 2018-05-16 Gynecologic ultrasonography
    • Suspected RT ovarian cyst
    • Suspected LT endometrioma

[MedRec]

  • 2023-05-15 SOAP Emergency
    • S
      • Dyspnea for 2 days
      • s/p thoracocentesis on 5/12 700ml
      • Poor intake for 2 days
      • Nausea and vomiting after inake
      • Phx: Ovarian cancer
      • Allergy: NKA
  • 2023-05-12 SOAP Hemato-Oncology
    • S: Today explain to patient 40 minutes for chemotherapy. But she still hestitate to receive chemotherapy.
    • P: explain the possibility of chemotherapy to control tumor, but patient still hestitate to receive C/T.
      • F/U weekly
      • refer to ER for chest tapping

[consultation]

  • 2023-09-10 Urology

    • Q
      • This is a 52 y/o woman with Ovarian malignancy with carcinomatosis, lymph nodes metastasis and left pleural effusion. cstage T3cN1bM1, status post neo-adjuvant chemotherapy (paclitaxel and carboplatin).
      • She will be recieving Debluking surgery + HIPEC on 112-09-11. We sincerely needed your expertise on double J tube insertion. Thank you very much!
    • A
      • We will arrange the procedure
  • 2023-06-08

  • 2023-05-19

  • 2023-05-18

  • 2023-05-17

  • 2023-04-21 Hemato-Oncology

    • Q
      • For ovarian cancer neuadjuvant chemotherapy
      • We have consulted GYN, who suggested neoadjuvant chemotherapy first, followed by debulking surgery and HIPEC.
      • Due to the above reasons, we sincerely need your expertise for the neoadjuvant chemotherapy. Thank you very much!
    • A
      • This 51 year old woman is a case of ovarian cancer with peritoneal carcinomatosis and bilateral pleura effusion. Pleura effusion cell block show pleomorphic tumor cells CK7(+), CK20(-), PAX8(+), WT-1(+), TTF1(-), NAPsin A(-), P40(-), GATA3(-),calretinin(-), and CD56(-), the result consistent with metastatic carcinoma from ovary.
      • Arrange 24 urine CCR, anti HBc, anti HBs, HBsAg, Anti HCV, breast echo and port A insertion. apply Major Disease” C56.9 stageIV.
      • We will arrange chemotherapy (palitaxel + carboplatin ) the next day of port A insertion (Expected to have chemotherapy next Tuesday). Arrange our OPD after discharge.
  • 2023-04-20 Obstetrics and Gynecology

    • Q
      • For evaluation of suspected ovarian cystic adenocarcinoma
      • This is a 51-year-old female with no underlying diseases. She presented to our ER with progressive dyspnea for 3 weeks, while CXR showed massive bilateral plerual effusion. Bilateral thoracentesis and right pigtail drainage was performed for symptom relief. Examination of the drainage showed to be exudative in nature.
        • Cancer/Tumor:
          • 4/18 Chest CT: bilateral lower lobes lung edema or pneumonitis and transudative left pleural effusion, due to connective tissue disease? abdominal ascites, cause? due to lesion in pelvic cavity?
          • 4/19 Abdominal CT: 1. Carcinomatosis is suspected. Please correlate with ascites cytology. 2. Cystic adenocarcinoma of the ovary is highly suspected. Please correlate with GYN. sonograph, MRI and CA125.
        • Tumor markers: pending results
        • TB, fungus, infection: pending results
        • Autoimmune: negative
      • Due to the above reasons, we sincerely need your expertise to evaluate the pelvic mass, suspect ovarian cystic adenocarcinoma. Thank you very much!
    • A
      • This is a 51 y/o woman who was hospitalized due to pleural effusion. Image survey with abdominbal CT showed suspected carcinomatosis of which ovarian cystic adenocarcinoma was highly suspected. Tumor markers were checked with the results pending. We were consulted for evaluation.
        • CC: Progressive dyspnea for 3 weeks.
        • ObGyn history: Sex(+), P0, menopaused
        • Sono: Pelvic mass, 101 x 78 mm (multiple papillary, with solid mass: 26 x 25 mm)
      • Impression
        • Huge pelvic mass, malignancy could not be ruled out
      • Suggestion
        • Please pursue the level of tumor markers.
        • Arrange EGD and colonoscopy.
        • Surgical intervention (laparotomy and frozen section) is suggested for diagnostic and therapeutic value. If malignancy is proven intraoperatively, debulking surgery is indicated.
        • Further cancer staging if malignancy is proven.
      • Addendum to consultation response 2023-04-21 14:45:54
        • Highly suspected cystic adenocarcinoma of the ovary with carcinomatosis and malignant plerual effusion, at least cstage IVA
        • Well explained current treatment plan and survival rate:
          • arrange EGD and colonoscopy first
          • consulted GS for port-A insertion and consulted Oncologist for neoadjuvant chemotherapy 3-4 times and followed debulking surgery and HIPEC

[chemotherapy]

  • 2023-11-22 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 30mg + cisplatin 30mg/m2 30mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-10-19 - paclitaxel 175mg/m2 170mg NS 250mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + sodium bicarbonate 3800mg + NS 1000mL] IP 1hr (70%)

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-11 - [liposome doxorubicin 30mg/m2 40mg D5W 250mL + carboplatin AUC 5 900mg NS 250mL] IP 90min

  • 2023-08-21 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-31 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-18 - paclitaxel 175mg/m2 135mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

    • dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 375mg NS 250mL 2hr

    • dexamethasone 4mg 5# PO Q6H at D0 2300 and D1 0500 + dexamethasone 4mg IVD + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-21

No medication reconciliation issues were found after reviewing PharmaCloud and HIS5.

2023-05-17

  • The patient’s serum albumin level has shown a decrease, potentially due to nausea and vomiting post-ingestion and several days of insufficient nutrition intake. Severe hypoalbuminemia could potentially exacerbate the patient’s pleural effusion. It might be necessary to provide additional nutritional support.
    • 2023-05-12 Albumin 3.1 g/dL
    • 2023-04-22 Albumin 3.5 g/dL
  • The recommendation is to include antiemetics as part of the premedication protocol for the upcoming dose of the current paclitaxel and carboplatin regimen.

700605406

231122

[exam findings]

  • 2023-11-16 CT - abdomen
    • History and indication:
      • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. General subcutaneous edema.
      • A fatty tumor (3.1cm) at left pelvic cavity.
      • A poor enhancing nodule (1.5cm) at S7 of liver.
      • Some lucent lesions in sacrum.
      • Minimal ascites.
    • IMP:
      • Swelling of left lower extremity. Skine thickening of left thigh. Enlarged LNs at retroperitoneum, pelvic cavity, left thigh and bil. inguinal regions. Disease progression is noted.
      • General subcutaneous edema.
      • A fatty tumor (3.1cm) at left pelvic cavity.
      • A poor enhancing nodule (1.5cm) at S7 of liver.
      • Some lucent lesions in sacrum.
  • 2023-09-15 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — No evidence of T-cell lymphoma with bone marrow involvement
    • MICROSCOPIC EXAMINATION
      • The sections show hypercellular marrow (60%). M/E ratio = 6:1. The myeloid cells show good maturation. The megakaryocytes are increased in number with a few small megakaryocytes. No lymphoid aggregates.
      • IHC, scattered small CD3+ T-cells and CD20+ B lymphocytes in interstitium are present. No CD30+ T lymphocyte can be found. There is no evidence of T-cell lymphoma with bone marrow involvement. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-09-14 PET
    • The [F-18]Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 235 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in the left supraclavicular lymph nodes (SUVmax early: 11.51, delay: 12.73), multiple abdominal and pelvic lymph nodes (SUVmax early: 18.92, delay: 20.04), multiple bilateral inguinal lymph nodes (SUVmax early: 17.54, delay: 19.32), some focal areas in the spleen (SUVmax early: 4.82, delay: 5.90) and multiple focal areas in the left upper thigh (SUVmax early: 13.20, delay: 16.80). Besides, there was increased FDG uptake in the bone marow of the skeleton (SUVmax early: 4.42, delay: 6.30).
    • IMPRESSION: The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
  • 2023-09-13 Patho - skin cyst/tag/debridement
    • DIAGNOSIS:
      • Labeled as “left thigh”, incisional biopsy — T cell lymphoma
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of 1 piece(s) of tan, irregular tissue measuring 4.0 x 2.0 x 1.3 cm. Representative tissue for section(s) in 2 cassette(s).
    • MICROSCOPIC DESCRIPTION:
      • Sections show skin with infiltration of abundant atypical lymphoid cells with many pleomorphic large neoplastic cells. IHC stains: CD3 and CD20: a predominant T cell sub-population. The large cells are CD30 (+), CD15 (+), ALK (-), cutaneous cd30-positive t-cell lymphoproliferative disorder is considered.
  • 2023-09-01 Patho - lymphnode biopsy
    • PATHOLOGIC DIAGNOSIS
      • Lymph node, groin, left, core needle biopsy— Peripheral T cell lymphoma, NOS
    • MACROSCOPIC DESCRIPTION
      • Operation procedure: core needle biopsy
      • Topology: left groin
      • Specimen size and number: 3 pieces, 1x 0.1x 0.1 cm
    • MICROSCOPIC EXAMINATION
      • Histology type:
        • T-cell neoplasms
        • Peripheral T-cell lymphoma, NOS
      • Immunohistochemical stain profiles: CK(-), CD3(+, diffuse), CD4(+, diffuse), CD20(focal + at background B cells), CD8(+), Ki-67 index: 50%, CD56 (focal +, < 5%), Granzyme B(-), EBV(-), CD15 (-), CD30 (+, 40%), CD10 (focal weak+), TdT(-), CD5(+), EBER(-)
      • ADDENDUM: IHC stain — ALK1: negative
      • ADDENDUM: Based on histopathologic and immunohistochemical features, the possibility of anaplastic large cell lymphoma (ALK negative) cannot be complelely excluded. Clinical correlation is necessary.
  • 2023-08-28 Peripheral Vascular Test - Artery, lower limbs
    • Clinical diagnosis: Leg swelling
    • Conclusions: Patent bilateral lower limbs arteries. Increased flow velocities at left CFA, SFA and PFA.
  • 2023-08-17 CTA - lower extremity
    • Indication: CT”V” r/o DVT
    • CTV of lower extremity shows:
      • multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. There are also some smaller lymph nodes at left paraaortic region.
      • irregular skin thickening at left posterior thigh with enhancement, etiology to be determined.
      • swelling and subcutaneous edema of left lower extremity, probably due to venous compression by the left inguinal and iliac lymphadenopathy.
      • two 2.7cm fat attenuated nodules in the pelvic cavity, probably adnexal origin. Terotoma or others?
      • enlarged and heterogeneous enhancement of uterus.
      • mild ascites in the cul de sac.
      • a 1.5cm hypoenhancing nodule in S7 liver, nature to be determined.
    • Impression:
      • Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof.
      • Irregular skin thickening at left posterior thigh. Suggest further evaluation.
      • Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound.
      • A 1.5cm hepatic nodule, nature to be determined.

[MedRec]

  • 2023-09-12 ~ 2023-09-22 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Cutaneous T-cell lymphoma, unspecified, lymph nodes of multiple sites
      • Primary cutaneous CD30-positive T-cell proliferations, primary cutaneous CD30-positive anaplastic large cell lymphoma (T cell and CD-30 positive), stage IV
    • CC
      • For further survey of suspected subcutaneous T cell lymphoma
    • Present illness
      • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma.
      • According to the patient herself and her husband, she had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy) with progressed erythematous change, but she did not search for medical help after labor.
      • She first went to PS OPD, and was referred to CVS afterwards. At CVS OPD, multiple check ups were done. Venous sonography reported: Venous thrombosis at bilateral superficial epigastric veins and superficial circumflex iliar veins were detected. The intra-abdominal veinous occlusion or compression couldn’t be ruled out completely, please correlate with clinical presentations and other image modalities.
      • CTA of lower extremitiy reported: 1. Multiple enlarged lymphadenopathy at bilateral inguinal regions, pelvic side wall and iliac chains, causing compression to left external iliac vein and left common femoral vein. Some smaller lymph nodes at left paraaortic region. Suggest tissue proof. 2. Irregular skin thickening at left posterior thigh. Suggest further evaluation. 3. Two fat-density nodules in the pelvic cavity, suspect teratoma? Enlarged uterus. Mild ascites. Suggest correlation with GYN ultrasound. 4. A 1.5cm hepatic nodule, nature to be determined.
      • Thus, she was prescribed with the medication of Eliquis and Furosemide, and was referred to GYNOPD for evaluation.
      • At GYN OPD, sonography reported: 1. Uterine myoma, 2. R/O Bilateral Teratoma, 3. R/O Lt adnexal mass: 90x50mm, so after explanation, she was referred to GS OPD for evaluation on the pelvic mass and bilateral teratoma.
      • After evaluation on previous history and image findings, sono guide biopsy of left inguinal lymph node was done by GS Dr. Li ChaoZhu, and pathology results later reported peripheral T cell lymphoma, so she was thus referred to Dr. Gao WeiYao’s OPD for furtehr management.
      • At Dr. Gao’s OPD. admission was arranged after evaluation on previous medical record and the patient’s condition. Besides from the skin lesion over her left thight, she also had accompanied symtpoms of fever up to 38.7’C with chillness for 2-3 days which could be partially relieved by antipyretics, night sweats for 1-2 weeks, and LLQ abdominal distension pain for a week. She had no headache or dizziness, no cough or rhinorrhea, no chest pain or dyspnea, no nausea or vomiting, no diarrhea or urinating pain.
      • Under the impression of suspected subcutaneous T cell lymphoma, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, we did routine follow up on the patient’s lab data, chest X-ray and EKG, and since the patient’s left thigh skin lesion was suspected cutaneous T cell lymphoma, we consulted PS doctor for skin biopsy.
      • PET/CT was arranged and done, and we consulted CVS doctor for port-A insertion. Skin biopsy and port-A insertion were combined and done on 2023-09-13, and the patient did not show continuous bleeding.
      • PET/CT was done on 2023-09-14, and the report showed lymphoma involving multiple lymph node regions on both sides of the diaphragm, spleen, bone marrow and left upper thigh (stage IV).
      • Antibiotic of Targocid was used since admission due to the patient had fever going on and off, and there was no more fever noted since 2023-09-13.
      • Chemotherapy with CHOEP had started on 2023-09-18, and lab data was followed up every day.
      • The patient showed no fever, no nausea or vomiting, no abdominal pain or dysuria during chemotherapy, but her body weight had increased 5kg in recent 1 week with edema noted at left thigh, so we added IV form of Lasix 20mg QD.
      • Under stable condition, the patient was discharged on 2023-09-22, with oral medications brought back and OPD follow up arranged on 2023-09-26.
    • Discharge prescription
      • Compesolon (prednisolone 5mg) 10# QN
      • Uretropic (furosemide 40mg) 1# PRNQD (if BW increase)
  • 2023-03-30 ~ 2023-04-02 POMR Obstetrics and Gynecology Zhang YinGuang
    • Discharge diagnosis
      • Term pregnancy at 40+4 weeks with mild preeclampsia for labor induction status post vaginal delivery on 2023/03/31
      • Mild to moderate pre-eclampsia, third trimester
      • Second degree perineal laceration during delivery
      • Streptococcus, group B, as the cause of diseases classified elsewhere
    • CC
      • Pregnancy at 40+3 weeks for labor induction        
    • Present illness
      • This 39 y/o, G2P1 (termination at GA 20 weeks due to cleft palate and holoprocencephaly), married woman with history of HTN which start medication control since pregnancy was currently pregnant at 40+3 weeks of gestation (LMP: 2022/05/28, EDC: 2023/03/27). She did not smoke, drink alcohol, or use illicit drugs.
      • She had received routine prenatal care at our hospital where normal maternal status and fetal development were diagnosed. There was no RPR/VDRL, HBsAg, HbeAg, Rubella IgG, HIV Ab, HPV 16 & 18, or Group B Streptococci infection. No gestational complication such as pregnancy induced hypertension, preclampsia or gestational diabetes mellitus. The labetalol 0.5# BID used for HTN control and aspirin used for preeclampsia prevention. Transabdominal ultrasound on 38+5 week revealed estimated fetal body weight (EFBW) as 3328gm. After discussed with the patient, she came to our delivery room on 2023/03/30 for the scheduled induction.
      • On examination, the blood pressure was 133/96mm Hg, the pulse 80 beats per minute, other vital signs and the remainder of the examination were normal. The fundus was firm; the height was consistent with the gestational age. Bilateral lower limbs edema 1+ noted on admission. Pelvic examination showed the cervix was 1 cm dilated and poor effaced. The fetal heart-rate tracing showed a rate of 130 to 139 beats per minute. She was then admitted to our ward for preparation of delivery. 
    • Course of inpatient treatment
      • This is a 33 years old female. G2P2 pregnancy at 40+4 weeks and admitted due to labor induction. Under local anesthesia, vaginal delivery was performed on 03/31/2023. A live female newborn with body weight 2925 gm, height 47 cm. Apgar score:9->9, EBL:200 ml. The breast engorgement without mass. EP wound without swelling and healed well. Uterine contraction was well. The Lochia showed redness and normal amount. Urination by self voiding was smooth. She was discharged & RTC after 6 weeks.
    • Discharge prescription
      • MgO 250mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • Alcos-Anal Oint (sodium oleate) BID EXT
      • Through (sennoside 12mg) 1# HS
  • 2023-03-04, 2022-11-12, -08-20 SOAP Cardiology Liu GuanLiang
    • Diagnosis: Primary HTN
    • Prescription x3
      • Trandate (labetalol 200mg) 0.5# BID

[consultation]

  • 2023-09-13 Cardiology
    • Q
      • The patient is a 39 y/o female with previous unerlying disease, with only medication history of HTN treatment recieved during pregnancy. She had noted multiple pruritic erytheamtous papule-vesicles over medial posterior side of left thigh for months (before pregnancy, currently 5 months after labor) with progressed erythematous change, and after multiple evaluation, she was diagnosed with peripheral T cell lymphoma.
      • This time, she was admitted for further survey of suspected subcutaneous T cell lymphoma, and skin biopsy was arranged ib 9/13 12:00.
      • We need your expertise on the patient’s port-A insertion, thank you very much!
    • A
      • I have had the pleasure of involving with this patient’s care. In brief, the patient is a 39 year old female seen in consultation for opinion regarding treatment options for port-A insertion for chemotherapy access.
        • The pt’s hx/Dx was noted for 1. Non-Hodgkin lymphoma, unspecified, lymph nodes of inguinal region and lower limb
        • Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites
        • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • Port-A insertion will be arranged on today right side, LMA combined with Dr Wei

[chemotherapy]

  • 2023-11-17 - cyclophosphamide 750mg/m2 1500mg NS 250mL + doxorubicin 50mg/m2 100mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 200mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-10-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-09-18 - cyclophosphamide 750mg/m2 1400mg NS 250mL + doxorubicin 50mg/m2 96mg NS 100mL 10min + vincristine 2mg/m2 2mg NS 50mL 10min + etoposide 100mg/m2 190mg NS 500mL 1hr D1-3 + prednisolone 50mg PO BID D1-5 [CHOEP]
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

==========

2023-11-22

[brentuximab vedotin] (not posted)

Health Insurance Medication Coverage Regulations (2023-10-24 version)

  • Brentuximab vedotin (such as Adcetris) is limited to use in adult patients with systemic anaplastic large cell lymphoma (sALCL):
      1. For use in combination with cyclophosphamide, doxorubicin, and prednisone in adult patients with previously untreated systemic anaplastic large cell lymphoma (sALCL) that is ALK-negative.
      1. For the treatment of relapsed or refractory systemic anaplastic large cell lymphoma (sALCL).
      1. Use requires prior review and approval:
      • I. For patients mentioned in (1): The initial application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 2 cycles may be covered; if the condition worsens, use must be discontinued. Health insurance coverage is limited to a maximum of 6 cycles.
        1. For patients mentioned in (2): Each application for treatment is limited to 4 cycles. Subsequent applications should include assessment data from previous treatment results. If the patient has achieved complete remission, an additional 4 cycles may be covered; if the condition worsens, use must be discontinued.
        1. The total lifetime coverage for the same patient under (1) and (2) is limited to a maximum of 16 cycles.

[family meeting] (not posted)

On the morning of 2023-11-22, at 10:00 AM in the 11A ward meeting room, a family meeting for the patient was convened by the attending physician, Dr. Gao. Attendees included the patient, her father, mother, elder sister, younger brother, and husband.

During the meeting, Dr. Gao thoroughly explained the current status of the disease, prognosis, and the conditions for health insurance coverage of targeted medications. The meeting particularly focused on ensuring that the patient’s family support network has a correct understanding of the condition and can provide timely support to the patient. The patient was also encouraged to actively raise any questions or concerns she might have during the treatment process and seek assistance from the medical team.

In an informal conversation after the meeting, outside the patient’s room, I further explained to the patient and her family about the risks of “tumor lysis syndrome” and “infusion reaction,” as well as the key points to cooperate with during treatment. The patient seemed willing to comply with the treatment.

700384230

231121

[lab data]

2023/03/17 Anti-HBc (NM) = Positive; 2023/03/17 HBsAg (NM) = Negative; 2023/03/17 HBsAg Value (NM) = 0.454; 2023/03/17 Anti-HBs (NM) = Positive; 2023/03/17 Anti-HCV (NM) = Negative;

[MedRec]

  • 2023-10-04 ~ 2023-10-16 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07 s/p chemotherapy with FOLFOX from 2023/10/12~
      • Chronic viral hepatitis B without delta-agent
      • Cachexia
      • Constipation, unspecified
    • CC
      • For prepare chemotherapy.
    • Present illness
      • This 63-year-old man patient suffered from discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent.
      • After discharge, he was keep follow up at our OPD. Body weight loss 16kg (70 -> 61 -> 54kg) from 2022/12 ~ 2023/05 ~ 2023/10.
      • Laparoscope choledocho-duodenostomy LC and Distal CBD biopsy on 2022/12/15 and Gallbladder, laparoscopic cholecystectomy pathology showed acute cholecystitis and Common bile duct, distal pathology showed chronic inflammation.
      • Abdominal CT on 2023/02/10 showed 1. Metastasis 1.5 x 1 cm in S6 liver is highly suspected, the differential diagnosis include atypical hemangioma, please correlate with MRI and biopsy. 2. Prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size. 3. Poor enhancing lesions in the hepatic hilum and ligamentum teres are suspected that may be metastatic nodes or lymphedema?
      • Abdominal echo on 2023/03/06 showed liver parenchymal disease, probable liver tumor: S6, GB sac not seen, pneumobilia, bilateral renal cysts and fatty infiltration of pancreas.
      • Liver MRI on 2023/03/15 showed 1. Prior CT identified a well-defined poor enhancing lesion 1.5 x 1 cm in S6 of the liver at portal venous phase images is not noted in the current MRI. 2. Prior CT identified poor enhancing lesions in the hepatic hilum and ligamentum teres are noted again, stationary, follow up is indicated and mild dilatation of both lobe IHDs and CHD.
      • PES on 2023/04/13 showed reflux esophagitis LA Classification grade A, superficial gastritis and duodenitis with stenosis, proximal of 2nd portion, s/p biopsy. Duodenum, proximal of 2nd portion, biopsy showed chronic erosive duodenitis.
      • EUS on 2023/05/11 showed rule out pancreatic tumor, head, abdominal lymphadenopathy and mild dilated left intrahepatic duct.
      • Abdominal SONO on 2023/05/12 showed 1. S/P cholecystectomy. 2. Pneumobilia. 3. There are several renal cysts on both kidney and the largest one measuring 2.86 cm in size at left upper pole. 4. Otherwise, no significant abnormal finding is noted.
      • Abdominal CT on 2023/07/07 showed prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size, in addition, there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
      • EUS on 2023/07/19 showed 1. Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB 2. Dilated CBD & MPD 3. Duodenal stenosis, SDA.
      • Upper GI series on 2023/07/20 showed 1. Luminal narrowing with irregularity contour at duodenum 1-2nd portion. 2. Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?).
      • Pancrease fine needle biopsy showed soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation.
      • Abdominal echo on 2023/07/20 showed postcholeycstectomy, pneumobilia, renal cyst, bilateral, dilated main pancreatic duct and abdominal lymphadenopathy.
      • Pancreato-duodenectomy whipple procedure with reconstruction on 2023/08/07 and pathology showed ampulla vater adenocarcinoma invading pancreatic head, IHC stains: CK7(+), CK20(-), CA19-9(weak +), CA125(-), CK19(+), pT3bpN0(if cM0); pStage: IIB, at least.
      • Port-A catheter implantation on 2023/10/03. Poor appetite with weaknees and weekly to LMD for intravenous nutrition injection from 2023/08.
      • Now, he was admitted to ward for prepare chemotherapy.  
    • Course of inpatient treatment
      • After admitted, Bfluid (self pay) + Lyo-povigent (self pay) and IVF suplementation for poor appetiet.
      • Gascon 1# po TID, Mopride 1# po TID and Cimetidine 1# po TID for abdominal distention.
      • Panadol 1# po PRNQ6H for Port-A wound pain control.
      • Explain his condition to his family (wife and son) on 2023/10/09.
      • Chemotherapy with FOLFOX (Oxalip (self pay) 50mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/10/12 ~ 2023/10/14.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H fro nausea and vomiting.
      • Chronic viral hepatitis B without delta-agent (Anti HBc(+)) with Vemlidy 1# po QD.
      • Cachexia with Megest 10ml po QD.
      • Constipation with Sennoside 2# po HS and MgO 2# po TID.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/16 and OPD followed up later.   
    • Discharge prescription
      • Gasmin (dimethylpolysiloxane 40mg) 1# TID
      • Megest (megestrol 40mg/mL) 10mL QD
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • MgO 250mg 2# TID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-09-14 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • Based on the pathological report, the pancreaticobiliary ad mixed typeis favored. The ajuvant treatemnt is favored.
      • Options:
        • Adjuvant chemotherapy alone
        • Adjuvnat chemotherapy plus CCRT
      • Regimens (Patient is weak and poor nutirion, may consider not too strong C/T, and nutrition support during admission)
        • HDFL / Capecitabine
        • Gem alone
        • Gem/CDDP
        • Gem/Cap
        • FOLFOX/CapOx -> Favored
        • mFOLFIRINOX
  • 2023-07-19 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Ampulla vater ductal adenocarcinoma invading pancreatic head, pT3bN0(cM0) Stage: IIB status post pancreato-duodenectomy whipple procedure with reconstruction with lymph node dissection on 2023/08/07. ECOG:1
      • Gastro-esophageal reflux disease with esophagitis
      • Essential (primary) hypertension
      • Acute pancreatitis, unspecified
      • Cholangitis
    • CC
      • enlarged nodes in hepatoduodenal ligament for scheduled EUS FNB
    • Present illness
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • At GS OPD, abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen. CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08). He had poor appetite, general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation. Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found. There was no URI symptoms, no chest tightness, no TOCC history found.
      • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen,he was admitted for scheduled EUS FNB.
    • Course of inpatient treatment
      • After admission, NPO with adquaet IV fluid supportwith PPN, Empirical antibiotic with Brosym was given.
      • The EUS FNB was performed smoothly on 2023/07/19, and reported
        • Lymphadenopathy, liver hilum and peripancreas, s/p CEH/EUS-FNB
        • Dilated CBD & MPD
        • Duodenal stenosis, SDA.
      • The Double contrast study of UGI series revealed:
        • Luminal narrowing with irregularity contour at duodenum 1-2nd portion.
        • Flow of contrast medium into the IHDs and CBD (s/p duodenocholedochostomy?)
      • Try liquid diet as toelrable and mild abdomen distension was noted depite medication treatment.
      • The pathology of Pancreas biopsy reported pancrease fine needle biopsy — soft tissue with marked bland lymphoid cells infiltration, in favor of chronic pancreatitis. IHC stains: CD3 and CD20: no predominant subpopulation. Consulted GS then he was tranferred to our ward for further treatment and pre-operation evaluation.
      • He underwent operation of Whipple on 2023/08/07, then he was transferred to SICU for post op care. We kept infection control with Brosym use. After trying weaning from ventilator, extubation was done smoothly on 2023/08/08, and he was then transfered to ordinary ward for care.
      • We monitor his vital sign and condition closely. Adequate pain control was given for patient. During the hospitalization course he has some numbness of right legs resulting from PCA usage. The problem resolved after we contacted anesthetia department and halt PCA usage. Throughout the hospitalization course there was no major complication.
      • Under stable vital sign and condition we discharged him with OPD follow up and take home medication.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# Q12H
      • MgO 250mg 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Protase (pancrelipase 280mg) 1# TIDCC
      • Rich (lansoprazole 30mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Xyzal (levocetirizine 5mg) 1# HS
      • Flu-D (fluconazole 150mg) 1# QD
      • Cravit (levofloxacin 500mg) 1.5# QDAC
  • 2022-12-14 ~ 2023-01-02 POMR General and Gastrointestinal Surgery Wu ChaoQun
    • Discharge diagnosis
      • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15
      • Intraabdomen leakage with infection (Candida, Enterococcus and Escherichia coli)
      • Wound infection due to Enterococcus releved
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
    • CC
      • Distal CBD stricture then s/p stent was noted since 3 months ago
    • Present illness
      • This 62-year-old man with past medical history of
        • hypertension,
        • gout,
        • hyperlipidemia.
        • distal CBD with stenosis s/p ERBD with stent on 2022/09/26.
      • According for his statement and medical record, he was discharged from our GI ward for obstructive jaundice then distal CBD with stnosis s/p ERCP with stent. After discharge, he was keep follow up at our OPD. Furhter MRI was performed and showed stenosis of distal CBD. S/P CBD stenting. A cystic lesion (1.0cm) in ucinate process of pancreas. Enlargement of pancreatic head. Mild dilatation of p-duct (3.6mm).
      • Due to no evidence of tumor or cancer result, he referred to our OPD for surgical intervention. He denied of nausea, vomit, abdominal pain, jaundice or loss of body weight in recently. After fully explain of surgical method, laparoscopic choledochoduodenostomy with cholecystectomy was planning. This time. he was admitted to our ward for surgical management.
    • Course of inpatient treatment
      • After admission, he received laparoscope choledocho-duodenostomy and cholecystectomy was processed successfully on 2022/12/15. Post operaively, we observed patient recovery and keep empiric antibiotic, stool softener and analgesic agent were administered and the wound management was performed. He try to introduced soft diet and can tolerate well to oral intake. However, bile leakage was noted since 2022/12/20. Then we kept NPO and nutrition support with PPN.
      • Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support.
      • Due to intraabdomen leakage, GI was also consulted then ERBD was indicated. However, bile leakage was reduced on 2022/12/26, then ERBD procedure was canceled. On the other side, wound reddness with pus dischrge was noted, then we kept Aqucel-Ag wet for wound care. His generally well beings and relativley stable. The bowel function, urinary or pulmonary function were normal and the wound pain was tolerable.
      • JP drainage with no pus dischrge then removal was done smoothly on 2022/12/31, then final ascites culture showed candida. Infection men was also consulted who suggest keep Flucon support.
      • Under improved general condition, he was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# QD
      • Strocain (oxethazaine, polymigel; 5mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# QD
      • Mopride (mosapride citrate 5mg) 1# TID
      • Flu-D (fluconazole 150mg) 1# QD
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
  • 2022-09-25 ~ 2022-09-28 POMR Gastroenterology Hong Yulong
    • Discharge diagnosis
      • Suspect malignant biliary obstrcution with lymphadenopathy, status post brushing and biopsy on 2022/09/26
      • Biliary obstrcution ststus post endoscopic retrograde biliary drainage with placement of a plastic stent
    • CC
      • For ERCP + IDUS
    • Present illness
      • This 62-year-old man with past medical history of hypertension, gout, hyperlipidemia. He was regular follow up at Rheu OPD.
      • He just discharged from GI ward for Obstructive jaundice s/p ERCP, Distal biliary stenosis, s/p precut with NKF, s/p EST, s/p ERBD with placement of a plastic stent.
      • Due to Painless jaundice for 2 wks visited GI OPD then admission, CT and MRI showed distal CBD stricture but no obvious tumor noted. ERCP showed distal CBD stricture also s/p ERBD, jaundice improving after ERCP then discharge.
      • For further survay, the EUS (on 2022/08/26) showed dilated CBD and sludge but no tumor. Had talked about IDUS. He agreed then arrange admssion 2022/09/25 for ERCP + IDUS on 2022/09/26. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool. He also denied TOCC history.
    • Course of inpatient treatment
      • After abmission to GI ward, ERCP and IDUS were arranged after explain indication and risk.
      • ERCP with IDUS was performed smoothly on 2022/09/26 and revealed suspect malignant biliary obstrcution with lymphadenopathy, s/p STERIS Infinity brushing and biopsy, s/p ERBD with placement of a plastic stent.
      • The pathology was pending. Analgesic agent for pain relief was prescribed. There was no fever episode after procedure.
      • Oral intake trying was administered and there was no abdominal discomfort.
      • Follow up laboratory data revealed mild leukocytosis and elevaeted pancreas enzyme.
      • Some patient in the same room was diagnosed to have COVID-19 infection then he was discahrged this early morning.
      • OPD follow-up was arranged.
  • 2022-08-08 SOAP Rheumatology and Immunology Chen JunXiong
    • Diagnosis
      • M10.00 - Idiopathic gout, unspecified site
      • M06.4 - Inflammatory polyarthropathy
      • E78.5 - Hyperlipidemia, unspecified
    • Prescription x3
      • Tulip (atorvastatin 20mg) 1# QD
      • colchichine 0.5mg 1# QD
      • Euricon (benzbromarone 50mg) 1# BID
  • 2022-07-21 ~ 2022-07-26 POMR Gastroenterology Hong Yulong
    • Discharge diagnosis
      • Distal common bile duct stenosis with obstructive jaundice, nature to be determinated
      • Chronic kidney disease
      • Duodenal ulcer
      • Acute diarrhea
    • CC
      • tea color urine and clay stool for 5 days
    • Present illness
      • This is a 62-year-old man with past medical history of 1. hypertension, 2. gout, 3. hyperlipidemia. He was regular follow up at Rheu OPD. He was admitted due to tea color urine and clay stool for 5 days.
      • According to the patient himself and the past medical record, he suffered from tea color urine and clay stool for 5 days. He denied abdominal pain or weight loss. He had a health exam on 2022/07/05 and elevated ALT up to 143 was noted. He then visited our hospital for help. There was no fever, no dizziness, no URI symptoms, no chest tightness, no epigastric pain, no tarry stool.She also denied TOCC history.
      • At OPD, the laboratory tests showed AST/ALT 205/398, TBI/DBI 6.87/4.52, CRE 1.71. CT was done and showed dilatation of bilateral IHDs and CBD with segmental wall thickening at distal CBD; no CBD stone or tumor was found in the exam.
      • Under the impression of obstructive jaundice. He was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, ERCP was performed on 2022/07/22 and distal CBD stanosis was noted but definite cause unknown. Platic stent was inserted. Besides, DU was also noted during the exam so oral Pariet was used. Blood test showed elevated pancreatic enzymes but no significant abdominal pain, the he start intake again.
      • Pancras MRI + MRCP was performed on 2022/07/23 and no definite lesion was seen in the CBD or pancreatic head. The jaundice improving after stent insertion.
      • The IgG4 level was normal. Because IgG4 related disease still couldn’t be excluded, EUS + FNB was arranged on 2022/07/26 to check tumor or random biopsy.
      • However, diarrhea about 10 times was noted since 2022/07/25 especially after the evening despide medication use.
      • The patient decided not to receive the EUS examination just because diarrhea couldn’t improve soon (bad mood).
      • Then he was discharged on 2022/07/26 and GI OPD follow-up was arranged.
    • Discharge prescription
      • Smecta (dioctahedral smecitite) 1# TIDAC
      • Pariet (rabeprazole 20mg) 1# QDAC
      • Buscopan (hyoscien-N-butylbromide 10mg) 1# TIDAC

[consultation]

  • 2023-08-17 Hemato-Oncology
    • Q
      • Ampulla vater cancer s/p whipple for further chemotherapy
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • He noted for CBD stricture with repet pancreatitis for half years. This time, he was admitted and received further operation of Whipple’s op on 2023/08/07.
      • Final pathology showed ampulla vater cancer invading pancreatic head with ductal adenocarcinoma. pT3bpN0(cM0); pStage: IIB.
      • Now, he tolerance well of semi-liquid diet. We need your help for further adjuvant chemotherapy for this case. Thanks for your time!!
    • A
      • This 62 year old man is a case of ampulla vater adenocarcinoma. pT3bpN0(cM0); pStage: IIB s/p Whipple’s op on 2023/08/07. He had underline disease of HTN, Gout, Hyperlipidemia, and Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15. We are consulted for cancer treatment.
      • Please arrange port A insertion. We will discuss with patient about further ajuvant chemotherapy (5-FU + leucovorin or gemcitabine (self-paid) or other regiment). Please arrange our OPD after discharge. Thanks for your consultation.
      • Ref:
        • The ESPAC-3 trial demonstrated significant improvements in DFS and overall survival (OS) with use of postoperative gemcitabine or 5-fluorouracil (5-FU) as adjuvant chemotherapy versus observation in resectable ampullary adenocarcinoma.
        • ESPAC-3 study results showed no significant difference in OS between 5-FU/leucovorin versus gemcitabine following surgery. When the groups receiving adjuvant 5-FU/leucovorin and adjuvant gemcitabine were compared, median survival was 23.0 months and 23.6 months, respectively.
  • 2023-07-25 General and Gastrointestinal Surgery
    • Q
      • This 62-year-old man with past medical history of
        • Hypertension.
        • Gout.
        • Hyperlipidemia.
        • Distal common bile duct stricture status post laparoscopic choledochoduodenostomy and cholecystectomy on 2022/12/15.
      • He was regular follow up at GS OPD.
      • At GS OPD,abdominal CT was performed on 2023/07/07 and reported prior CT identified few enlarged nodes in hepatoduodenal ligament are noted again, mild increasing in size,there are several new developed enlarged nodes in the omentum and mesentery of RUQ abdomen.
      • CA 199 from 903.59 U/mL(2023/05/02) up to 1317.82 U/mL(2023/06/08).
      • He had poor appetite,general weakness and weight loss 14 kg (2022/12 70kg -> 2023/07 56kg) after operation.
      • Fever up to 38.4 on 2023/07/17 and deep yellowish urine for 3 days were found.
      • There was no URI symptoms, no chest tightness, no TOCC history found.
      • Under the impresison of enlarged nodes in hepatoduodenal ligament and new developed enlarged nodes in the omentum and mesentery of RUQ abdomen, he was admitted for scheduled EUS FNB.
      • The EUS FNB pathology was pending, we need your expertise for his Distal common bile duct stricture Thanks~
    • A
      • Please TPN for nutrition support for pre-op
      • Further OP method: Whipple op or GJ bypass
  • 2022-12-31 Infectious Disease
    • Q
      • bile leakage with intraabdomen infection
      • ascites showed CRKP, E-coli, enterococcus, and yeast
      • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20.
      • Bile culture showed CRKP, enterococcus and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. Unbilical wound infection was also noted and culture also revealed enterococcus. 2022/12/29 recheck ascites still show yeast like and WBC: 13300, CRP:2.21 was noted.
      • Now, we kep tienam + oral ciproxin and zyvox + flucon support for intraabdomen infection control. We need your help for further antibiotic recommendation.
    • A
      • Consultation for Zyvox and Culin (Tienam) antibiotic use.
        • Postoperative polymicrobial cholangitis and umbilical wound infection case.
        • Inital ascites culture showed CRKP and Enterococcus faecalis on 2022/12/16, follow up ascites culture on 2022/12/20 revealed MDR-E.coli and Eneterococcus.
        • The latest ascites on 2022/12/29 showed Yeast.
        • Patient is receiving the 2nd week Culin, oral Cipro, iv fluconazole and newly-added oral Zyvox.
        • Antibioticv adjustment indicated.
      • Suggestion:
        • Culin de-escalted to Brosym,
        • DC Zyvox, since no MRSA or VRE evidence.
        • DC oral Cipro since no effect for E.coli.
        • Continue iv fluconazole for the most possible Candida superinfection.
  • 2022-12-23 Gastroenterology
    • Q
      • post laparoscope choledocho-duodenostomy with bile leakage for endo stent
      • This 62 y/o male was a case of distal CBD stricture with stent since 3 months ago. This time, he was admitted and received laparoscope choledocho-duodenostomy and LC on 2022/12/15. However, post operation with bile leakage was noted since 2022/12/20. Bile culture showed CRKP and E-coli, we keep antibiotic with Tienam + Doripenam + Unasym support. We need your help for endo stent replacement for bile leakage control. Thanks for your time!!
    • A
      • Pre-ERCP evaluation
        • Indication: post operation bile leakage
        • Medication anti-coagulant: denied
        • Previous operation history: laparoscope choledocho-duodenostomy and LC
      • Suggestion
        • Please check amylase and lipase “before” ERCP
        • Set IC in right arm (if no contraindication)
        • ERCP intervention could be arranged on 2022/12/26 in the afternoon
          • well inform-consent to the patient and the family, including the current condition, the indication for ERCP, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, biliary tract infection, post-ERCP pancreatitis, post-ERCP bleeding, etc.)
          • if the patient and families all understand ERCP intervention, may take the risk, and sign permit for ERCP, we would arrange ERCP
          • please keep NPO at least 8 hours before ERCP as possible
          • correct bleeding tendency, and avoid any antiplatelets/anticoagulants before ERCP;
        • Keep current empirical antibiotics use and IV line before ERCP, and closely follow up the patient’s clinical condition for fear of further septic shock due to biliary tract infection;
        • Please inform us if any clinical sign deterioation before and after ERCP

[surgical operation]

  • 2023-08-07
    • Surgery
      • Pancreato-duodenectomy whipple procedure with reconstruction.
      • Including:
        • Partial gastrectomy
        • pancreato-duodenal anastomosis +
        • Billroth II
        • Braun anastomosis
    • Finding
      • Severe adhesion of previous operation site.
      • Solid medium-hard of Vater region was noted from resecction tissue, malignancy suspected.
      • Pending pathology report.
  • 2022-12-15
    • Surgery
      • laparoscope choledocho-duodenostomy
      • LC
      • Distal CBD biopsy
    • Finding
      • distal CBD stricture with stent in place

[chemotherapy]

  • 2023-11-20 - oxaliplatin 75mg/m2 125mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-11-01 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-12 - oxaliplatin 50mg/m2 80mg D5W 250mL 2hr + leucovirin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-11-21

After the surgical operation on 2023-08-07 (Pancreato-duodenectomy Whipple procedure with reconstruction, which included partial gastrectomy, pancreato-duodenal anastomosis, Billroth II, and Braun anastomosis), the tumor marker CA199 significantly decreased from four digits to two digits.

  • 2023-11-20 CA199 55.17 U/mL
  • 2023-09-14 CA199 59.52 U/mL
  • 2023-08-03 CA199 1754.46 U/mL
  • 2023-06-08 CA199 1317.82 U/mL
  • 2023-05-03 CA199 903.59 U/mL
  • 2023-04-13 CA199 806.27 U/mL
  • 2023-03-06 CA199 698.53 U/mL
  • 2023-01-31 CA199 653.74 U/mL

Lab data from 2023-11-20 indicates that, apart from slightly impaired renal function, liver function, electrolytes, and blood counts are largely within normal ranges.

No medication discrepancies identified.

700507094

231120

==========

2023-11-20

[vancomycin TDM]

U-Vanco (vancomycin) has been administered at a dose of 1000mg Q12H IVD since 2023-11-18, with scheduled administration times at 09:00 and 21:00. The blood sample was drawn on 2023-11-20 at 02:25:37, following the administration at 20:19 on 2023-11-19, and before the next dose at 12:47 on 2023-11-20. If the aim is to measure the trough level, the ideal time for blood sampling should be within half an hour before the next dose. Please confirm if the timing of the blood draw was correct.

If after confirmation, the blood draw timing is deemed accurate (indicating a vancomycin concentration of 22 mg/L is reliable), then the current dosage of 1000mg Q12H should be reduced to 750mg Q12H.

701504241

231120

[exam findings]

  • 2023-11-18 CXR - abdomen
    • Clinical history: 83 y/o female patient with cecal soft tissue mass is suspected. Liver low density lesion. Colon cancer with liver meta?
    • With and without contrast enhancement CT of abdomen:
      • Thickening wall at the sigmoid colon with pericolonic infiltrates and abutting pelvic side wall, r/o sigmoid colon malignancy.
      • Edema/thickening wall at the cecum, syncrhonous colon malignancy?
      • Irregular cystic tumor, 2.4cm in S8 liver, complicated cyst or cystic metastasis? Suggest further study.
      • Bilateral renal cysts, up to 3.2cm in left kidney.
      • Liver cysts.
      • Fibrocalcified infiltrates in right upper lung.
      • Irregular contour of urinary bladder, r/o chronic cystitis.
      • T12 and L3 compresion fractures.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:Mx(M_value) STAGE:____(Stage_value)
    • Impression:
      • Sigmoid colon malignany, cstage T4N1Mx(cystic liver tumor, r/o complicated cyst or cystic metastasis, suggest further study).
      • Edema/thickening wall at the cecum, syncrhonous colon malignancy? Suggest colonoscope study.
  • 2023-11-17 ECG
    • Sinus rhythm with Premature atrial complexes
    • Otherwise normal ECG
  • 2023-11-17 CXR (erect)
    • Fibro-calcified shadows of right upper lung are noted, which may be due to old TB. Please correlate with clinical history.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-11-10 KUB
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
    • Compression fracture of T12 and L3 vertebral body.
  • 2023-11-06 CT - abdomen
    • Indication: a case of uterine ca s/p (10 yrs ago; loss F/U) RLQ pain for 1 m. appetite: OK. stool: OK. refer for GYN. dysuria (-). fever (-)tx at LMD in vain R/O colon leison
    • Abdominal CT without IV enhancement revealed:
      • Diffuse swelling of the cecum measuring 7.45cm in largest dimension is found. Some lymph nodes (n=4) are found at RLQ of the abdomen.
      • Low density lesion at S7/8 of liver measuring 2.35cm in largest dimension. Nature?
      • Left renal cyst measuring 3.55cm is found.
      • The spleen, pancreas, both adrenals are intact.
    • Imp:
      • Cecal soft tissue mass is suspected.
      • Liver low density lesion.
      • Colon cancer with liver meta? Suggest further study.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)

700127430

231116

[lab data]

  • 2021-09-01
    • HBsAg Nonreactive
    • HBsAg Value 0.36 S/CO
    • Anti-HBc Reactive
    • Anti-HBc Value 4.02 S/CO
    • Anti-HBc IgM Nonreactive
    • Anti-HBs >1,000mIU/mL

[exam findings] (not completed)

  • 2023-11-16 CT - abdomen
    • History and indication: Ovarian Cancer, pT3bN0Mx, stage IIB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump. S/P Port-A infusion catheter insertion. S/P right side double J catheter insertion. A nodule (2.0cm) at left pelvic cavity.
      • Colonic diverticula. Small size of left kidney.
      • Gallbladder stone (2.0cm). R/O distal CBD stones (2-3mm).
      • Atherosclerosis of aorta.
    • IMP:
      • S/P hysterectomy. Stable condition of recurrent cancer at vaginal stump.
  • 2023-11-07 KUB
    • S/P double J catheter insertion in place, right side.
    • Round calcification, 2.2cm in RUQ, r/o gallbladder stone.
  • 2023-11-07 SONO - kidney (urology)
    • Diagnosis: Left renal cyst
  • 2023-11-07 Bladder Sonography
    • PVR:5.8ml
  • 2023-09-06 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • A calcified gallstone is noted.
    • S/P double J catheter insertion, right side urinary tract.
  • YYYY-MM-DD XXX…

[MedRec]

  • 2017-01-06 SOAP Hemato-Oncology Wan XiangLin
    • S
      • Ovarian cancer, S/P op and C/T (C8, 20161109), for recheck, poor appetite after chemotherpay.
      • Gall stone at last abdominal CT examination.
      • S/P lab. test for tumor markers.
    • O
      • 20161205 abdominal CT
        • Findings
          • S/P operation.
          • Gall stone (1.5cm).
        • Impression:
          • S/P operation. No evidence of tumor recurrence.
          • Gall stone (1.5cm).
    • Diagnosis
      • Malignant ovary neoplasm [C56.2]
      • Leiomyoma of uterus, unspecified [D25.9]
    • Prescription
      • Agglutex (heparin 25000U/5mL) 5mL ST
      • NS 20mL ST
  • 2017-01-06 SOAP Neurology
    • Diagnosis
      • Cerebral artery occlusion, with cerebral infarction [I63.50]
      • Malignant ovary neoplasm [C56.2]
      • Essential hypertension, benign [I10]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
      • Myalgia and myositis,unspecified [M79.1]
    • Prescription x3
      • Eurodin (estazolam 2mg) 0.5# HS
      • Schnin (ginkgo biloba 9.6mg) 1# BID

[chemotherapy]

  • 2023-11-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-10-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-09-06 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-08-02 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-07-04 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-05-30 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-03-28 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-02-15 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2023-01-13 - liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr (Lipo-dox Q4W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2022-01-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-11-26 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-11-06 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-10-14 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-09-23 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-09-02 - bevacizumab 7.5mg/m2 400mg NS 250mL 90min + paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

700136377

231116

[lab data]

2023-05-05 Anti-HBc Reactive
2023-05-05 Anti-HBc-Value 6.66 S/CO
2023-05-05 Anti-HBs 414.12 mIU/mL
2023-05-05 Anti-HCV Nonreactive
2023-05-05 Anti-HCV Value 0.08 S/CO

[exam findings]

  • 2023-08-26 CT - abdomen
    • History and indication: S-colon cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
      • Left renal cyst (8mm).
      • Right ovary cyst (2.4cm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon operation. Right liver metastases s/p operation with biloma formation (2.9cm).
  • 2023-04-20 All-RAS + BRAF gene mutation analysis
    • ALL-RAS: Detected (KRAS codon 146 GCA>CCA, p.A146P)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-20 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S6, partial resection — Metastatic colonic mucinous adenocarcinoma
    • MACROSCOPIC EXAMINATION
      • Procedures: S6 partial resection
      • Specimen Size: 6.2 x 4.0 x 3.0 cm and 39.2 gm
      • Tumor Focality: Solitary
      • Tumor Site: S6
      • Tumor Size: 3.0 x 2.5 x 2.5 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A5
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic mucinous adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Present
      • Tumor necrosis: Absent
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.7 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Moderate to mild lymphocytic portal inflammation, and mild fatty change (5%)
  • 2023-04-19 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, colectomy —- Adenocarcinoma, moderately differentiated
      • Peritoneum, left abdominal wall, excision —- Adenocarcinoma, by direct invasion
      • Uterus, excision —- Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- metastatic adenocarcinoma (2/19)
      • Lymph node, IMA / SMA, dissection —- not received
      • AJCC 8th edition Pathology stage: pStage IVA, pT4bN1bM1a
    • Gross Description:
      • Operation procedure: sigmoid colectomy with a portion of left abdominal wall and uterus
      • Specimen site: sigmoid colon
      • Specimen size: Colon: 8.0 cm in length; left abdominal wall: 3 x 3 x 0.9 cm; uterus: 2 x 1 x 0.8 cm
      • Tumor size: 4 x 3.5 cm
      • Tumor location: 2.2 cm and 1.7 cm away from the two resection margins, respectively.
      • Depth of invasion grossly: left abdominal wall
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as:
        • A1: colon, non-tumor; A2-6: tumor (A2 and A3: with left abdominal wall; A4: with uterus); A7-9: lymph node, mesocolic; A10: tumor, ink serosa; B: proximal cutend; C: distal cutend.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor directly invades adjacent structures (specify: left abdominal wall)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Present, Specify number of deposits: 4
      • Regional Lymph Nodes: Number of Lymph Nodes Involved/Examined: 2/19
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT):pT4b: Tumor directly invades or adheres to adjacent organs or structures
          • Regional Lymph Nodes (pN): pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM): pM1a: Metastasis to one site or organ is identified without peritoneal metastasis (S2023-07515)
      • Additional Pathologic Findings (select all that apply): None identified
  • 2023-03-31 CT - abdomen
    • CC: One mass was noted in the sigmoid colon (25 cm from anal verge)
    • Indication: adenocarcinoma of the sigmoid colon, CT staging
    • Findings:
      • There is segmental circumferential asymmetrical wall thickening at the sigmoid colon, measuring 8 cm in length, with irregular contour and suggestive direct invasion left round ligament.
        • It is c/w adenocarcinoma of the sigmoid colon (T4b).
        • In addition, there are seven enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass 2.6 cm in S6 of the liver that is c/w metastasis (M1a).
      • There are several renal cysts on both kidney and the largest one measuring 0.8 cm in size at left middle pole.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-03-31 Patho - colorectal polyp
    • DIAGNOSIS:
      • Colon, sigmoid, 25 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.5 x 0.3 x 0.1 cm. All for section in one cassette.
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).

[MedRec]

  • 2023-04-18 ~ 2023-04-27 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Adenocarcinoma of sigmoid with direct invasion to left abdominal wall, and liver metastasis , cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pStage IVA, pT4bN1bM1a
    • CC
      • intermittent lower abdominal pain for three months
    • Present illness
      • This is a 74-year-old female without any underlying diseases. She suffered from intermittent lower abdominal pain for three months. Bowel habit change with loose stool for one year was also mentioned. She had no diarrhea, no tarry stool, no anal fresh bleeding, no significant body weight loss. She then visited colon and rectum surgery outpatient department for help. After series of work-up, she was diagnosed with adenocarcinoma of sigmoid with liver metastasis, cT4bN2bM1a, stage4a. This time, she was admitted to our ward for sigmoid colectomy and liver resection on 2023/04/19.   - Course of inpatient treatment
      • After admission with ward routine, operation of sigmoid colectomy and liver resection were done on 2023/04/19 under general anesthesia. After the operation, wound healing went well without erythema change. Chewing cookies, toast, rice with gum was started at op day. The wound pain was tolerated under PCEA. Lab data checked on 4/20 showed Hb 7.9, WBC 11730, GOT 192, GPT 216, total bilirubin 0.38, direct bilirubin 0.07, CRP 6.76. Blood transfusion of LPRBC 2u and K1 supplement were arranged. Empirical antibiotic with Cefoxitin and self-pay Plasbumin were given for three days. There were no nausea and no vomiting. Flatus and stool passage were noted after operation. She was able to tolerate low residual diet. During her stay at our ward, there were no fever.
      • The final pathology report revealed liver, S6, partial resection metastatic colonic mucinous adenocarcinoma; large intestine, sigmoid colon, colectomy, adenocarcinoma, moderately differentiated/peritoneum, left abdominal wall, excision, adenocarcinoma, by direct invasion; Uterus, excision, negative for malignancy, pT4bN1bM1a.
      • Under stable condition, she discharged on 2023/04/27 and OPD follow up was arranged.
    • Discharge prescription
      • Deflam-K (diclofenac 25mg) 1# PRNQ8H
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
      • MgO 250mg 1# TID
  • 2020-02-24 SOAP Neurosurgery Dai BoAn
    • Diagnosis
      • Other spondylosis with myelopathy, site unspecified [M47.10]
      • Other spondylosis with radiculopathy, lumbar region [M47.26]
    • Prescription
      • U-Ca (calcitriol 0.25ug) 1# QD
      • CaCO3 500mg 2# QD
      • Vit B1 (thiamine 100mg) 1# QD
      • Arcoxia (etoricoxib 60mg) 1# QD
      • Stidine (tizanidine 2mg) 1# HS

[consultation]

  • 2023-10-26 Dermatology
    • Q
      • The patient is an 74-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
      • She presented left armpit with redness and itchy was found about for 2 weeks. We need your further evaluation and management.
    • A
      • Under the impression of tinea corprois et intertrigo eczema over axilla.
      • The following sugeetion:
        • Zalain cream 1 tube topical bid use over large area of axilla first.
        • Mycomb cream 1 tube topical PRN bid use over itchy area.
  • 2023-08-10 Dermatology
    • Q
      • The patient is an 73-year-old female with a history of Adenocarcinoma of sigmoid with direct invasion to left abdominal wall and liver metastases, cT4bN2bM1a, stage IVA status post sigmoid colectomy and liver resection on 2023/04/19, pT4bN1bM1a, pStage IVA s/p chemotherapy with FOLFOX from 2023/05/24~.
      • She presented with Hand-foot syndrome was found, after chemotherapy. we need your further evaluation and management.
    • A
      • The patient had sufferred from reedish swelling over digitals.
      • Under the impression of hand foot syndrome with remssion stage.
      • The following sugeetion:
        • Enhance skin mositurzation first. Topysm cream 1 tube topical bid use over erythematous swelling lesions.
        • Sinphraderm 1 tube topical QN use over thick/ scales lesions.

[surgical operation]

  • 2023-04-19
    • Surgery: S6 partial resection of liver
    • Finding: 3 x 2.5 x 2.5 cm metastatic tumor
  • 2023-04-19
    • Surgery: Sigmoid colectomy     
    • Finding
      • tumor direct invasion to uterus and left abdominal wall    
      • Splenic flexure was mobilized    

[chemotherapy]

  • 2023-10-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-28 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, omitting 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-10 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W, reduced Oxa due to ANC 1076)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-10 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - oxaliplatin 75mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-24 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-27

There were no issues found during medication reconciliation, and based on the patient’s latest lab results indicating normal renal and liver function, no dose adjustments are required.

700352403

231113

[MedRec]

  • 2018-12-07 ~ 2018-12-14 POMR Gastroenterology Li ZhongXian
    • Discharge diagnosis
      • K63.3 - Post polypectomy wound with propable recent bleeding
      • K52.9 - Colitis of A colon
      • C20 - Malignant rectum neoplasm, DUKE C(T3N1M0) s/p surgery and chemotherapy
      • E87.1 - Hyponatremia
      • I11.9 - Hypertensive heart disease
    • CC
      • Passage of bloody stool and fever, general weakness, abdominal pain for one day AFTER COLON POLYPECTOMY
    • Present illness
      • This 73 year old MAN had history of
        • HCVD
        • cerebral artherosclerosis
        • rectal cancer s/p surgery with lung metastses and had been taking drugs for many years as prescribed.
      • He regularly follow up with appointment at Neurolgy and Oncology specialist.
      • He just received colon scope examination yesterday afternoon and polypectomy was performed.
      • After discharged, he presented with passage of bloody stool and fever, general weakness, abdominal pain.
      • Hence the patient was brought to our ER for evaluation and management.
      • An examination of the patient’s abdomen in the ER showed soft and flat, no abdomen tenderness, no rebound tenderness, no icteric sclera, no pale conjuctiva A series of examinations including blood routine, blood biochemistry, cultures, urine routine and image were performed.
      • CT of the abdomen showed Bowel wall thickeing at ascending colon. Nature to be determined; propable left renal cyst; propable left adrenal tumor.
      • Under the tentative diagnosis of LGI bleeding.Propable post polypectomy wound bleeding and Leukocytosis and fever.
      • Propable colitis of A colon, the patient was admitted for further evaluation and treatment.
    • Course of inpatient treatment
      • Patient was admitted to our hospital due to passage of bloody stool and fever,general weakness,abdominal pain for one day.CT of the abdomen showed Bowel wall thickeing at ascending colon.
      • One day before admission, he received polypectomy at our surgery departement. Under the impression of lower GI bleeding, we underwent colon fiberoscopy and sawed polypectomy site was identified at A-colon and a clip was placed no bleeding was seen.
      • We observed his condition after colonscopy.There was no bloody stool after medical treatment. Abdominal pain improved. Normal yellow color stool passage was told.
      • We also consulted social worker for post colon polypectomy condition. The issue was reported and will keep close contact with family members and patient.Under stable condition he was discharge and OPD follow up
    • Discharge prescription
      • Ulstop (famotidine 20mg) 1# BID
      • Trand (tranexamic acid 250mg) 1# BID
      • Cero (cefaclor 250mg) 2# Q8H
  • 2017-01-02 SOAP Neurology Lin XinGuang
    • Diagnosis
      • Cerebral atherosclerosis [I67.2]
      • Essential hypertention, unspecified [I10]
      • Neuralgia, neuritis, and radiculitis, unspecified [M79.2]
      • Intervertebral disc disorder with myelopathy, unspecified region [M51.9]
      • Arthropathy, unspecified,unspecified sites [M12.9]
    • Prescription x3
      • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRN
      • Licodin (ticlopidine 100mg) 1# QD
      • Trandate (labetalol 200mg) 1# QD
      • Norvasc (amlodipine 5mg) 1# BID
      • Trileptal (oxcarbazepine 600mg) 1# BID

==========

2023-11-13

[reconciliation]

On 2023-10-18, the patient attended JingMei Hospital for treatment of polyneuropathy and received a 28-day prescription for mecobalamin, chlorzoxazone, brotizolam, and trazodone. These medications have not been recorded in the current medication list. Please verify if this constitutes a discrepancy.

700041739

231110

[MedRec]

  • 2021-05-17 ~ 2021-05-24 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • Cecal adenocarcinoma with mesocolon and visceral peritoneum involvement, moderately differentiated, EGFR (+) PMS2(+) MSH6(+) MSH2(+) MLH1 (+), pT4aN2b(cM0) stageIIIC, status post right hemicolectomy on 2021-05-18
      • Iron deficiency anemia, unspecified
    • CC
      • Intermittent right lower quadrant abdominal pain with lower grade fever since 1 month ago
    • Present illness
      • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week in April of 2021. He went to local clinics with 3-day antibiotics and analgesics and condition much improved, but the pain progressively recurred 2 days later. He traveled to ChangHua on 2021/04/10 and fever with RLQ pain were noted. He visited ChangHua Christian Hospital and was diagnosed with acute appendicitis by CT. He was transferred to our ED due to living nearby. Antibiotic treatment with Flumarin was given and his fever was subsided. However, stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. He was discharged after one week of treatment. PES and colonoscopy were arranged and cecal tumor with lumen obstruction at 130cm AAV was noted. Tracing back his clinical symptom and sign, he had abdominal fullness and decreased appetite. No body weight loss of bloody/tarry stool was noted.
      • The pathology disclosed adnocarcinoma of cecum. Therefore, he was referred to CRS OPD and surgical intervention was recommanded. After knowning the benefits and the risks of the operation, he was admitted to our ward for right hemicolectomy.
    • Course of inpatient treatment
      • The patient was admitted to our ward after finishing the pre-op assessments. The COVID-19 rapid test showed negative result. Mild anemia was found in hemogram. Other data were within normal limits. He received right hemicolectomy on 110-05-18 uneventfully. (1) Cecal cancer with obstruction, (2) anastomosis by GIA 75/4.8mm x2, and (3) One jp drain at pelvic area were noted intraoperatively. The patient tolerated the procedure well. He tried water and oral chewing on the operation day. Flatus and stool passage occurred on 110-05-20. Oral feeding with low residue soft diet was recruited then. The pathology showed cecal adenocarcinoma pT4aN2b(cM0) stageIIIC and we had applied Major Illness. Foley catheter and J-vac were removed smoothly during recovering course. Under a realtive stable clinical condition, he was discharged and OPD f/u will be arranged on 2021-05-31.
    • Discharge prescription
      • Meitifen (diclofenac 75mg) 1# PRNQD
      • MgO 250mg 2# BID
      • Acetal (acetaminophen 500mg) 1# QID
  • 2021-04-10 ~ 2021-04-17 POMR General and Gastrointestinal Surgery Zhang JianHui
    • Discharge diagnosis
      • Acute appendicitis with perforation and tumor formation
      • Anemia
    • CC
      • RLQ abdominal pain for 1 week.
    • Present illness
      • This 64 years old male who denied systemic or surgic history presented with RLQ abdominal pain for 1 week. At the second day, he went to local clinics with 3-day antibiotics and analgesics and condition much improved, But 2 days after the pain progressively recurred. Today when he traveled to ChangHua, fever and RLQ pain were noted and came to ChangHua Christian Hospital diagnosed with acute appendicitis by CT then transferred to our ED due to living nearby.
      • Arrived ER, vital sign TPR: 36.5/100/19, BP:152/96mmHg, clear of consciousness. Physical examination showed abdomen soft and flat, RLQ tenderness, no rebound tenderness, no muscle guarding. Under the impression of acute appendicitis with perforation and tumor formation, GS doctor was consulted who suggest admitted for antibiotic treatment and further care.
    • Course of inpatient treatment
      • After admission, Blood examination was done that revealed leukocytosis and Anemia, then antibiotic with Flumarin was given. We check stool occult blood revaled 3+ then add PPI for prevent gastric ulcer. After improved of condition and lab data. He was discharged today and take medication with antibiotic and PPI. He will be follow up at GS and GI OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • MgO 250mg 1# TID
      • Pariet (rabeprazole 20mg) 1# QDAC stool OB 3+
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Through (sennoside 12mg) 1# PRNHS
  • 2021-04-10 SOAP Medical Emergency He YaoCan
    • Diagnosis:
      • K35.80 Unspecified acute appendicitis
    • Prescription:
      • Lifoxitin (cefoxitin 1g/vial) 1 ST IVD
      • NS 500mL ST IVD

[surgical operation]

  • 2022-12-14
    • Surgery
      • Right ureteral catheterization
    • Finding
      • High bladder neck
      • No gross bladder tumor in the urinary bladder
      • A 6Fr. ureteral catheter inserted into right ureter
  • 2022-12-14
    • Surgery
      • Resection of retroperitoneal tumor, small bowel resection with anastomosis    
    • Finding
      • Retroperitoneal tumor with dense invaded to right testicular vessel and small bowel mesentery, close to right ureter (Right RP was inserted)
      • Iatrogenic small bowel perforation due to enterolysis and dense adhesion
  • 2021-05-18
    • Surgery
      • Right hemicolectomy        
    • Finding
      • Cecal cancer with obstruction
      • Anastomosis by GIA 75/4.8mm x2
      • One jp drain at pelvic area

[chemotherapy]

  • 2023-11-09 A-FOLFIRI He JingLiang

  • 2023-10-19 A-FOLFIRI He JingLiang

  • 2023-09-22 A-FOLFIRI He JingLiang

  • 2023-09-01 A-FOLFIRI He JingLiang

  • 2023-08-07 A-FOLFIRI He JingLiang

  • 2023-07-24 A-FOLFIRI He JingLiang

  • 2023-07-06 A-FOLFIRI He JingLiang

  • 2023-06-15 A-FOLFIRI He JingLiang

  • 2023-05-19 A-FOLFIRI Wan XiangLin

  • 2023-05-05 A-FOLFIRI Wan XiangLin

  • 2023-04-07 A-FOLFIRI Wan XiangLin

  • 2023-03-20 A-FOLFIRI Wan XiangLin

  • 2023-03-03 FOLFIRI Wan XiangLin

  • 2023-02-14 FOLFIRI Zhang ShouYi

  • 2022-12-27 FOLFIRI Zhang ShouYi

  • 2021-10-28 XELOX Xiao GuangHong

  • 2021-10-07 XELOX Xiao GuangHong

  • 2021-09-16 XELOX Xiao GuangHong

  • 2021-08-26 XELOX Xiao GuangHong

  • 2021-08-05 XELOX Xiao GuangHong

  • 2021-07-15 XELOX Xiao GuangHong

  • 2021-06-24 XELOX Xiao GuangHong

  • 2021-06-03 XELOX Xiao GuangHong

Medication

  • UFT

700130863

231110

{S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019-09-11 s/p post-Op adjuvant chemotherapy FOLFOX finishing in 2020-04 with periotneal seeding s/p laparoscope rt diaphram tumor excision 2021-06-09}

[past history]

  • Left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch

  • Gastric polyp, body s/p biopsy (biopsy: Hyperplastic polyp) in 2019/08

  • past operation

    • S/P ovarian cystectomy 30+ years ago
    • S/P tubal ligation surgery 30+ years ago
  • double cancer

    • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11.
    • RUL cancer, adenocarcinoma,pT1NoMi(cMx), stage IA1 if cM0, status post 3D VATS RUL lobectomy + RLND on 2019/09/30.
    • Left port-a implantation was done on 2019/10/07.
    • Lung, right upper lobe, lobectomy 2019/09/11 pathology showed minimally invasive adenocarcinoma, pT1miN0(cMx), Stage IA1 if cM0.

[lab data]

  • 2021-07-19 All-RAS mutations assay
    • S2021-8200
    • There was no variant detected in the KRAS/NRAS gene.
  • 2021-06-30 BRAF mutations assay
    • S2021-08200
    • There was no variant detected in the BRAF gene.
  • 2021-06-25 EGFR
    • S2021-08200
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
  • 2021-06-29 Anti-HBc Reactive
  • 2021-06-29 Anti-HBc-Value 1.89 S/CO
  • 2021-06-10 Anti-HBs 33.61 mIU/mL
  • 2021-06-10 HBsAg Nonreactive
  • 2021-06-10 HBsAg (Value) 0.40 S/CO
  • 2021-06-10 Anti-HCV Nonreactive
  • 2021-06-10 Anti-HCV Value 0.22 S/CO

[exam findings]

  • 2023-09-25 KUB
    • Contrast medium in collecting system
    • L2 pathologic fracture
  • 2023-09-25 CXR
    • Right apical pleural thickening
    • A pathologic fracture of L2
  • 2023-09-25 CT - abdomen
    • Indication: Sigmoid cancer with peritoneal carcinomatosis
    • Abdominal CT with and without enhancement revealed:
      • Low density lesions are found at S7/8 of liver measuring 2.46cm, S5/6 measuring 1.86cm and S2 measuring 1.97cm in largest dimension. In comparison with CT dated on 2023-06-21, these nodules are new. Liver meta is considered.
      • Several soft tissue nodules are found in the peritoneal space, peritoneal seeding is considered. In enlargement.
      • Wall thickening at rectum is found. Stable.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • s/p double J catheter placement at both sides.
      • s/p right upper lobe lobectomy.
      • S/p port-A placement with its tip at Superior vena cava.
      • Loculated effusion at right apical lung is found.
    • Imp:
      • rectal cancer with peritoneal tumor seeding, in progression. New liver meta and bone meta.
  • 2023-08-02 KUB
    • S/P double J catheter insertion in place, both sides.
    • Lumbar spondylosis.
  • 2023-08-01 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2023-06-21 CT - abdomen
    • History:
      • 20190902 CT: S-colon cancer, cT3N2aM0 s/p LAR n 2019/09/11 s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/04,
      • 20190826 CT: lung: an irregular GGO 16 mm with central solid component 5mm in RUL. path: Minimal invasive adenocarcinoma, pT1miNoMo, pStage:IA1
      • 20210531 CT: Multiple metastases at peritoneal cavity.
      • 20211203 CT: Omentum metastases S/P C/T show stable disease.
    • FINDINGS: Comparison prior CT dated 2023/03/29.
      • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion 1.1 cm is noted again, mild increasing in size to 1.5 cm.
        • Tumor seeding S/P C/T with stable disease is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • Liver and renal cysts (up to 2.4cm).
        • S/P double J catheter insertion, right and left side urinary tract.
        • There are marked bilateral hydroureteronephrosis.
        • Please correlate with retrograde pyelography.
      • There is no focal lesion in mediastinum.
        • There is a lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • There are marked bilateral hydroureteronephrosis. Please correlate with retrograde pyelography.
  • 2023-05-30 CXR
    • Prior plain chest film identified Patchy opacity projecting at right apical lung with lung volume decrease is noted again, stationary.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-03-29 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/12/28.
      • Prior CT identified an enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size to 1.1 cm.
        • Tumor seeding S/P C/T with stable disease is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        • There is no ascites or lymphadenopathy.
        • There is no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show stable disease. please correlate with clinical condition.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild increasing in size.
  • 2023-01-30 PET
    • Glucose-hypermetabolism lesions in the perirectal region and in bilateral inguinal lymph nodes are new compared with the previous study on 2021-05-17, the nature is to be determined, suggesting biopsy for investigation.
    • Glucose-hypermetabolism in bilateral mediastinal lymph nodes and bilateral pulmonary hilar lymph nodes, probably reactive nodes.
    • Glucose-hypermetabolism in the left adrenal region, probably benign or malignant tumor of the left adrenal gland.
    • Increased FDG accumulation in the left kidney and ureter, suggesting left GU tract obstruction (resulting from perirectal tumor ?).
    • A glucose hypometabolism lesion in the right upper lung, compatible with right lung cancer s/p treatment.
  • 2023-01-12 Sigmoidoscopy
    • Left lateral rectal wall scar , suspect extrarectal tumor with regression
  • 2023-01-09 KUB
    • S/P double J catheter insertion in place, left side.
    • Non-specific bowel gas pattern.
    • Calcifications in LUQ, r/o left renal stones.
    • Lumbar spondylosis.
  • 2023-01-09 Body fluid cytology - urine
    • Atypia, favor reactive change
    • Smears show lymphocytes, crystals and instrument-associated cellular urothelial clusters with mild nuclear atypia and crush artifact, favor reactive atypia and less likely a neoplasm. Follow up.
  • 2023-01-05 ECG
    • Normal sinus rhythm
    • S1-S2-S3 pattern, consider pulmonary disease, RVH, or normal variant
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-12-28 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/06/10.
      • Prior CT identified a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion is noted again, marked decreasing in size and poor margination.
        • Tumor seeding S/P C/T with partial response is highly suspected.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in the rectum S/P C/T show partial response. please correlate with clinical condition.
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2022-10-27, -03-21 Anoscopy
    • Mixed hemorrhoid and posterior fissure
  • 2022-09-29 CT - abdomen
    • History and indication: Sigmoid cancer with peritoneal seeding and local recurrence s/p OP, s/p R/T, s/p C/T
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of peritoneal seeding.
      • Liver and renal cysts (up to 2.4cm).
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Mild regression of peritoneal seeding.
  • 2022-09-23, -09-21 KUB
    • Fecal material store in the colon.
    • S/P LAR with autosuture retention over the sigmoid colon.
  • 2022-09-03 Foot Lt
    • left 5th metatarsal neck fracture
    • Acceptable alignment with few callus
  • 2022-06-10 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2022/03/11.
      • There is a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vagina invasion, measuring 3.2 x 2.1 cm in size (Srs:7 Img:115) .
        • Tumor seeding is highly suspected.
        • The differential diagnosis include rectal cancer.
      • S/P LAR with autosuture retention over the sigmoid colon.
        • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion is suspected.
        • The differential diagnosis include rectal cancer. please correlate with clinical condition.
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2022-03-20 CXR
    • Opacification of right apical lung.
  • 2022-03-20 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2022-03-20 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
  • 2022-03-11 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2021/12/03.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, stable in size.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2021-12-23 Nasopharyngoscopy
    • Findings: smooth NPx, oropharynx, hypopharynx; bloody crust coating over right inferior and bilateral middle turbinates.
    • Conclusion: epistaxis, no nasal or nasopharynx tumor found
  • 2021-12-16, -10-07 CXR
    • Patchy opacity projecting at right apical lung with lung volume decrease was noted. Please correlate with CT.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2021-12-03 CT - abdomen
    • FINDINGS: Comparison prior CT dated 2021/09/03.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Prior CT identified multiple small soft tissue nodules in the omentum (metastases) are noted again, mild decreasing in size (up to 1.5cm, srs:302, img:73,75,79,83,87,90,93,96,98,101).
      • Prior CT identified a mixed soft tissue and fat lesion in left upper pelvis wall is not noted in the current CT.
      • Liver and renal cysts (up to 2.4cm).
      • There is no focal lesion in mediastinum.
        • There is a cystic lesion with lung volume decrease and autosuture in RUL of the lung that is c/w post-operative change.
        • please correlate with clinical history.
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
  • 2021-09-03 CT - abdomen
    • FINDINGS:
      • S/P LAR with autosuture retention over the sigmoid colon.
      • Multiple soft tissue nodules in the omentum are noted that are compatible with omentum metastases (up to 1.9cm, srs:301, img:71,74,78,85,89,91,95).
      • There is a mixed soft tissue and fat lesion in left upper pelvis wall (Srs:301 Img:82) that may be tumor seeding or post-operative change.
      • Liver and renal cysts (up to 2.4cm).
    • IMP:
      • Multiple omentum metastases S/P C/T show stable disease.
      • Metastasis or post-operative change in left upper pelic wall ?
  • 2021-06-09 Patho - colon ca s/p at 2018 with intraabd recurrent, including bilat diaphragm, T-colon stomach surface and rt liver surface
    • Tumor, R’t diaphragm, biopsy - Metastatic colonic adenocarcinoma
    • IHC: CK7(-), CK20(+), CDX2(+) and TTF-1(-) for tumor.
    • IHC: EGFR (+, weakly); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+)
    • According to clinical information and above histopathologic findings, it indicated a case of metastatic colonic adenocarcinoma.
  • 2021-05-31 CT - whole abdomen, pelvis
    • S/P colon operation. Multiple metastases at peritoneal cavity.
  • 2021-05-17 Whole body PET scan
    • Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases.
    • Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases.
    • S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-05-14 MRI - MR Cholangiography (MRCP)
    • Multiple cysts on both hepatic lobes.
  • 2019-08-26 CT - lung cancer screening (Low-dose CT)
    • RUL lung cancer TmiNOMO stage IA1
  • 2019-10-09 Patho - Uterus, cervix, biopsy
    • Chronic cervicitis with reactive aypia
    • IHC, the epithelial cells are negative for p16 and ki-67 proliferation index <5%.
  • 2019-10-01 Patho - Lung, right upper lobe, lobectomy
    • Minimally invasive adenocarcinoma
    • Lymph nodes, group 2+4, 7, 11; RLND - No metastatic carcinoma
    • pTNM Pathology stage: pT1miN0(cMx), Stage IA1 if cM0
  • 2019-09-12 Patho - Malignant sigmoid colon neoplasm
    • Sigmoid colon, LAR - Adenocarcinoma, moderately differentiated
    • Lymph node, mesocolic, dissection - Positive for tumor metastasis (4/16) with extracapsular extension (3/4)
    • AJCC pathologic stage - pT4bN2aMx, stage IIIC at least
  • 2019-09-02 CT - liver, spleen, biliary duct
    • T3N2aMx
  • 2019-08-29 Whole body PET scan
    • A glucose hypermetabolic lesion in the sigmoid colon, compatible with colon malignancy.
    • A faint glucose hypermetabolic lesion in the upper lobe of right lung. The nature is to be determined.
    • Glucose hypermetabolism in the right pulmonary hilar region. The nature is to be determined.
    • Mild glucose hypermetabolism in the left lobe of the thyroid gland.
  • 2019-08-26 Patho - colon, sigmoid or rectosigmoid junction, biopsy
    • Ademocarcinoma
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).

[MedRec]

  • 2023-10-19, -07-20, -04-11, -01-17 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • F32.1 - Major Depressive Disorder, Single Episode, Moderate
      • G47.00 - Insomnia, Unspecified
    • Prescription x3
      • Lexapro (escitalopram 10mg) 0.5# QN
      • Mirtapine Orally Disintegrating (mirtazapine 30mg) 1# QN
  • 2023-10-17 SOAP Hemato-Oncology Xia HeXiong
    • P: Already provide two options:
      • TAS-102 plus self-pay bevacizumab -> Favored by patient and family
      • Regorafenib
      • Trial
    • Prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Stogamet (cimetidine 300mg) 1# BID
  • 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Xeloda (capecitabine 500mg) 2# BID 28D
      • Sinpharderm Cream (urea) BID TOPI
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Stogamet (cimetidine 300mg) 1# BID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# HS
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
  • 2023-04-06 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • Because the maximal effect of Erbitux-FOLFIRI is achieved based on the findings of CT on 2023-03-29, oral C/T is suggested on 2023-04-06.
    • Prescription
      • Xeloda (capecitabine 500mg) 2# BID 28D
      • Sinpharderm Cream (urea) BID TOPI
  • 2019-09-29 ~ 2019-10-08 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • C34.91 - Minimally invasive adenocarcinoma of lung ove right upper lobe status post three dimensional video-assisted thoracic surgery right upper lobectomy and radical lymph node dissection on 2019/09/30, pT1miN0M0, Stage IA1.
      • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
    • CC
      • Abnormal findings were noted on CT during health exam
    • Present illness
      • This 76 years old famale patient has history of
        • Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11
        • left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch
        • s/p ovarian cystectomy
        • s/p tubal ligation surgery 30+ years ago.
      • This time, she had been received health examination and the chest CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD (Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 was dignosed, status post laparoscopic anterior resection and enterolysis on 2019/09/11) and CS OPD for further evaluation and primary lung cancer was impressed. After discussing with the patient and her family on the benefits of surgical treatment as well as subsequent risks and possible complications, she was admitted for VATS RUL lobectomy + RLND.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of 3D VATS RUL lobectomy and RLND was performed smoothly on 2019/09/30. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Right chest tube with free drainage was done due to mild air leak. Chest tube was removed and left port-a implantation was done on 2019/10/07. We also consulted hemo-onlcologist and radiation-oncologist for further treatment. She was discharged under stable hemodynamics on 2019/10/08. CT simulation will be arranged on 2019/10/09 and treatment will be started 4-5 days later. She will be admitted to hemo-onlcology ward for adjuvant chemotherpay on 2019/10/15.
    • Discharge prescription
      • Bafen (baclofen 5mg) 1# Q12H
      • Mopride (mosapride citrate) 1# TID Zofran (ondansetron 8mg) 1# QD
  • 2019-09-10 ~ 2019-09-16 POMR Colorectal Surgery Xiao GuangHong
    • Discharge diagnosis
      • C18.7 - Adenocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis
      • J98.4 - Part solid nodule (about 16 mm) in right upper lobe, suspect primary lung cancer
    • CC
      • admission for surgical treatment of sigmoid cancer with partial obstruction, cT3N2aM0
      • intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08.
    • Present illness
      • This 76 years old famale patient has history of left thyrioid goiter for 3-4 years with follow up at Taipei City Hospital FuYou Branch; and s/p ovarian cystectomy and s/p tubal ligation surgery 30+ years ago.
      • This time, she had been received health examination and colonscopy showed colon Ca, sigmoid colon or rectosigmoid junction with stenosis s/p biopsy; mixed hemorrhoid on 2019/08/26. The biopsy proved adenocarcinoma. She also complained of intermittent upper abdominal fullness and had passage of bloody stool twice in 2019/08. The lund CT revealed RUL part solid nodule (about 16 mm), seems stationary as compared with CT on 2018/08/15, favors malignant nodule. Whole body PET scan revealed glucose hypermetabolic lesion in the sigmoid colon, upper lobe of right lung, right pulmonary hilar region. She was referred to our CRS OPD and CS OPD for further evaluation and primary lung cancer was impressed. Arrange abdominal CT revealed S-colon cancer, cstage T3N2aMx on 2019/09/02. Surgical treatment of 3D laparoscopic LAR was suggested. After fully explaination, she was admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and blood examination were done. Operation of laparoscopic anterior resection and enterolysis under general anesthesia were performed on 2019/09/11. NPO and IV fluids support; analgesics treatment for pain relief. Nausea with vomit were noted post op day and improved after IV fluids hydration and medications by Novamin were treated. The wound healing well and no erythema change. Chewing cookies, toast, rice with gum was started at op day. No nausea and no vomiting, flatus passage. Try eat semi-liquid diet at post-op day 2 with tolerance and then on low residual diet was started at post-op day 3. Well bowel movement and stools passage (+) with diet well tolerated. No fever and no complication. Removal of JP drain at post-op day 3. Discharged in general condition stable on 108/09/16 and will follow up in our out-patient department next week. Suspected primary lung cancer by lund CT and whole body PET scan result; she will further evaluation and treatment at CS OPD.
    • Discharge diagnosis
      • Lactam (acetaminophen 500mg) 1# PRNQ6H
  • 2017-02-21 SOAP Gastroenterology Lin XianHong
    • Diagnosis
      • Pure hypercholesterolemia [E78.0]
      • Dyspepsia & other specified disorders of function of stomach [K30]
    • Prescription x3
      • Dexilant (dexlansoprazole 60mg) 1# QDAC

[consultation]

  • 2022-12-10 Dermatology
    • Q
      • This 80-year-old woman patient is a case of S-colon cancer, cT3N2aM0, stage IVC s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy with FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope right diaphram tumor excision on 2021/06/09 s/p palliative chemotherapy with FOLFIRI from 2021/07/01~2022/07/27 and Avastin from 2021/10/08~2022/07/27 with tumor seeding in left lateral anterior aspect of the rectum with left uterine cervix and vaignal invasion s/p radiotherapy to anal tumor s/p palliative chemotherapy with Erbitux/FOLFIRI from 2022/09/08. She was adnmitted for chemotheraopy with Erbitux/FOLFIRI(C4D1).
      • This time, for right thumb nail gap redness, swelling with pain, suspected paronychia.
    • A
      • This patient suffered from dyskeratotic nails for months and erytheamtous patches for days
      • Imp:
        • Tinea unguim
        • Asteatotic dermatitis
      • Suggestion:
        • Excelderm solution (sulconazole) x 4 BT/Bid
        • Mycomb (nystatin, neomycin, triamcinolone acetonide, gramicidin) x 4 tubes/bid
  • 2022-08-27 Psychosomatic Medicine
    • Q
      • This 79-year-old woman patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy wt FOLFOX finishing in 2020/04 with periotneal seeding s/p laparoscope rt diaphram tumor excision on 2021/06/09. He was admitted for palliative chemotherapy. This time, for depression, anxiety. Now, for evaluate drug therapy. Thank you.   
    • A
      • This 79-year-old woman, our YiDe Mama. She was diagnosed as colon cancer in 2018. She could tried hard to cope with it, untill 2021/5, she developed RLQ pain and exams revealed relapse and metastesis of cancer. She started to develop low and anxious mood, unspokable distress, lack of pleasure and poor appetite, and rumination of negative thoughts. Psychiatrist was consulted in 2021/11 and she also started a conseling with onco-psychologist. The mood condition has been partially improved under mirtazapine 30mg 1# HS, however she still percieved low and tense mood (invisible stress all day), lack of appetite, preoccupation on the somatic distress, ruminated thoughts about the intrafamilial issue (worried that her daughters will not get along well), some demoralize feelings about treatment (she feels that chemotherapy is a long way off, and there is no hope). She tried to cope with walking outside with daughter and watching TV show but lack of true pleasure.
      • She denied obvious impairment on cognitive function, denied sleep problem nor suicidal ideation.
      • MSE: Low and anxious mood, inner tension, ruminated and negative thoughts, hopelessness and demoralized feelings. lack of pleasure and motivation.
      • IMP: Depressive disorder
        • suspected Adjustment disorder with depressive mood
      • Suggestion:
        • Keep mirtazapine 30mg 1# HS.
        • Add sulpiride 50mg 1# HS for adjuctive therapy of depression.
        • Carthasis and empathy. Psychoeducation to the family and the patient.
        • Arrange PSY OPD follow up.
  • 2021-11-18 Mental Health
    • Clinical impression:
      • Depressive disorder
      • Adjusment disorder
    • Clinical course:
      • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis s/p post-Op C/T with periotneal seeding s/p laparoscope rt diaphram tumor excision. She was admitted for chemotherapy with Avastin/FOLFIRI(C5D1).
      • We were consult for depressed mood and poor appetite.
      • According to past medical record, during admission in July for chemotherapy, psychiatric department was consulted once for panic symptoms, but no further OPD follow up.
      • At bedside, the patient is conscious clear, lying on the bed resting, with her daugher at the bedside. She started to percieved dysphoric and low mood since she was diagnosed with cancer on 2018, but she tried hard to modify her mindset and cope with the distress, and able to maintain acceptable mood. Until this year 2021-05, she suffered from right lower abdominal pain, and PET scan found metastatis of the cancer, and started to recieved treatment again.
      • Recently, she noted that she began to be easily irritable and dysphoric, unspoken stressfulness feeling, high inner tention, decrease of reward sensation and low mood, decrease appetite, negative thoughts, sleep disturbance (poor maintainence, unstable), got worse in recnent 2 weeks.
      • She received psychotherapy in recent half year, feel better at first, but noticing unable to control now.
    • MSE:
      • Kempt, polite. Frowning and distressful look. Sometimes she smiles when talk about the people who support her so much.
      • Coherent and relevant speech, articulate
      • Fair attention lasting
      • Depressed mood, low drive and energy, fatigue
      • Ruminated thought
      • Denied hopeless or helplessness, denied suicide ideation
      • Poor appetite and insomnia
    • Suggestion:
      • Psychoeducaiton and emotional support
      • Add mirtapine (30) 1#HS for depressive mood, enhacing appetite. Eurodin 1#HS for insomnia
      • Arrange psychiatric OPD follow up
  • 2021-07-20 Mental Health
    • Psychiatric impression:
      • Panic attack
      • Suspected anxiety disorder
    • Psychiatric history:
      • This 78-year-old female patient is a case of S-colon cancer, cT3N2aM0 s/p laparoscopic anterior resection and enterolysis on 2019/09/11 s/p post-Op adjuvant chemotherapy (FOLFOX) finishing in 2020/04 and peritoneal seeding s/p laparoscope Rt. diaphragm tumor excision 2021/06/09. Palliative chemotherapy with FOLFIRI(Campto 90mg/m2, LV 400mg/m2, 5FU 2400mg/m2)(C1D15) was done during 2021/07/15~2021/07/17. We were consult for anxiety. According to the patient, she suffered from episodic chest tightness, dizziness, general weakness, tremors and feeling loss of control since early July. She also perceived low mood and negative thinking intermittently for several weeks. During this admission, frequent experience of chest tightness, hands tremor, limb numbness and parathesia (hot and cold sensation). She feeling frustration form physical discomfort and these panic like symptoms.
    • MSE:
      • Coherent and relevant speech
      • Fair attention lasting
      • Depressed mood, low drive and energy, fatigue
      • Ruminated thought
      • Denied hopeless or helplessness, denied suicide ideation
      • Poor appetite and insomnia with terminal type under stilnox
    • Suggestion:
      • Psychoeducaiton and emotional support
      • Add mirtapine (30) 0.5mg HS
      • Arrange psychiatric OPD follow up
  • 2021-06-09 Hemato-Oncology
    • Q
      • for chemotherapy
      • This is a 78y/o female with past history of 1) Adenocarcinoma of sigmoid colon with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 2019/09/11, s/p post-Op adjuvant C/T wt FOLFOX finishing in 2020/4; 2) Bilateral thyroid tumors status post bilateral thyroidectomy on May 26, 2020; 3) Minimal invasive adenocarcinoma of lung over RUL, s/p VATS segmentectomy + RLND, pT1miN0M0, stage IA1 on 2019/09/30; 4) s/p ovarian cystectomy; 5) s/p tubal ligation surgery 30+ years ago.
      • This time she was visited our OPD due to LLQ abdominal pain for about 3 months, which several examination were arranged, MRI on 5/14 showed multiple cysts on both hepatic lobes;
      • Whole body PET scan on 5/18 revealed 1. Glucose-hypermetabolism in the right mediastinal lymph nodes, probably recurrent lung cancer with regional lymph nodes involvement. 2. Glucose-hypermetabolism in the left mediastinal lymph nodes and left pulmonary hilar lymph nodes, probably reactive nodes or recurrent lung cancer with regional lymph nodes involvement. 3. Glucose-hypermetabolism in bilateral adrenal regions, probably recurrent lung cancer with bilateral adrenal glands metastases. 4. Glucose-hypermetabolism in peritoneal lymph nodes in the epigastric region, right hypochondriac region, and bilateral lumbar regions of abdomen, probably recurrent colon cancer with peritoneal metastases. 5. S-colon cancer s/p treatment with tumor recurrence, rcTxNxM1c, stage IVC (AJCC 8th ed.); right lung cancer s/p treatment with tumor recurrence, rcTxN2-3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
      • Abdominal CT on 5/31 showed Multiple metastases (up to 2.4cm) at peritoneal cavity. Therefore under impression of multiple tumor recurrance and metastases, she was admitted to GS ward on 6/3.
      • She received operation with laparoscopic and showed multiple tumor seedind was noted right diaphragm (2) and right liver surface, gasric antrum surface(1), left diaphragm (2). T-colon (3) left lower quadrant (1), PCI: 9/39 and liver metas was noted. So further percedure with laparoscope right diaphram tumor excision and HIPEC with Oxalip 300mg/M2(408mg) for 60mins was processed successfully on 6/9. We need your help for further chemotherapy evaluation of 5FU since 6/10. Thanks for your time!!
    • A
      • Patient examined and Chart reviewed. A case of sigmoid colon cancwer is noted. I am conslted for further management.
      • My suggestions would be:
        • Please prescribe the 5-FU as follows: 5-FU 1200 mg/m2 NS 500 mL IVD 24 hours for 2 days, LV 120 mg/m2 in NS 500 mL IVD 24 hours for 2days.
        • Please arrange my OPD appointment after being discharged.
        • Any issue, please let me know.
  • 2020-03-30 Colorectal Surgery
    • Q
      • This 77 years old famale patient has history denocarcinoma of sigmoid with partial obstruction, cT3N2aM0 status post laparoscopic anterior resection and enterolysis on 108/09/11 (Bloody stool on 108/8) under chemotherapy as FOLFOX. Due to hemorrhoid with bleeding bother her, so we need your help for management.
    • A
      • We had visited the patient that she was a case of mild mixed hemorrhoids.
      • PE:
        • No induration, no redness, no perianal pain
        • No palpable mass around low rectum, no obvious bloody clot on gloves
      • IMP:
        • Mild mixed hemorrhoids, no obvious external hemorrhoid
      • Suggest:
        • Alcos-anal ointment was considered
        • Change habit of stool passage
        • Education about sitz bath and have more water/fiber food
        • Arrange CRS OPD if she still have hemorrhoidal problems

[surgical operation]

  • 2023-01-09
    • Surgery
      • Ureterorenoscopic exam & double-J stenting (tumor stent), left.        
    • Finding
      • Left lower and upper ureter stricture and kinking.
  • 2021-06-09
    • Surgery
      • Laparoscope rt diaphram tumor excision
      • HIPEC with oxalip 300mg/m2 for 60 mins
    • Finding
      • right diaphragm (2) and right liver surface
      • gasric antrum surface (1), left diaphragm (2). T-colon (3) left lower quadrant (1)
      • PCI: 9/39 and liver mets
      • ascite: nil
  • 2020-05-26
    • Surgery
      • L’t lobectomy + right partial thyroidectomy
    • Finding
      • enlargement of left thyroid gland with multiple goiter lesions and trachea deviation noted
      • some goiter lesions over right thyroid gland also noted
  • 2019-09-30 Thoracoscopic Lobectomy
  • 2019-09-11 Laparoscopic anterior resection and anastomosis, sigmoid colon resection, tumor

[radiotherapy]

[immunochemotherapy]

  • 2023-03-24 - cetuximab 500mg/m2 500mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-24 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-06 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-09 - irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-25 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-07 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-21 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-09-08 - cetuximab 500mg/m2 600mg 2hr + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2800mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-08-26 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-08-12 - irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-07-27 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-07-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-29 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 230mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2800mg/m2 3500mg 46hr
  • 2022-06-01 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-05-20 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-05-06 - irinotecan 150mg/m2 190mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-04-24 - irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-04-08 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-03-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-03-11 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-02-25 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-02-07 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2022-01-14 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-30 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-15 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-12-03 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 500mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-11-17 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-11-05 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 200mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-10-22 - bevacizumab 5mg/kg 200mg 90min + irinotecan 150mg/m2 175mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-10-08 - bevacizumab 5mg/kg 200mg 90min + irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-09-20 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 520mg 2hr + fluorouracil 2600mg/m2 3300mg 46hr
  • 2021-09-03 - irinotecan 120mg/m2 150mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-08-20 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-07-15 - irinotecan 120mg/m2 140mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-07-01 - irinotecan 90mg/m2 120mg 90min + leucovorin 400mg/m2 550mg 2hr + fluorouracil 2600mg/m2 3200mg 46hr
  • 2021-06-10 - leucovorin 120mg/m2 165mg 24hr D1-2 + 5-Fu 1200mg/m2 1635mg 24hr D1-2
  • 2021-06-09 - oxaliplatin 300mg/m2 408mg 90min
  • 2021-04-13 - oxaliplatin 85mg/m2 110mg 2hr + leucovorin 400mg/m2 530mg 2hr + fluorouracil 2800mg/m2 3700mg 46hr
  • 2021-03-30 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-03-16 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-03-02 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-02-14 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-01-31 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr
  • 2021-01-09 - oxaliplatin 85mg/m2 114mg 2hr + leucovorin 400mg/m2 540mg 2hr + fluorouracil 2800mg/m2 3800mg 46hr

==========

2023-11-10

[Lonsurf combination therapy for mCRC: dosage considerations in patients with low BSA]

Both tumor markers CEA and CA199 trend upward in 2023.

  • 2023-10-17 CEA 79.30 ng/mL

  • 2023-09-05 CEA 34.28 ng/mL

  • 2023-07-18 CEA 20.55 ng/mL

  • 2023-05-30 CEA 12.06 ng/mL

  • 2023-05-05 CEA 5.88 ng/mL

  • 2023-04-03 CEA 4.42 ng/mL

  • 2023-03-08 CEA 4.25 ng/mL

  • 2023-01-31 CEA 3.12 ng/mL

  • 2023-01-06 CEA 2.70 ng/mL

  • 2023-10-17 CA199 389.11 U/mL

  • 2023-09-05 CA199 69.02 U/mL

  • 2023-07-18 CA199 71.84 U/mL

  • 2023-05-30 CA199 60.36 U/mL

  • 2023-05-05 CA199 56.00 U/mL

  • 2023-04-03 CA199 82.57 U/mL

  • 2023-03-08 CA199 85.56 U/mL

  • 2023-01-31 CA199 83.54 U/mL

  • 2023-01-06 CA199 69.10 U/mL

On 2023-10-17, at the patient’s Hemato-Oncology outpatient department visit, it was recorded that the patient and her family have opted for further treatment with TAS-102 (Lonsurf) along with bevacizumab, which they will be self-financing.

Lonsurf (two dosage combinations: trifluridine 15mg + tipiracil 7.065mg; trifluridine 20mg + tipiracil 9.42mg) is a temporary purchase item in our hospital currently.

Lonsurf combination therapy for patients with metastatic colorectal cancer: Oral 35 mg/m2/dose (based on the trifluridine component) twice daily on days 1 to 5 and days 8 to 12 of a 28-day cycle (in combination with bevacizumab; maximum per dose: trifluridine 80 mg); continue until disease progression or unacceptable toxicity.

The patient has a relatively low BSA. 2023-10-09 BH 150cm, BW 40.8kg -> BMI 18.1kg/m2, BSA 1.30m2.

Recommended trifluridine/tipiracil metastatic colorectal cancer dosagea according to the patient’s BSA will be 45mg (based on the trifluridine component) BID, i.e., [trifluridine 15mg + tipiracil 7.065mg] 3# BID.

2023-03-09

  • The patient has been diagnosed with major depressive disorder and a sleep disorder and is currently receiving regular follow-up care from our psychologist. The medications Lexapro (escitalopram) and Mirtapine (mirtazapine) are appropriately added to her active drug list and there are no issues with reconciliation.
  • Lab data showed that her TSH and T4 levels have been within the normal range for the past six months. Her hypothyroidism is being well-managed with a weekly dosage of 850ug of Eltroxin (levothyroxine).
  • New glucose-hypermetabolism lesions detected in perirectal region and bilateral inguinal lymph nodes in 2023-01-30 PET scan. Nature of lesions unknown. In addition, the PET result also revealed that glucose-hypermetabolism has been detected in bilateral mediastinal and pulmonary hilar lymph nodes, which are likely reactive nodes. (The patient underwent a 3D VATS RUL lobectomy and RLND on 2019-09-30, for her adenocarcinoma in the RUL, which was classified as pT1NoMi(cMx), stage IA1 if cM0.)
  • There are no issues with the current prescription.

2022-06-30

  • CT images on 2022-06-10 showed a newly-developed enhancing soft tissue mass in the rectum with suggestive left uterine cervix and vaginal invasion. A number of small soft tissue nodules were identified in the omentum (mets) and were still stable in size as compared to prior CTs under FOLFIRI (administered since 2021-07). Therefore, the newly developed lesion might be different from the original in some respects.

2022-06-02

  • The patient received FOLFOX during 2020-01 to 2020-04 and has been receiving FOLFIRI since 2021-06 (plus bevacizumab since 2021-10).
  • A time series of CT scans showed that the size of omentum mets stayed stable from 2021-09 to 2022-03-11 (most recent). The regimen is considered to be effective at keeping the disease stable.
  • Hypothyroidism is still an active problem and Eltroxin (levothyroxine) can be found in recent PharmaCloud records. It is recommended that levothyroxine be prescribed as a self-carried item until the problem is resolved.

2022-03-11

  • the last exam report is dated on 2021-12-23, no updated image; CEA, CA199 readings remain stable around 9ng/mL, 53U/mL, respectively; most WBC and CBC items and all the liver, kidney function tests (reported on 2022-03-09) were in normal range; the systolic blood pressure was slightly higher (159mmHg) at 13:14 2022-03-11.
  • the underlying diseases are treated with the drugs in the current medication list without issue.

2022-02-08

  • according to time-serial CT images, CEA, CA199 readings, the disease remains stable in recent months under current regimen.
  • no drug allergy recorded in database, no issue found with active medication.

2021-08-13

[loss of appetite]

visiting the patient (with her daughter accompanied) at around 16:20 on 2021-08-13.

S:

  • the patient does not feel like to eat these days.

O:

  • poor appetite, not eat much.
  • cachexia still in problem list.

A:

  • chemo not applied yet since this hospitalization, not chemo induced poor appetite for sure, could be psychogenic.
    • psychological counselor had visited the patient on 2021-08-09.
  • some appetite stimulant could be of help.

Suggestion

  • Megejohn (megestrol 160mg/tab) PO QD could be an option to serve as appetite stimulant.
    • dronabinol and oxandrolone are not available in the hospital.

701045543

231109

[exam findings]

  • 2023-11-08 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • s/p resection of rectosigmoid junction and end sigmoid colostomy.
      • Dilatation of small bowel with collapse of distal ileum and colon, r/o obstruction
      • A low density lesion, 1.6 x 0.6cm, in right liver dome (S4). Liver cysts.
      • Mild fat stranding in pelvis.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • No bony destructive lesion on these images.
    • Impression
      • Post-OP change
      • Small bowel obstruction
      • Right liver dome lesion, stationary
  • 2023-11-07 KUB
    • Dilatation of small bowel
  • 2023-11-02 PET
    • Glucose hypermetabolism in the lower pelvic region near the previous operative area. Recurrent malignancy can not be ruled out. Please correlate with other clinical findings for further evaluation. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-09-22 CT - abdomen
    • Findings: Comparison prior CT dated 2023/05/13.
      • S/P Hartmann operation and autosuture in the sigmoid colon.
      • S/P hysterectomy.
      • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
    • Impression:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • There is no evidence of tumor recurrence.
      • Prior CT identified a soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is noted again, decreasing in size to 1 cm.
        • Follow up is indicated.
  • 2023-08-18 KUB
    • Radiopaque spots at pelvic region.
    • Presence of ileus.
  • 2023-06-15 SONO - breast
    • Diagnosis: Bil. fibroadenomas
    • BI-RADS: 2. benign finding
  • 2023-05-19 Mammography
    • Indication: Screening.
    • No previous mammography is available for comparison.
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • No definite masses.
      • No asymmetric density.
      • No clustered microcalcification.
      • No architectural distortion.
      • Benign coarse calcifications in bilateral breasts.
      • Diffuse punctate round microcalcifications loosely scattered in left breast, favor benign.
    • Final assessment:
      • BI-RADS category 2, Benign finding.
      • Suggest annual mammographic follow up.
  • 2023-05-13 CT - abdomen
    • Abdominal CT with and without IV contrast ehnancement shows:
      • Visible Chest:
        • Bilteral tiny nodules at both thyroid glands is found.
        • One enhanced nodule at right breast measuring 1.6cm is found. Breast tumor is favored. Suggest mamography and sonography.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p LAR and colostomy with its orifice at LLQ.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs
        • The urinary bladder is well distended without soft tissue lesion.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
    • Imp:
      • s/p LAR and colostomy.
      • No evidence of recurrent/residual tumor in the study.
      • Right breast tumor. 1.6cm. Suggest further study.
  • 2023-03-27 KUB
    • S/P colostomy of left lower abdominal wall
    • S/P metalic autosuture projecting at the middle pelvis.
    • Transitional vertebra of L5-S1, left side.
  • 2023-03-24 CT - abdomen
    • With and without contrast enhancement CT of abdomen shows:
      • s/p Hartmann operation and descending colostomy.
      • Dilatation of small bowel and collapse of colon, r/o obstruction.
      • Presence of ascites.
      • Several liver cysts, up to 1.8cm. A soft tissue density, 1.6cm, at liver dome, stationary.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • No bony destructive lesion on these images.
    • Impression
      • s/p Hartmann operation
      • Small bowel obstruction
      • Ascites
  • 2023-03-23 KUB
    • s/p descending colostomy
    • A metallic clip over pelvis
  • 2023-03-10 PET
    • A glucose hypermetabolic lesion in the lower pelvic region near the previous operative area. Either residual malignancy or post-operative inflammation may show this picture. However, no prominent FDG uptake was noted in the S7 dome of the subphrenic space.
    • Glucose hypermetabolism in a focal area in the right paraaortic region. The nature is to be determined (inflammatory process? a metastatic lymph node of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-02-17 CT - abdomen
    • History:
      • 20221117 CT: S-colon CA wt uterus invasion, cT4bN2bM0, stage IIIC
      • 20221223 CT: S-colon CA with perforation is highly suspected.
      • 20221224 S/P Hartmann operation:S-colon CA wt uterus invasion and involving bil. ovaries (Two sites?).pT4bN0M1b; pstage: IVB.
    • Findings:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • S/P hysterectomy.
      • There is mild dilatation of the terminal ileum.
        • please correlate with clinical condition.
      • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
      • There is no focal lesion in both lung and mediastinum.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
      • There is no evidence of ascites and lymphadenopathy.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • S/P Hartmann operation and autosuture in the sigmoid colon.
        • There is no evidence of tumor recurrence.
      • There is mild dilatation of the terminal ileum.
        • please correlate with clinical condition.
      • A soft tissue lesion 1.6 cm in S7 dome of the subphrenic space is highly suspected, nature? Follow up is indicated.
  • 2023-02-03 KUB
    • Stool retention in the bowel.
  • 2023-01-13, -01-06, -01-05 KUB
    • Presence of ileus.
  • 2022-12-26 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectosigmoid colon, exploratory laparotomy with Hartmann operation — Adenocarcinoma, moderately differentiated
      • Resection margins: bilateral margins free; radial margin involved.
      • Lymph node, mesocolic, dissection — free (0/13)
      • pT4b pN0 pM1b, at least; Pathology stage: IVB, at least. NOTE: Please correlate with clinical and image findings.
    • Gross Description:
      • Procedure - exploratory laparotomy with Hartmann operation
      • Tumor Site - Rectosigmoid region
      • Tumor Size: 4.5 x 3.5 x 3.5 cm.
      • Macroscopic Tumor Perforation: Present
      • Macroscopic Intactness of Mesorectum - Incomplete
      • Sections are taken and labeled as: A1-2: bilateral cut ends; A3-8: tumor; A9-10: lymph nodes.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - Tumor invades the visceral peritoneum and involving myometrium as well as bilateral ovaries.
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding- none.
      • Type of Polyp in Which Invasive Carcinoma Arose: none.
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes - free
        • Number of Lymph Nodes Involved/Examined: 0/13
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) - not applicable.
        • Primary Tumor (pT) - pT4b: Tumor directly invades or adheres to adjacent organs or structures
        • Regional Lymph Nodes (pN) - pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) - pM1b: Metastasis to two or more sites or organs is identified without peritoneal metastasis
      • Additional Pathologic Findings - None identified
      • Ancillary Studies – result of S2022-20393. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • REFERENCE: S2022-23261: uterus and bilateral adnexae: involved by tumor.
  • 2023-12-26 Patho - uterus with or without SO non-neoplastic/prolapse
    • DIAGNOSIS:
      • Uterus, cervix, total abdominal hysterectomy — No pathological changes.
      • Uterus, endometrium, total abdominal hysterectomy — Polyp, Proliferative phase
      • Uterus, corpus, total abdominal hysterectomy — adenocarcinoma, invasion of myometrium.
      • Adenxae, bilateral, bilateral salpingo-oophorectomy — adenocarcinoma, involving bilateral ovaries.
    • GROSS DESCRIPTION:
      • Specimen submitted in formalin consists of one uterus weighing 230 gm and measuring 10 x 6 x 3 cm. The external surface of the uterus is mucoid in appearance. On cut, there are multiple foci of mucoid tumor invading the outer half of the myometrium.
      • The endometrial cavity is 5 x 4 x 3 cm in size and the endometrium is 0.2 cm in thickness. One polyp measuring 0.8 x 0.3 x 0.3 cm is present in the endometrial cavity. The cervix measuring 4 x 3 x 2 cm is normal in appearance. The left ovary and tube measuring 6 x 4 x 3 cm and 5 x 0.5 x 0.4 cm and the right ovry and tube measuring 8 x 7 x 6 cm and 5 x 0.5 x 0.5 cm show tumor invasion of bilateral ovaries. Representative tissue for sections in the following cassettes: A1-2: left ovary and tube; A3-6: right ovary and tube; A7-10: endometrium and uterine corpus; A11: cervix.
    • MICROSCOPIC DESCRIPTION:
      • Section of the cervix shows no pathological changes. The endometrium and polyp show proliferative phase. The myometrium shows adenocarcinoma with abundant mucinous pools invading the external half of the myometrium. The bilateral ovaries are involved by adenocarcinoma with abundant mucinous pools.
  • 2022-12-23 CT - abdomen
    • Findings:
      • There is pneumoperitoneum with more gas bubbles in the lower pelvis omentum, and mild fatty stranding of the omentum that is c/w hollow organ perforation and highly suspicious sigmoid colon cancer perforation?
        • please correlate with clinical condition.
      • There is smudggy appearnace of the lower pelvis omentum that may be peritonitis or carcinomatosis?
      • Prior CT identified sigmoid colon cancer and regional LNs metastases is noted again, stationary.
        • The proximal colon, beyond sigmoid colon, shows dilatation and Eqivocal pneumatosis?
        • Sigmoid colon cancer induce near complete obstruction is suspected.
      • There are several hepatic cysts in both lobes and the largest one 1.6 cm in size at S4.
      • Prior CT identified left ovary dermoid cyst (3.9cm), Right ovary cyst (6.2cm), and some csytic lesions (up to 1.3cm) in the uterus are noted again, stationary.
    • Impression:
      • Pneumoperitoneums is noted.
      • Sigmoid colon cancer perforation is highly suspected.
  • 2022-11-25 All-RAS + BRAF mutations assay
    • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • There was no variant detect in the BRAF gene.
  • 2022-11-28 KUB
    • Transitional vertebra of L5-S1, left side.
  • 2022-11-22 Exercise Electrocardiogram Bruce
    • Findings
      • The patient exercised according to the BRUCE for 06:14 min:s, achieving a work level of max METS: 7.3.
      • The resting heart rate of 59 bpm rose to a maximal heart rate of 130 bpm.
      • This value represents 71 % of the maximal, age-predicted heart rate.
      • The resting blood pressure of 110/76 mmHg, rose to a maximum blood pressure of 159/70 mmHg.
      • The exercise test was stopped due to Dyspnea, Frequent PVCs, Fatigue.
    • Conclusion
      • Resting ECG: normal sinus rhythm
      • Arrhythmia: VPC bigeminy during exam
      • Interpretation: No significant ST-T change during exercise and recovery phases.
      • Conclusion Inconclusive, submaximal stress
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 35) / 108 = 67.59%
      • M-mode (Teichholz) = 67.9
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Mild MR, PR
  • 2022-11-18 Patho - colorectal polyp
    • Colorectum, rectosigmoid 15 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Specimen submitted in formalin consists of 2 pieces of tan, irregular tissue measuring 0.4 x 0.2 x 0.1 cm.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-11-17 CT - abdomen
    • History and indication: Abdominal pain
    • Findings
      • Wall thickening of S-colon with uterus invasion and regional LAP.
      • Liver cysts (up to 1.3cm).
      • Suspected left ovary dermoid cyst (3.9cm). Right ovary cyst (6.2cm). Some csytic lesions (up to 1.3cm) in uterus.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2022-11-17 ECG
    • Sinus rhythm with short PR
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2022-11-17 Sigmoidoscopy
    • Findings
      • Rectosigmoid cancer with partial obstruction at 15 cm from AV, biopsy was done
      • Tattooing was performed
    • Diagnosis
      • Rectosigmoid cancer with partial obstruction s/p biopsy and tattooed
    • Suggestion
      • Elective colectomy
    • Complication
      • No immediate complication

[MedRec]

  • 2023-03-03 SOAP Gastroenterology Su WeiZhi
    • S: AFP 11, anti-HBs (+)
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-12-05 SOAP Gastroenterology Su WeiZhi
    • S: Anti-HBc (+); HBsAg (-) HBV DNA undetectable, check anti-HBs
    • Prescription x3
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-11-23 ~ 2023-11-28 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of sigmoid colon
      • S-colon CA wt uterus invasion, cT4b N2b M0, stage III
    • CC
      • for #1 CCRT with FOLFOX
    • Present illness
      • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
      • Image study with sigmoidoscopy (11/17 22) showed rectosigmoid cancer with partial obstruction at 15 cm from AV, s/p biopsy. Abd CT (11/17 22) revealed Wall thickening of S-colon with uterus invasion and regional LAP.Imp: T4b N2b M0, stage III,
      • Surgical pathology with colorectum, rectosigmoid 15 cm above anal verge, biopsy (11/18 22) proved adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • She referred to our hemato-oncologic clinic on 11/21 22 for pre-Op CCRT by Dr Xiao GuangHong.
      • We explain to pt & her husband about the indication & risk / benefit of pre-Op CCRT with FOLFOX plus R/T then do abd CT for response evaluation.
      • HBsAg, anti-HCV (11/22 22) showed negative and anti-Hbc: positive under anti-virus Tx.
      • R/T to rectal tumor by Dr Wang YuNong on 11/28 22.
      • Will give pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 plus R/T.
      • Today, she was admitted for #1 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 11/23 22.
    • Course of inpatient treatment
      • After admission, repeat pathology (11/18 22) proved Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Chemotherapy with Oxalip (70mg/m2) plus leucovorin (400mg/m2) and 5-FU (2800mg/m2) were given on 11/25-11/27 22, smoothly without obvious side effect.
      • She complained of abdominal pain and constipation post C/T and KUB showed massive stool impaction in colon.
      • Ultracet 1# po was given for pain control.
      • She felt abdominal pain much better and she was discharged on 11/28 22 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Megejohn (megestrol acetate 160mg) 1# QD
  • 2022-11-21 SOAP Radiation Oncology Wang YuNong
    • A: Advanced RS cancer with uterus, ovary invasion, cT4bN2bM0
    • P: Suggest CCRT then OP
      • CT-simulation will be arranged on 11/24. Plan to deliver 45 Gy/ 25 fx to the pelvis.
      • Then boost the S-colon tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 11/28.

[consultation]

  • 2023-11-08 Colorectal Surgery
    • Q
      • right abdominal pain since yesterday, radiation to periumbilical area
      • nausea and vomiting, once eating
      • watery stool from colostomy noted today
      • Past history:
        • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb
        • Hepatitis B, Anti-Hbc : positive
        • Allergy: denied
    • A
      • S: Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy ) on 2022/12/24. T4bN0M1b stage IVb under paliative chemotherapy, CEA keeping growing.
      • O: ileus is noted and consider carcinomatosis and ileus.
      • P: pleasea medical treatment first.
  • 2023-03-24 Colorectal Surgery
    • Q
      • CC: low abd pain for 5 hours
        • vomiting once
        • mild epigastric pain +
        • chest pain +
        • no headache, no dyspnea, no diarrhea, no fever
      • past history:
        • Sigmoid colon cancer with uterus invasion, cT4b N2b M0, stage III status post Hartmann operation (resection of rectosigmoid junction and end S colostomy) on 2022/12/24. T4bN0M1b stage IVb s/p OP
      • nka
    • A
      • suspect ileus by CT image, still has defecation.
      • medical treatment first including antibiotics treatment
  • 2022-12-23 Colorectal Surgery
    • Q
      • for tenderness at RLQ, LLQ noted, suspect S-colon rupture.
      • This 46-year-old female, a pt of S-colon CA wt uterus invasion, cT4b N2b M0, stage III, Dx in Nov 2022 by Dr Xiao GuangHong, suffered from initial presentation of bloody stool passage since Sep 2022 and body weight loss 3-5kg, poor appetite were also noted.
      • she was admitted for #3 pre-Op adjuvant CCRT with mFOLFOX6 IV Q2W x 6 on 12/22 22. Then the patient complaints abdomen pain since last night, and took the painkillers with Tramacet twice, not useful.
      • She suffered from tenderness at RLQ, LLQ noted, follow-up abdomen CT, and pending report, so we need your help, thanks a lot!
    • A
      • suspect RS colon cancer with obstruction and rupture with sepsis
      • suggest emergent Hartman’s operation and ICU care.
  • 2022-12-23 General and Gastrointestinal Surgery
    • Q (same question as colorectal surgery on the same day)
      • Due to symptoms got worse, CT was arranged and hollow organ perforation is suspected.
    • A
      • O: vital signs: BP:97/56; HR:78; BT:36.8’C; RR:18; SpO2:96%
        • abdomen: soft, ovoid, decrease bowel sound, low abdojminal tenderness and muscle guarding, positive rebounding pain, tympanic percussion
        • lab data: see chart
        • CT: free air accumulation in low abdomen
      • A: hollow organ perforation, suspect colon tumor related perforation
      • P: Please consult CRS for further evaluation

[surgical operation]

  • 2022-12-24
    • Surgery
      • Impression:
        • Advanced RS cancer with uterus , ovary invasion, cT4bN2bM0, stage IIIC
        • r/o rupture of right ovarian cyst
        • Pelvic adhesion
      • Procedure:
        • Abdominal total hysterectomy+ bilateral salpingoophorectomy  +pelvic/abdominal adhesiolysis
    • Finding
      • Uterus: one 2x1cm subserosal uterine myoma at left anterior uterine wall; severe adhesion between posterior wall to sigmoid colon and CDS.
      • RAD: suspected rupture of right ovarian cyst before, r/o tumor invasion, severe adhesion to sigmoid colon, adhesion lysis was performed smoothly
      • LAD: a 4x3 cm left ovarian cystic lesion
      • CDS: severe adhesion between lower sigmoid colon and posterior uterine wall, adhesion lysis was performed.
      • Estimated blood loss: 400ml
      • Blood transfusion: pRBC 4U
      • Complication: nil  
  • 2022-12-24
    • Surgery: Hartmann operation (resection of RS colon and end S colostomy )
    • Finding
      • tumor of S colon invasion to uterin + bilateral ovary and right side ovary necrosis and rupture with S colon cancer.
      • much pus/ascites over abdomen

[radiotherapy]

[chemotherapy]

  • 2023-10-18 - irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.25mg + NS 250mL
  • 2023-09-26 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-30 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-08-02 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-05 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-07 - irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-05-11 - irinotecan 180mg/m2 295mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-04-13 - irinotecan 170mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2400mg/m2 3840mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-02-16 - irinotecan 160mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + aprepitant 125mg PO + NS 250mL
  • 2022-12-08 - oxaliplatin 70mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 660mg NS 250mL 2hr + fluorouracil 2400mg/m2 3970mg NS 500mL 46hr (FOLFOX Q2W)
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL
  • 2022-11-25 - oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)
    • diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg + NS 250mL

==========

2023-11-09

[monitoring CEA levels post-Hartmann surgery: signs of emerging resistance to FOLFIRI regimen]

The Hartmann procedure was performed on 2022-12-24, after which the tumor marker CEA significantly decreased to within normal limits and remained so until August 2023. Recently, there has been an increase in the CEA levels, which could indicate the potential emergence of resistance to the current treatment regimen FOLFIRI which has been initiated since 2023-02-16.

  • 2023-11-07 CEA (NM) 16.050 ng/ml **
  • 2023-10-24 CEA (NM) 13.781 ng/ml **
  • 2023-10-03 CEA (NM) 9.779 ng/ml *
  • 2023-09-22 CEA (NM) 8.919 ng/ml *
  • 2023-09-05 CEA (NM) 7.765 ng/ml *
  • 2023-08-01 CEA (NM) 4.826 ng/ml
  • 2023-07-04 CEA (NM) 3.796 ng/ml
  • 2023-02-20 CEA (NM) 4.302 ng/ml
  • 2022-11-25 CEA (NM) 73.723 ng/ml ***
  • 2022-11-23 CEA (NM) 75.097 ng/ml ***

[small bowel obstruction]

On 2023-11-08, a CT scan revealed a small bowel obstruction (SBO) in the patient, with a prior episode of postoperative ileus evidenced by KUB imaging in January 2023.

Patients with SBO may experience significant fluid loss, metabolic acidosis or alkalosis, and electrolyte imbalances. This is particularly true for patients with prolific vomiting from a proximal SBO, those with symptoms lasting several days before presentation, or those with an obstruction that results in large-volume fluid sequestration within the bowel. The patient is currently on an intravenous regimen of normal saline 500mL twice daily and Taita No.5 solution 500mL every 12 hours, which is considered an appropriate treatment.

In cases of SBO with significant distension, nausea, and/or vomiting, nasogastric tube decompression may be considered. Patients with these symptoms likely have a complete or high-grade obstruction; decompression can improve comfort and minimize the worsening of distension due to swallowed air.

Antibiotics are indicated if there is a suspicion of bowel compromise, such as ischemia, necrosis, or perforation.

2022-12-23

  • Loperamide is an opioid medication that is used to treat diarrhea. Loperamide works by slowing the movement of the intestines, which helps to reduce the frequency of diarrhea.
  • Lactulose is a type of laxative that is used to treat constipation and to help regulate bowel movements. Lactulose works by drawing water into the intestines, which helps to soften stools and make them easier to pass.
  • When loperamide and lactulose are coadministered (the current situation), there is no specific expected effect on the body.

701464962

231107

[exam findings]

  • 2023-10-24 CT - abdomen
    • History and indication: Malignant neoplasm of rectum
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation.
      • Multiple nodules in liver.
      • Renal cysts (up to 0.8cm).
      • A cystic lesion (2.8cm) at right iliacus muscle.
      • Tiny gallbladder stones.
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Rectal cancer s/p operation. Multiple liver metastases.
  • 2023-10-24, -09-21, -08-17 Sigmoidoscopy
    • Rectal cancer s/p op, anastomotic leakage with improvement
  • 2023-08-04 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, status post concurrent chemoradiotherapy, Transanal Transabdominal Total Mesorectal Excision — adenocarcinoma, moderately differentiated. Margins free.
      • Lymph node, pericolonic, dissection — metastatic adenocarcinoma.
      • Anastomosis, proximal site, excision — free
      • Anastomosis, distal site, excision — free
      • ypT3 ypN1b (if cM0); ypStage: IIIB, at least
    • Gross Description:
      • Procedure - Transanal Transabdominal Total Mesorectal Excision: 12 x 5 x 5 cm
      • Tumor Site - Rectum, 0.5 cm from resection margin
      • Tumor Size: 6 x 4.5 x 4.5 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum - Complete
      • Sections are taken and labeled as: A1-6: tumor; A7: tumor cut ends; A8-15: lymph nodes; B: Anastomosis, proximal site; C: Anastomosis, distal site.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
        • Distance of tumor from margin: 5 mm
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2) - Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 3/15 with extranodal extension.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) ; yp Stage: IIIB, at least.
        • TNM Descriptors (required only if applicable) - y (posttreatment)
        • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM) - if cM0
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department (director) and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • Additional Pathologic Findings (select all that apply) - None identified
      • Ancillary Studies : result of S2022- 22864 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-07-17 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs. Some GGO at bil. lungs.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Stable condition of rectal cancer.
  • 2023-07-13 Sigmoidoscopy
    • ectal cancer s/p CCRT; a ulcerative mass at 10 cm from AV
  • 2023-07-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 18.7) / 104 = 82.02%
      • M-mode (Teichholz) = 82.0 - 75.0
    • Conclusion:
      • Normal AV with mild AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
      • Dilated LA
  • 2023-04-11 CT - abdomen
    • History and indication:
      • A case of newly diagnosed rectal cancer at 10-14 cm AAV Advanced rectal cancer, cT4aN2bM0 pre-op CCRT
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • IMP:
      • Stable condition of rectal cancer.
  • 2023-04-11 ECG
    • Sinus bradycardia with occasional Premature ventricular complexes
  • 2023-04-11 Colonoscopy
    • Rectal cancer s/p CCRT, mild regression
  • 2023-03-16 CT - abdomen
    • History and indication:
      • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of rectal cancer.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • IMP:
      • Mild regression of rectal cancer.
  • 2023-03-01 CXR
    • Atherosclerotic change of aortic arch
  • 2023-02-06 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-01-30 CXR
    • Atherosclerotic change of aortic arch
  • 2023-01-04 ECG
    • Sinus bradycardia with 1st degree A-V block
    • Nonspecific ST abnormality
  • 2022-12-22 Patho - colrectal polyp
    • Rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, moderately differentiated, composed of low columnar to couboidal neoplastic cells, arranged in glandular and cribrifrom patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-12-20 Sigmoidoscopy
    • Rectal cancer s/p biopsy
    • Rectal polyp s/p polypectomy
  • 2022-12-19 CT - abdomen
    • History and indication: A case of newly diagnosed rectal cancer at 10-14 cm AAV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP.
      • Renal cysts (up to 0.8cm).
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
      • Emphysema at bil. upper lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T: T4a(T_value) N: N2b(N_value) M: M0(M_value) STAGE: IIIC(Stage_value)

[MedRec]

  • 2023-02-16 SOAP Colorectal Surgery
    • A/P
      • radiotherapy on 2023-01-05 ~ 2023-02-13
      • CCRT with FOLFOX IV Q2W x 4~6 months
  • 2023-02-21 SOAP Radiation Oncology
    • O: RT (2022-12-30 ~ 2023-02-13): 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.
  • 2023-02-06 SOAP Hemato-Oncology
    • S: c/o vague abd discomfort, KUB: stool impact, give Lactulose.
  • 2023-01-10 SOAP Hemato-Oncology
    • S
      • HBsAg, anti-HCV (12/26 22): negative. anti-HBc: positive… on Baraclude
      • On R/T to rectal tumor by Dr Huang Jingmin.
      • Owing to advanced stage of rectal CA, pre-Op CCRT wt FOLFOX is preferred rather than lower dose 5-FU 24 hr QD x 5 per wk x 6 plus R/T (20230110).
      • #1 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T on 20230103.
      • Adm on 20230130 for #2 pre-Op CCRT wt mFOLFOX6 IV Q2W x 3 plus R/T.
  • 2023-01-03 ~ 2023-01-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
      • Chronic viral hepatitis B without delta-agent, 2022/12/26 Anti-HBc: postive
      • Porta catheter insertion at right Internal Jugular Vein on 2023/01/4
    • Present illness
      • This a 77 year-old male, who has hypertension for years, a patient of Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC), diagnosis in Dec 2022.
      • He suffered from initial presentation of jaundice & clay-colored stool in May 2016. The palpatedv small elastic nodule, 3 cm in size, painless & non-tender, movable at upper back from June 2015. So, he went to GS OPD for help on 2022/12/19.
      • Follow-up Abdomen CT (12/19 22): Adenocarcinoma, moderately differentiated, of the rectum, stage cT4aN2bM0 (IIIC).
      • Sigmoidoscopy : Rectal cancer s/p biopsy. Rectal polyp s/p polypectomy on 2022/12/20.
      • The rectum, 10 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated. IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+) on 2022/12/20.
      • He was referred to our hemato-oncologic clinic on 12/26 14 by Dr Xiao Guanghong for CCRT with FOLFOX Q2W IV x 4-6 months.
      • Consult Dr. Huang Jingmin for CCRT enaluation. Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed. Starting on 2022/12/30.
      • HBsAg, Anti-HBc, Anti-HCV: negative on 12/26 22.
      • Port-a insertion on 2023/1/4 by Dr. Chen Yanzhi
      • This time, he is admitted for CCRT with FOLFOX Q2W IV x 4-6 months.
    • Course of Inpatient Treatment
      • After be admitted, he received radiotherapy with deliver 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed, since 2022/12/30 until now.
      • CCRT with #1 FOLFOX (oxalip 6070mg/m2, covorin 400mg/m2, 5-FU 2400mg/m2) IV Q2W x 6 on 1/3-1/5 22, Imperan + Promeran for vomitin, hydration, and Baraclude 0.5mg/tab 1tab QDAC for Anti-HBC(+). The port-a catheter insertion at right Internal Jugular Vein on 2023/01/04.
      • After chemotherapy, he denied having a fever, chillness, vomiting, diarrhea, and the surgery wound condition stably.
      • Under the stable condition, he can be discharged on 2023/01/05, the OPD follow-up and the next admission will be arranged.
  • 2022-12-22 SOAP Radiation Oncology
    • A: Adenocarcinoma, moderately differentiated, of the rectum, EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+), stage cT4aN2bM0 (IIIC).
    • P: Radiotherapy is indicated for this patient with the following indicators: stage T4aN2bM0
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-12-27.
  • 2022-12-22 SOAP Colorectal Surgery
    • A: Advanced rectal cancer , cT4aN2bM0
    • P: Suggest pre-op CCRT (favor TNT) then OP
  • 2022-12-19 SOAP Colorectal Surgery
    • S
      • A case of newly diagnosed rectal cancer at 10-14 cm AAV
      • PH: HTN
    • O
      • pre-op study
      • Arrange sigmoidoscopy for R/O colonic lesion

[surgical operation]

  • 2023-08-02
    • Surgery
      • Transanal Transabdominal Total Mesorectal Excision        
    • Finding
      • Large rectal cancer s/p CCRT, narrow pelvis and the tumor and rectum occupied the pelvic cavity     
      • Tumor location: 8 cm from Av    

[radiotherapy]

  • 2022-12-30 ~ 2023-02-13 - 4500cGy/25 fractions (15 MV photon) of the pelvic, and 5040cGy/28 fractions (15 MV photon) of the rectal tumor bed area.

[chemotherapy]

  • 2023-11-06 - irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (FOLFIRI Q2W 80% dose)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + aprepitant 125mg PO + NS 250mL
  • 2023-06-23 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-09 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 730mg NS 200mL 2hr + fluorouracil 2400mg/m2 4380mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-11 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4410mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-26 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4435mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-12 - oxaliplatin 70mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 735mg NS 200mL 2hr + fluorouracil 2400mg/m2 4415mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-15 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-01 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-13 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4450mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-03 - oxaliplatin 60mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 200mL 2hr + fluorouracil 2400mg/m2 4510mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-11-07

The patient’s repeat prescription from WanFang Hospital, which includes clopidogrel, nicorandil, indapamide, nifedipine, rosuvastatin, and benzbromarone, was last filled on 2023-10-17. However, not all of these medications are listed as currently active. Verification is required to determine if the medications not in use have been intentionally discontinued.

2023-05-29

  • According to the PharmaCloud database, the patient had visited WanFang Hospital and a local clinic for upper respiratory symptoms in late March and early May. However, the prescriptions from these healthcare providers have now expired. No medication reconciliation issues were identified during this patient’s current admission.

2023-05-12

  • According to the PharmaCloud database, the patient visited WanFang Hospital on 2023-03-27 for his unspecified chronic bronchitis and visited Dr. Wu’s local clinic on 2023-03-29 for an unspecified acute upper respiratory infection. To date, no current respiratory problems have been reported and no medication reconciliation issues have been identified.
  • The patient underwent radiotherapy with 4500 cGy/25 fractions (15 MV photon) to the pelvic region and 5040 cGy/28 fractions (15 MV photon) to the rectal tumor bed from 2022-12-30 to 2023-02-13. Concurrently, the patient has been receiving chemotherapy with the FOLFOX regimen since 2023-01-03. The initial treatment plan was to reduce the tumor size for possible surgical resection. However, the CT scans of 2023-04-11 showed stable disease compared to 2023-03-16, which showed a slight regression, suggesting that the treatment may not be as effective as it once was. It would be recommended to obtain new tumor marker lab data to assist in evaluating the efficacy of the current treatment.

701476645

231106

[exam findings] (not completed)

  • 2023-10-13 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Fusiform like necrotic tumor at left breast measuring 4.2cm in largest dimension is found. In comparison with CT dated on 2023-07-28, the lesion is stationary.
      • Lymphadenopathy at left axillary region is found. In enlargement.
      • Minimal interstitial change at bilateral lungs is found. However, the changes improved markedly as compared with previous CT.
    • Imp:
      • Left breast tumor. stable
      • Left axillary lymphadenopathy, in marked enlargment
      • The opacities over bilateral lungs regressed markedly.
  • 2023-09-11 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free of carcinoma
      • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
      • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 14.5 x 11.5 x 3.8 cm
      • Skin Size: 13.0 x 3.4 cm
      • Nipple: Not retracted
      • Tumor Size: 3.4 x 1.8 x 1.0 cm
      • Resection Margin: Free, 1.2 cm from the deep margin
      • Lymph node: Axillary sentinel and axillary
      • Representative parts are taken for section and labeled: F2023-00408. FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
    • MICROSCOPIC EXAMINATION
      • Microscopy
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: 12 mm from deep margin
      • Nodal status: Metastatic carcinoma (2/4)
        • number of lymph node examined: 2 (sentinel), 2 (axillary)
        • number with macrometastases (>2mm): 2
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
        • Extranodal extension: Present
      • Treatment Effect:
        • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
        • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
      • Lymphovascular invasion: Present
      • Perineural invasion: Absent
      • Tumor-infiltrating lymphocytes: 5%
    • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score 1+)
      • Ki-67: 80-90%
  • 2023-09-11 Patho - lymph node region resection
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free of carcinoma
      • Lymph node, axillary sentinel and axillary, LND — Metastatic carcinoma (2/4)
      • AJCC 8 th edition, Pathology stage: ypT2N1a(cM0); Anatomic stage IIB; Prognostic stage IIIA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 14.5 x 11.5 x 3.8 cm
      • Skin Size: 13.0 x 3.4 cm
      • Nipple: Not retracted
      • Tumor Size: 3.4 x 1.8 x 1.0 cm
      • Resection Margin: Free, 1.2 cm from the deep margin
      • Lymph node: Axillary sentinel and axillary
      • Representative parts are taken for section and labeled: F2023-00408FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= axillary sentinel LNs, A1= nipple, A2= skin + tumor, A3-A6= tumor, A7= non-tumor. S2023-18125= axillary lymph nodes
    • MICROSCOPIC EXAMINATION
      • Type
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 3.4 x 1.8 x 1.0 cm
        • Histologic grade (Nottingham histologic score): Grade 3 (score= 8)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: 12 mm from deep margin
      • Nodal status: Metastatic carcinoma (2/4)
        • number of lymph node examined: 2 (sentinel), 2 (axillary)
        • number with macrometastases (> 2mm): 2
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Extranodal extension: Present
      • Treatment Effect:
        • Treatment effect in the breast: Probable or definite response to presurgical therapy in the invasive carcinoma
        • Treatment effect in the lymph nodes: Two sentinel lymph nodes metastasis. Another two axillary lymph nodes show fibrous scar, possibly related to prior lymph node metastasis with pathologic complete response
      • Lymphovascular invasion: Present
      • Perineural invasion: Absent
      • Tumor-infiltrating lymphocytes: 5%
    • IMMUNOHISTOCHEMICAL STUDY (S2023-06120)
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score 1+)
      • Ki-67: 80-90%
  • 2023-08-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72 - 11.3) / 72 = 84.31%
      • M-mode (Teichholz) = 84
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR, trivial AR
      • No regional wall motion abnormalities
  • 2023-08-10 Flow volume loop chart
    • r/o mild restrictive ventilatory defect
  • 2023-07-28 CT - chest
    • Indication: Left breast invasive carcinoma, cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. ECOG performance: 0
    • Chest CT with and without IV contrast ehnancement shows:
      • Some lymph nodes are found at both sides of the mediastinum.
      • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
      • Necrotic mass at left breast measuring 2.9cm is noted. Stable.
      • Minimal bilateral pleural effusion is noted.
    • Imp:
      • Diffuse ground glass opacities over both lungs are found. Chemothorapy related pneumonitis is suspected.
  • 2023-07-01 CT - chest
    • Indication: left breast cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • Mass like lesion at left breast measuring 3.34cm is found. In comparison with CT dated on 2023-03-30, the lesion is stationary.
      • Small lymph nodes are found at left axillary region.
    • Imp:
      • Left breast cancer with left axillary lymph nodes s/p C/T. Stationary.
  • 2023-06-05 SONO - breast
    • diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • treatment
      • Open biopsy
    • suggestion
      • Follow up breast sonography in next OPD visit, Admission for surgical intervention
    • BI-RADS:
      • 6-Known Biopsy - Proven Malignancy
  • 2023-04-14 Patho - lymphnode biopsy
    • Labeled as “left axilla”, biopsy — invasive carcinoma.
    • Section shows lymph node with invasive carcinoma.
    • IHC stain: GATA-3 (+).
  • 2023-04-14 Tc-99m MDP bone scan
    • Mildly increased activity in the lower L-spines, bilateral S-I joints and sacrum. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages and a faint hot spot in the left pubic bone. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, right knee and both feet, compatible with benign joint lesions.
  • 2023-04-13 Flow volume loop chart
    • Mild restrictive ventilatory impairment
  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (50 - 9) / 50 = 82.00%
      • M-mode (Teichholz) = 82
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Trivial MR; trivial AR; mild PR.
  • 2023-04-12 PD-L1 (22C3)
    • Tissue block No.: S2023-06120
    • RESULTS:
      • Combined Positive Score(CPS) assessment: CPS<1
      • Combined Positive Score(CPS): 0.5
  • 2023-04-12 Mammography
    • Impression: Dense breast.
      • Focal asymmetry in left breast, around 12’region, clinical proven malignancy.
      • Benign calcifications in bilateral breasts.
    • BI-RADS: Category 6-proven malignancy.
  • 2023-03-31 Patho - breast biopsy (no need margin)
    • Breast tumor, left 1/3 cm region, core needle biopsy — Invasive carcinoma of no special type
    • Microscopically, the sections show a picture of invasive carcinoma of no special type characterized by tumor cells arranged in linear or nest pattern infiltrating in the stroma with focal necrosis and microcalcification.
    • Immunohistochemistry shows P63(-), E-cadherin(+), ER(-, 0%), PR(-, 0%), Her2/neu(-, Dako score 1+) and Ki-67: 80-90% for tumor.
  • 2023-03-30 CT - chest
    • Indication: Disorder of breast, unspecified; Unspecified lump in breast
    • Chest CT with and without IV contrast ehnancement shows:
      • Low density lesion at left breast with marginal enhancement measuring 2.63cm in largest dimension. Breast cancer is considered first but infection cannot be excluded.
      • Enlarged lymph nodes are found at left axillary region.
    • Imp:
      • Left breast tumor. 2.63cm, r/o breast cancer or others.
      • Lymphadenopathy at left axillary region.
  • 2023-03-27 SONO - breast
    • diagnosis
      • Highly suspicious of malignancy,with sonographic negative axillary LNs
    • treatment
      • Sono-guided biopsy, Core-needle biopsy, Open biopsy
    • suggestion:
      • Arrange mammography, Arrange breast MRI, Arrange excisional biopsy, Admission for surgical intervention
    • BI-RADS:
      • 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[MedRec]

  • 2023-04-12 ~ 2023-04-15 POMR General and Gastrointestinal Surgery Wang ShengLin
    • Discharge diagnosis
      • Left breast invasive carcinoma status post port-A insertion on 2023/4/13. cT2N0M0, stage IIA. ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%.
      • For 1st neoadjuvant chemotherpy with Lipo-dox + Endoxan + Keytruda.
    • CC
      • noted a palpable mass at left breast on 2023/03.
    • Present illness
      • This 70-year-old women patient denied any past history including DM, HTN, HBV, heart disease or cancer. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at left breast on 2023/03. Then she came to our OPD for help. Breast SONO showed Left breast heterogenous hypoechoic lesion at 1/3cm, size:2.63cmx2.63cm, highly suspicious of malignancy, suggested core needle biopsy. Chest CT showed 1) Left breast tumor. 2.63cm, r/o breast cancer or others. 2) Lymphadenopathy at left axillary region. Left breast core needle biposy showed invasive carcinoma, ER(-, 0%), PR(-, 0%), Her2/neu(-, 1+), Ki-67: 80-90%. She had no dizzines, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, nor body weight loss. PE:1). symmetrical of bilateral breasts. a hard, nontender, movable mass and irregular margin at left breast around 5*5cm without discharge. The left nipple was dimping without exudative nor bloody discharge and no retraction. The bilateral breast skin had no cellulite change. no clinical palpable mass in left axillary. SDM for this patient.
      • Neoadjuvent chemotherapy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 and Keytruda. Operation, in the future were suggest.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of port a insertion and 1st neoadjuvant chemotherpy with Lipo-dox 35mg/m2 + Endoxan 600mg/m2 and Keytruda.
    • Course of inpatient treatment
      • After admission, port-A insertion was performed on 2023/04/13. Bone scan and abdomen echo showed no obvious lesion for metastasis. Cardiac echo showed LVEF:82%. Lung funsion test showed Mild restrictive ventilatory impairment. SONO Guiding for marker clips for left breast tumor was done on 2023-04-14. Sono-guided biopsy for left axillary lymph node was dones on 2023-04-14, final report was pending. 1st neo-adjuvant chemotherapy with Lipo dox + Endoxan and keytruda were given. The port-A wound is clean and dry. No discomfort after chemotherapy. Under the stable condition, she was discharged today, wound will be follow up OPD. And arrange next admission three weeks later.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Through (sennoside 12mg) 1# HS
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Acetal (acetaminophen 500mg) 1# QID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Emend (aprepitant 125mg) 1# QD

[surgical operation]

  • 2023-09-08
    • Surgery
      • Left partial mastectomy + ALND (2/2)
    • Finding
      • Left breast cancer at 12/1cm, size: 2.5x2.2cm
      • Left axillary sentinel lymph node metastasis (2/2) -> ALND
  • 2023-03-31
    • Surgery
      • Left breast core needle biopsy
    • Finding
      • Left breast heterogenous hypoechoic lesion at 1/3cm, size: 2.63cmx2.63cm

[immunochemotherapy]

  • 2023-11-03 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-27 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-20 - paclitaxel 80mg/m2 120mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-10-13 - paclitaxel 80mg/m2 118mg NS 250mL 120min (T QW adjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-06-30 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 928mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-05 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 913mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL + lenograstim 250ug
  • 2023-05-12 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 919mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-04-15 - pembrolizumab 200mg NS 100mL 30min + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 899mg NS 500mL 1hr (AC(Lipo) Q3W neoadjuvant)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-11-06

[leukopenia; G-CSF administration is usually begun 24 to 72 hours after cessation of chemotherapy]

Continuing from the previous pharmacist note replied on 2023-10-30.

New episodes of leukopenia were observed in late Oct and early Nov. Granocyte (lenograstim) was administered on 2023-11-03, just prior to paclitaxel chemotherapy.

  • 2023-11-03 WBC 1.97 x10^3/uL
  • 2023-10-27 WBC 1.86 x10^3/uL
  • 2023-10-20 WBC 5.36 x10^3/uL
  • 2023-10-13 WBC 5.27 x10^3/uL

Timing of G-CSF - When used for primary and secondary prophylaxis, therapy is usually begun 24 to 72 hours after cessation of chemotherapy. (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation)

  • Macaire et al. (2020) conducted a study on the impact of granulocyte colony-stimulating factor (G-CSF) on FOLFIRINOX-induced neutropenia. They found that pegylated-G-CSF administration 24 hours after the end of chemotherapy may be an optimal schedule to reduce neutropenia. (Impact of granulocyte colony‐stimulating factor on folfirinox‐induced neutropenia prevention: a population pharmacokinetic/pharmacodynamic approach. British Journal of Clinical Pharmacology, 86(12), 2473-2485. https://doi.org/10.1111/bcp.14356)
  • Mackey et al. (2020) emphasized that delaying supportive G-CSF therapy to 6-7 days after chemotherapy can mitigate myelosuppressive effects. (The timing of cyclic cytotoxic chemotherapy can worsen neutropenia and neutrophilia. British Journal of Clinical Pharmacology, 87(2), 687-693. https://doi.org/10.1111/bcp.14424)
  • Salem et al. (2016) compared different post-chemotherapy G-CSF administration regimens and suggested that administration from Days 2-5 or Days 5-9 cycles may have optimal effects on immune cell recovery and antigen-specific immune responses. (Effect of administration timing of postchemotherapy granulocyte colony-stimulating factor on host-immune cell recovery and cd8+ t-cell response. Journal of Immunotoxicology, 13(6), 784-792. https://doi.org/10.1080/1547691x.2016.1194917)
  • Yankelevich et al. (2008) mentioned that delaying G-CSF until 5 days after completion of chemotherapy has not resulted in a longer duration of neutropenia. (Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Experimental Hematology, 36(1), 9-16. https://doi.org/10.1016/j.exphem.2007.08.019)

2023-10-30

[leukopenia]

Several episodes of leukopenia have been observed since the start of immunochemotherapy on 2023-04-15. The most recent episode occurred on 2023-10-27 with WBC at 1.86K, neutrophil and band at 58.9%, and ANC at 1095. This coincided with the administration of adjuvant paclitaxel. Paclitaxel has a known association with leukopenia (90%; grade 4: 17%). It’s generally not recommended for patients with solid tumors who have a baseline neutrophil count below 1500/uL. If there’s a high risk of infection, the use of G-CSF is recommended.

  • 2023-10-27 WBC 1.86 x10^3/uL **
  • 2023-10-20 WBC 5.36 x10^3/uL
  • 2023-10-13 WBC 5.27 x10^3/uL
  • 2023-09-06 WBC 4.46 x10^3/uL
  • 2023-08-10 WBC 5.95 x10^3/uL
  • 2023-08-03 WBC 5.20 x10^3/uL
  • 2023-07-31 WBC 6.15 x10^3/uL
  • 2023-07-29 WBC 1.85 x10^3/uL **
  • 2023-07-28 WBC 3.71 x10^3/uL
  • 2023-07-06 WBC 5.56 x10^3/uL
  • 2023-06-30 WBC 5.41 x10^3/uL
  • 2023-06-12 WBC 2.71 x10^3/uL *
  • 2023-06-05 WBC 2.71 x10^3/uL *
  • 2023-06-05 WBC 3.31 x10^3/uL
  • 2023-05-18 WBC 3.32 x10^3/uL
  • 2023-05-11 WBC 3.92 x10^3/uL
  • 2023-05-05 WBC 1.44 x10^3/uL **
  • 2023-04-20 WBC 5.36 x10^3/uL
  • 2023-04-12 WBC 4.24 x10^3/uL

701487478

231106

[exam findings]

  • 2023-03-15 MRI - abdomen (Yonghe Cardinal Tien Hospital)
    • Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation;
    • Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy.

[MedRec]

  • 2023-07-11 SOAP Hemato-Oncology He JingLiang
    • S: 2023-07-11 first C/T with CDDP + gemzar
    • Prescription
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Hepac Lock Flush (heprarin sodium) 10mL IRRI
  • 2023-06-25 ~ 2023-07-01 POMR General and Gastrointestinal Surgery Li ChaoZhu
    • Discharge diagnosis
      • Malignant neoplasm of gallbladder
      • Gallbladder cancer, adenocarcinoma, billiary type, poorly differentiated, pT2bN1(cM1), stage IV with multiple retroperitoneal and left supraclavicular (Virchow’s node) lymph nodes metastases status post laparoscopic cholecystectomy and lymph node dissection on 2023-0626; ECOG 0
      • post Port-A insertion on 2023-06-30
    • CC
      • noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01.
    • Present illness
      • This is a 61 years old woman patient, she denied any past history including cancer, hypertention, diabetes mellitus, cancer and heart disease. She denied any TOCC histories in recent 3 months.
      • She noted tea-colored urine, intermittent right epigastric dull pain without radiating to back on 2023/01. No aggravating factors and relieving factors. She went to Yonghe Cardinal Tien Hospital and National Taiwan University Hospital for help. Abdomen magnetic resonance imaging showed 1). Irregular to nodular thickening of gallbladder wall, neogrowth cannot be ruled out, suggest further evaluation; 2). Enlarged lymph nodes in hepatic hilar, retropancreatic, paraaortic and aortocaval regions, up to 1.5cm in size, more in favor of metastatic lymphadenopathy, on 2023/3/15 in Yonghe Cardinal Tien Hospital. Due to personal reason, she for persaol reason came to our outpatient department for help. Abdominal sono showed suspicious of gallblader tumor.
      • Physical examination showed pink conjunctiva and anicteric sclera, abdomen: soft and ovoid, normal bowel sound. No tenderness, Murphy’s sign positive, rebounding pain and no tympanic percussion. She denied fever, fatigue or appetite change. She had jaundice, but no clay stool.
      • Under suspicious of gallblader tumor was impressed. After fully explaination the treatment surgical of method, this patient decided to treat surgically. She admitted for laparscopic cholecystectomy and further management.       
    • Course of inpatient treatment
      • After admission, laparoscopic cholecystectomy and laparoscopic lymph node dissection (for the pathologic report disclosed malignancy) was performed on 2023/06/26. The post-operative course was relatively smooth.
      • Due to pathology report showed Gallbladder adenocarcinoma, lymph node metastatic carcinoma, arrange bone scan, the report showed some faint hot spots in the skull.
      • Consult Hematologic-Oncology and Radiation Oncology for future treatment.
      • Consult psychosomatic medicine and an oncology psychologist for insomnia at night and psychological suicide risk factors: 13 points.
      • Follow up PET for bone scan showed some faint hot spots in the skull. PET scan showed 1). Glucose hypermetabolism in multiple lymph nodes in the retropancreatic, aortocaval and bilateral paraaortic regions, compatible with multiple metastatic lymph nodes; 2).Glucose hypermetabolism in multiple left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out.
      • Port-A insertion was performed on 2023/06/30. Arrange SONO Guide biopsy-Lymph nodes (left neck) on 6/30.
      • The wound is clean and dry. Under the stable condition, she was discharged today and final report will be follow up in OPD.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Acetal (acetaminophen 500mg) 1# TID
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Eurodin (estazolam 2mg) 1# HS

[chemmotherapy]

  • 2023-11-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 500mL 2hr + fluorouracil 2400mg/m2 3900mg NS 500mL 45hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-10-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-10-04 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C5D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-09-20 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-09-13 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C4D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-30 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 55mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-23 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C3D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-09 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-08-02 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-07-19 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D8)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL
  • 2023-07-11 - gemcitabine 1000mg/m2 1400mg NS 250mL 30min + cisplatin 40mg/m2 50mg NS 500mL 1hr + NS 500mL 30min (after CDDP) (C1D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL

Gemcitabine and cisplatin for locally advanced or metastatic biliary tract and pancreatic cancer - 2023-11-06 - https://www.uptodate.com/contents/image?imageKey=ONC%2F89633

  • Cycle length: 21 days.

  • Duration of therapy: Maximum of 8 cycles.

  • Regimen

    • Cisplatin
      • 25 mg/m2 IV daily
      • Dilute in 1000 mL NS with 20 mEq (20 mmol) of potassium chloride and 2 grams (8 mmol) of magnesium sulfate and administer over 60 minutes. Do not administer with aluminum needles or IV sets. Follow infusion with 500 mL NS over 30 minutes.
      • Days 1 and 8
    • Gemcitabine
      • 1000 mg/m2 IV daily
      • Dilute in 250 mL NS (concentration no more than 40 mg/mL) and administer over 30 minutes after cisplatin and IV fluid.
      • Days 1 and 8

==========

2023-11-06

[reconciliation]

The patient recently renewed her prescriptions for lorazepam and alprazolam on 2023-10-31 at a community pharmacy. Alprazolam is listed as currently in use, but lorazepam is not included in the active medication list. It might be advisable to ascertain if lorazepam is no longer required.

700282560

231105

[diagnosis] - 2023-04-06 admission note

  • Acute promyelocytic leukemia, not having achieved remission
  • Gout, unspecified

[lab data]

2023-06-28 CMV IgM Nonreactive
2023-06-28 CMV IgM Value 0.04 Index
2023-06-28 FLT3/ITD Presence of mutation * 2023-06-28 NPM1 Undetectable
2023-06-28 PML-RARA 0.0000
2023-06-28 BCR/abl Undetectable
2023-06-28 CMV viral load assay Target not detecetedIU/mL

2023-04-22 CMV IgM Nonreactive
2023-04-22 CMV IgM Value 0.08 Index
2023-04-22 CMV_IgG Reactive
2023-04-22 CMV_IgG Value 49.0 AU/mL

2023-02-01 CMV viral load assay Target not detecetedIU/mL

2023-01-27 CMV_IgG Reactive
2023-01-27 CMV_IgG Value 22.8 AU/mL
2023-01-27 CMV IgM Nonreactive
2023-01-27 CMV IgM Value 0.12 Index

2023-01-20 BM chromosome analyz
- CYTOGENETICS LABORATORY REPORT - Chromosome Analysis: - Tissue Examined:Bone marrow - Staining Method:G-Banding - Colony number:NA - Bands level:350 - Chromosome Counts: - 45-()、46-(20)、47-()、Other-() Total-(20) - Karyotype:46,XY[20] - Interpretation: - Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected. - Note: - ROUTINE BANDED LEVEL DOES NOT RULE OUT REARRANGEMENT ONLY SEEN AT HIGHER LEVELS OF RESOLUTIONS.

2023-01-17 FLT3-D835 Undetectable
2023-01-12 PML-RARA Presence of mutation *

2023-01-12 BCR/abl Undetectable
2023-01-12 FLT3/ITD Presence of mutation * 2023-01-12 NPM1 Undetectable

2023-01-10 CMV IgM Nonreactive
2023-01-10 CMV IgM Value 0.21 Index
2023-01-10 CMV_IgG Reactive
2023-01-10 CMV_IgG Value 11.8 AU/mL
2023-01-10 Anti-HBc Nonreactive
2023-01-10 Anti-HBc-Value 0.70 S/CO
2023-01-10 HBsAg Nonreactive
2023-01-10 HBsAg (Value) 0.33 S/CO
2023-01-10 Anti-HCV Nonreactive
2023-01-10 Anti-HCV Value 0.13 S/CO

[exam findings]

  • 2023-06-01 CXR
    • Increased lung markings on both lower lung are noted.
  • 2023-06-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Acute myeloid leukemia
    • Microscopically, it shows hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers (> 40%) and highlighted by CD34 and CD117.
    • Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
  • 2023-04-07, -02-27, -02-21 Body fluid cytology - CSF
    • negative
  • 2023-02-02 SONO - abdomen
    • splenomegaly
    • accessory spleen
  • 2023-01-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, s/p chemotherapy, biopsy — hypocellularity.
    • IHC stains: CD117: <1 %; CD34: <1 %; MPO: 45-50%, CD61: <5 %; CD71: 45-50 % (of the nucleated cells).
    • REFERENCE: S2023-00105: Bone marrow, biopsy — Compatible with acute myeloid leukemia
    • Section shows piece(s) of bone marrow with 10% cellularity and M:E ratio of approximately 1:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are reduced in number.
  • 2023-01-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 44) / 143 = 69.23%
      • M-mode (Teichholz) = 69
    • Conclusions
      • Dilated LV; normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; normal LV diastolic function.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR.
      • PICC catheter in right atrium.
  • 2023-01-03 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia
    • The sections show hypercellular marrow (90%). The marrow space is replaced by a population of medium to large-sized immature cells with oval nucleus and moderate amount cytoplasm. The CD71+ erythroid precursors are marked decreased. Increased CD34+ and/or CD117+ blasts, constitue 40% of marrow cells. Some of blasts are positive for MPO (50%). Scattered CD68+ cells (10%) can be found. The finding is compatible with acute myeloid leukemia. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-01-02 CT - abdomen
    • History and indication: Suspect perirectal abscess
    • IMP:
      • Wall thickening of rectum with adjacent fat stranding suspected malignancy.
      • Some LNs (up to 0.9cm) at paraaortic region.
      • Some calcifications at right adrenal gland.
      • Splenomegaly with focal low attenuation suspected infarct.
  • 2023-01-02 Anoscopy
    • Findings
      • Stool color: normal
      • Rectal mucosa: normal
      • Anal canal: abnormal
    • Impression
      • Bloody mucus in rectum
      • Rectal edema at left & right lateral, anterior wall

[MedRec]

  • 2023-10-31 ~ 2023-11-05 POMR Family Medicine Chen ZhengYu
    • Discharge diagnosis
      • Acute myeloid leukemia, FLT3/ITD mutation and NPM1 undetectable
    • CC
      • for SOB, gastric pain for 3 days and vomit blood since ysterday
    • Present illness
      • This 37-year-old man has history of acute promylocytic leukemia and perineal abscess. He received induction chemotherapy with I3A7 on 2023/01/9. Followed bone marrow biopsy on 2023/01/27 showed hypocellularity. IHC stains: CD117: <1%; CD34: <1%; MPO: 45-50%, CD61: <5%; CD71: 45-50 % (of the nucleated cells). Compatible with acute myeloid leukemia.
      • C1 reinduction chemotherapy with D3A7 was administered on 2023/02/23. C1 IT chemotherapy (Cytosar 50mg/MTX 12mg/ Hydrocortisone 30mg) weekly *5 on 2023/02/20. C2 IT on 2023/02/27. C2 Consolidation chemotherapy with D3A5 on 2023/04/07 plus C3 IT on 2023/04/07.
      • 2023/06/20 repeat bone marrow showed acute myeloid leukemia, hypercellularity of marrow (approximately > 95%). Blasts are markedly increased in numbers ( > 40%) and highlighted by CD34 and CD117. Immunohisotchemical stain reveals CD138 (focal+, 1~2%), MPO (+), CD71 (focal+, sparse), CD61 (focal+, sparse), TdT (focal +).
      • We change newly chemotherapy with C1 FLAG on 2023/06/21. C2 FLAG on 2023/07/16.
      • Rydapt 25mg/cap (Midostaurin) 2# q12h treatment during neutropenia stage. Bone marrow was done for bone marrow suppression. Family conference was done on 2023/08/17. Social worker was consulted for economic evaluation.
      • C3 FLAG-IDA as (Fudarabine 30mg/m2 = 50mg qd since 2023/08/29 ~ 2023/09/03, Ara-C 1500mg/m2 = 3150 qd since 2023/08/30 ~ 2023/09/03, Venectoclax 100 mg qd since 2023/08/29 ~ 2023/09/04 and Posaconazole 300mg qd since 2023/08/29.)
      • KP bacteremia and pneumonia over LUL during hospitalization.
      • VS explainted his refractory condition maybe can’t PBSCT.
      • Patient understood and wish hospice care later.
      • This time, he has SOB, gastric pain for 3 days and vomit blood since ysterday. Due to progress of SOB, so he was brought to our ED for help on 2023/10/30 night. At ED, he has gum bleeding and hypothermia 35.8’C. The lab data showed leukocytosis, severe anemia and thrombocytopenia. Initial blood transfusion with LRP, transamine and steroid for symptom control. Under the impression of refractory AML, so he was admitted for management on 2023/10/31.
    • Course of inpatient treatment
      • The patient was admitted to palliative ward on 31st October.
      • The patient suffered from LUQ pain while breathing, therefore we upgraded the pain control agents from tramadol to Morphine (3mg Q6H). The first two days it was effective. However, Nausea and vomitting remained, only partially improved after the presciption of Gasmin PO 1# BID and antihistamine.
      • However, the patient’s condition went down on 4th, he experienced short of breathe, Decan and steroid was given and only limited effect was seen.
      • On 5th, he was found collapsed on the ground when the caregiver was away for few minutues, duty doctor was informed and the death announcement was made at 0831 2023-11-05.

[consultation]

  • 2023-07-28 Colorectal Surgery
    • Q
      • The 37 y/o man has AML /p chemotherapy with neutropenic stage. Due to anal pain and swelling, so we need your help for management.
    • A
      • This is a 37- year old man with anal pain for days
      • DRE:
        • anal fissure over 6 and 12 o’clock region, swelling over anal region
        • no obvious abscess formation
      • A: perianal pain and anal fissure, R/I AML induced
      • P:
        • warm water sitz bath
        • alcos anal ointment topic use
        • pain control
        • control underlying disease
  • 2023-07-05 Denatal
    • Q
      • This 37 year old male is a case of Acute promylocytic leukemia status post induction chemotherapy with D3A7 on 2023/01/09, Consolidation chemotherapy with D3A7 plus weekly IT on 2023/02/20, transformation to Acute myeloid leukemia, FLT3/ITD mutation in 2023-06. FLAG was administered on 2023/06/21-27. However, a swelling mass was noted on left buccal. We need your expertise for further management, thanks
    • A
      • Patient complains of left lower facial pain.
      • Take panoramic radiography for examination.
      • #35 suspect dental caries with no symptoms.
      • Oral hygiene instructions with ultra-soft tooth brush.
      • Suggest follow up closely and visit dental OPD endodontic clinic if symptoms persist.
  • 2023-05-02 Dermatology
    • Q
      • for skin rash, redness and itchy around waist, and bilateral groins due to suspect allergy
      • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy. Due to neutropenia fever, so gave antibitic with Cefepime, Targocid treatment since 2023/04/19, then he suffered from skin rash, rednessand itchy around waist, and bilateral groins due to suspect allergy.
      • We would like to consult your expertise, thank you!
    • A
      • The patient had sufferred from erythematous macules with hyperpigmentation change over trunk and axilla.
      • Under the impression of frictional eczema with secondary candidasis infestation.
      • The following suggetion:
        • keep regional body dry and clean.
        • Zalaine cream 1 tube topical QN use for large area of the pigmetation lesions and Mycomb cream 1 tube topical bid use over itchy lesions.
        • consider sinbaby lotion 1 bot topical PRN use for body occlussion/pruritus control.
  • 2023-03-15 Colorectal Surgery
    • Q
      • This is a 36 years old male with acute promylocytic leukemia and perineal abscess under chemotherapy
      • He suffered from intermittent perianal pain and swelling. High fever was noted and perianal pain progressed. He denied diarrhea or constipation. He visited our CRS outpatient department for help. Digital rectal examination showed no blood on the finger, nor palpable mass in the distance of finger length, nor palpable abscess cavity. Anoscopy showed normal color stool, normal rectal mucosa, while bloody mucus in rectum, rectal edema at left & right lateral, anterior wall were noted.
      • We would like to consult your expertise, thank you!
    • A
      • DRE: mild tendernes(+), no definite perianal abscess or fistula formation, mild hemorrhoids
      • A: Anal pain, R/O perianal infection
      • P:
        • Neomycin ointment bid use
        • Because no definite perianal abscess or fistula formation, surgical intervention is not necessary at present
        • CRS OPD follow-up
        • Please inform us if any problems
  • 2023-03-07 Infectious Disease
    • Q
      • Backline controlled antibiotics, consultation with an infectious disease specialist is required.
    • A
      • This is acse of AML with neutropenic fever.
      • Agree with your use of mepem and targocid.
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-01-28 Colorectal Surgery
    • Q
      • This 36 y/o male patient is a case of acute promyelocytic leukemia post induction chemotherapy with WBC tending to improve but still in severe neutropenic stage. We need your expertise for anal pain evaluation and recommendation, sincerely thanks.
    • A
      • I’ve visited this case.
      • PR: left lateral perianal superficial fistula tract and shallow ulcer, well drained  no abscess formation and no perianal infection sign
      • Suggestion
        • Treat underlying disease
        • Biomycin oint topical use
        • Pain control using NSAID or Paran (acetaminophen) if no contraindication
  • 2023-01-03 Hemato-Oncology
    • Q
      • For suspect acute leukemia,
      • This 36 year old man without underlying history was admitted with suspect perianal abscess.
      • Digital rectal examination showed no blood on the finger nor palpable mass in the distance of finger length. No palpable abscess cavity.
      • Anoscopy showed normal color stool, normal rectal mucosa, bloody mucus in rectum, rectal edema at left & right lateral, anterior wall.
      • Lab data showed
        • WBC (163720), Blast (66%), promyelocyte (3%), myelocyte (1%), metamyelocyte (1%)
        • Hb (9.4), PLT (26000), Cr (1.56), total bilirubin (2.6), AST (75), ALT(65)
        • Under the impression of suspect perianal abscess and suspect acute leukemia, he was admitted to our ward for further care.
    • A
      • Recommendation:
        • bone marrow with special stain, flowcytometer and chromosome study is indicated for this patient.
        • alkalinzation of urine with sodium bicarbonate to prevent tumor lysis syndrome
        • emperic antibiotics

[chemotherapy]

  • 2023-07-19 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
  • 2023-06-21 - fludarabine 30mg/m2 50mg NS 100mL 30min D1-6 + cytarabine 2000mg/m2 4200mg NS 500mL 4hr D1-5 (FLAG, Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-6
  • 2023-04-12 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-04-07 - daunorubicin 45mg/m2 90mg NS 100mL 30min D1-3 + cytarabine 2000mg/m2 4000mg NS 500mL 3hr Q12H D1-5 + [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal) D1
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-02-27 - [cytarabine 50mg + methotrexate 15mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-02-23 - daunorubicin 45mg/m2 80mg NS 100mL 30min D1-3 + cytarabine 200mg/m2 390mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3
  • 2023-02-21 - [cytarabine 50mg + methotrexate 12mg + hydrocortisone 30mg] IT (intrathecal)
  • 2023-01-09 - idarubicin 12mg/m2 24mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 200mg NS 500mL 24hr D1-7
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1

Granocyte (lenograstim 250ug) CGRAN01

  • 2023-03-03 ~ 2023-03-14
  • 2023-01-18 ~ 2023-01-31

G-CSF (filgrastim 150ug) CGCSF01

  • 2023-03-03 ~ 2023-03-14
  • 2023-01-18 ~ 2023-01-31

2023-01-13 - tretinoin 50mg

[note]

Rydapt (midostaurin) — 2023-08-31 - https://www.uptodate.com/contents/midostaurin-drug-information

  • Dosing - Adult - Acute myeloid leukemia (AML), FLT3-positive: Oral:
    • Induction: 50 mg twice daily on days 8 to 21 of each induction cycle (in combination with daunorubicin and cytarabine); administer a second induction cycle if there is definitive evidence of (clinically significant) residual leukemia.
    • Consolidation: 50 mg twice daily on days 8 to 21 of each 28-day consolidation cycle (in combination with high-dose cytarabine) for 4 consolidation cycles.
    • Maintenance (off- label): 50 mg twice daily on days 1 to 28 of each 28-day maintenance cycle for 12 cycles or until relapse, whichever occurs first.

Chemotherapy regimens for relapsed or refractory acute myeloid leukemia (AML) in adults — 2023-07-04 - https://www.uptodate.com/contents/image?imageKey=HEME%2F82823

  • Cytarabine plus daunorubicin
    • Common nonhematologic side effects seen in the majority of patients include stomatitis (mostly mild), alopecia, nausea and vomiting (10 percent severe), and diarrhea (mostly mild). Daunorubicin can be associated with an infusion reaction and cardiac arrhythmias; a flu-like syndrome and rash due to cytarabine may be seen during induction.
    • Re-induction with cytarabine plus daunorubicin will produce a complete remission in approximately 50 percent of patients with a first remission lasting longer than one year[1].
  • High-dose cytarabine (HiDAC)
    • The most common nonhematologic toxicities are nausea and vomiting, abnormal liver chemistries, diarrhea, conjunctivitis, rash, and cerebellar dysfunction. Toxicity is high in most patients over the age of 60 years.
    • HiDAC may be effective in 35 to 40 percent of patients resistant to conventional dose cytarabine regimens[2].
  • High-dose cytarabine plus mitoxantrone (HAM)
    • In addition to the side effects described for HiDAC above, nonhematologic toxicities include stomatitis, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
    • If an anthracycline (eg, daunorubicin) was not used during initial induction, the combination of HiDAC plus the synthetic anthracycline analogue, mitoxantrone, may produce higher response rates than HiDAC alone[3].
  • High-dose cytarabine plus etoposide
    • In addition to the side effects described for HiDAC above, nonhematologic toxicities include hepatic toxicity, peripheral neuropathy, and anaphylactic-like reaction.
    • HiDAC plus etoposide results in similar response rates as HiDAC alone with a nonsignificant trend towards longer remission duration[4].
  • Mitoxantrone plus etoposide
    • Nonhematologic toxicities include stomatitis, nausea, infections, and neutropenic fever. Infrequent transient, mild cardiac failure and tachyarrhythmias have also been reported.
    • Mitoxantrone and etoposide given together for five days is a commonly used regimen to treat refractory or relapsed AML and has demonstrated complete response rates of approximately 40 percent[5].
  • Mitoxantrone, etoposide, cytarabine (MEC)
    • Side effects are similar to those described for mitoxantrone plus etoposide above, but also include hepatic dysfunction.
    • MEC demonstrates a trend towards higher complete response rates for patients <60 years old and those with unfavorable risk cytogenetics when compared with mitoxantrone plus etoposide alone[6].
  • Gemtuzumab ozogamicin (GO) as a single agent or plus cytarabine and mitoxantrone
    • Serious adverse reactions to GO include fatal anaphylaxis, hemorrhage, teratogenicity, and hepatic injury including sinusoidal obstruction syndrome (also known as hepatic veno-occlusive disease), plus side effects similar to mitoxantrone plus cytarabine, above.
    • GO as a single agent or in combination with mitoxantrone plus cytarabine can achieve complete remission in up to 25 to 35 percent[7].
  • Fludarabine, cytarabine, plus G-CSF (FLAG)
    • Studies including older adults have reported mild nonhematologic toxicity, most commonly with mucositis.
    • FLAG has reported complete remission rates of 45 to 55 percent in patients with primary refractory or relapsing AML[8].
  • Cladribine, cytarabine, G-CSF (CLAG)
    • Nonhematologic toxicity is generally mild to moderate (grade I/II) and includes fever/infection, mucositis, nausea and vomiting, diarrhea, and alopecia.
    • CLAG results in a complete remission in approximately 50 percent of patients, with a median duration of response of 16 weeks[9].
  • Cyclophosphamide plus high-dose etoposide
    • The most common non-hematologic toxicities include fever/infection, mucositis, hepatic toxicity, and hemorrhagic cystitis.
    • Approximately 42 percent of patients with resistant AML will achieve a complete remission[10].
  • Patients with resistant or relapsed AML should be encouraged to enroll on a clinical trial. While a number of chemotherapy regimens have been used for patients with resistant or relapsed disease, none results in acceptable long term remission rates. Many of these combinations are dose-intensive and cannot easily be applied in older patients. Since these regimens have not been directly compared, a choice is primarily based upon clinical experience and patient co-morbidities. A selection of these regimens is described above. Although response rates are presented for some of these regimens, an individual’s chance of responding to a particular regimen is influenced not only by prior exposure to chemotherapy but also by other patient- and leukemia-associated factors. In theory, the preferred regimen to treat relapsed AML would exclude agents at dose levels which the patient has been exposed to recently.

Cytarabine — 2023-04-12 - https://www.uptodate.com/contents/cytarabine-conventional-drug-information

  • Dosing: Adult - Note: Antiemetics may be recommended to prevent nausea and vomiting; IV doses >1,000 mg/m2 are associated with a moderate emetic potential. Consider hydration and antihyperuricemic therapy to prevent tumor lysis syndrome.
    • Acute lymphoblastic leukemia (off-label dosing):
      • Induction regimen, relapsed or refractory: IV: 3,000 mg/m2 over 3 hours daily for 5 days (in combination with idarubicin [day 3]).
      • Dose-intensive regimen: IV: 3,000 mg/m2 over 2 hours every 12 hours days 2 and 3 (4 doses/cycle) of even numbered cycles (in combination with methotrexate; alternates with Hyper-CVAD).
      • CALGB 8811 regimen:
        • Early-intensification phase: SUBQ: 75 mg/m2/dose days 1 to 4 and 8 to 11 (4-week cycle; repeat once).
        • Late-intensification phase: SUBQ: 75 mg/m2/dose days 29 to 32 and 36 to 39.
      • Linker protocol: Adults <50 years of age: IV: 300 mg/m2/day days 1, 4, 8, and 11 of even numbered consolidation cycles (in combination with teniposide).
      • CALGB 10403 regimen (as part of multi-agent, multicourse chemotherapy; refer to protocol for further details):
        • Adults <40 years of age:
          • Remission consolidation phase (course 2): IV, SUBQ: 75 mg/m2 on days 1 to 4, 8 to 11, 29 to 32, and 36 to 39.
          • Delayed intensification phase (course 4): IV, SUBQ: 75 mg/m2 on days 29 to 32 and 36 to 39.
    • Acute myeloid leukemia remission induction
      • Standard-dose; in combination with other chemotherapy agents): IV: 100 mg/m2/day continuous infusion for 7 days or 200 mg/m2/day continuous infusion (as 100 mg/m2 over 12 hours every 12 hours) for 7 days.
      • 7 + 3 regimens (a second induction course may be administered if needed; refer to specific references): IV: 100 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin or idarubicin or mitoxantrone) or (Adults <60 years) 200 mg/m2/day continuous infusion for 7 days (in combination with daunorubicin).
      • Low-intensity therapy (off-label dosing):
        • Adults >=65 years of age: SUBQ: 20 mg/m2/day for 14 days out of every 28-day cycle for at least 4 cycles or 10 mg/m2 every 12 hours for 21 days; if complete response not achieved, may repeat a second course after 15 days.
        • Adults >=60 years of age (and ineligible for intensive chemotherapy): SUBQ : 20 mg/m2 once daily on days 1 to 10 every 28 days (in combination with venetoclax) until disease progression or unacceptable toxicity.
        • Adults >=55 years of age (and unsuitable for intensive therapy): SUBQ : 20 mg (flat dose) twice daily on days 1 to 10 every 28 days (in combination with glasdegib) until disease progression or unacceptable toxicity.
    • Acute myeloid leukemia consolidation (off-label use):
      • 5 + 2 regimens: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin or idarubicin or mitoxantrone).
      • 5 + 2 + 5 regimen: IV: 100 mg/m2/day continuous infusion for 5 days (in combination with daunorubicin and etoposide).
      • Single-agent: Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours on days 1, 3, and 5 (total of 6 doses); repeat every 28 to 35 days for 4 courses.
    • Acute myeloid leukemia salvage treatment (off-label use):
      • CLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine and G-CSF); may repeat once if needed.
      • CLAG-M regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with cladribine, G-CSF, and mitoxantrone); may repeat once if needed.
      • FLAG regimen: IV: 2,000 mg/m2/day over 4 hours for 5 days (in combination with fludarabine and G-CSF); may repeat once if needed.
      • GCLAC regimen: Adults 18 to 70 years:
        • Induction: IV: 2,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine); may repeat induction once if needed.
        • Consolidation: IV: 1,000 mg/m2 over 2 hours once daily for 5 days (in combination with clofarabine and filgrastim; administer 4 hours after initiation of clofarabine) for 1 or 2 cycles.
      • HiDAC (high-dose cytarabine) ± an anthracycline: IV: 3,000 mg/m2 over 1 hour every 12 hours for 6 days (total of 12 doses).
      • MEC regimen: IV: 1,000 mg/m2/day over 6 hours for 6 days (in combination with mitoxantrone and etoposide) or
        • Adults <60 years of age: IV: 500 mg/m2/day continuous infusion days 1, 2, and 3 and days 8, 9, and 10 (in combination with mitoxantrone and etoposide); may administer a second course if needed.
    • Acute promyelocytic leukemia induction (off-label dosing): IV: 200 mg/m2/day continuous infusion for 7 days beginning on day 3 of treatment (in combination with tretinoin and daunorubicin).
    • Acute promyelocytic leukemia consolidation (off-label use):
      • In combination with idarubicin and tretinoin: High-risk patients (WBC >=10,000/mm3): Adults <=60 years of age:
        • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
        • Third consolidation course: IV: 150 mg/m2 every 8 hours for 4 days.
      • In combination with idarubicin, tretinoin, and thioguanine: High-risk patients (WBC >10,000/mm3): Adults <=61 years of age:
        • First consolidation course: IV: 1,000 mg/m2/day for 4 days.
        • Third consolidation course: IV: 150 mg/m2 every 8 hours for 5 days.
      • In combination with daunorubicin:
        • First consolidation course: IV: 200 mg/m2/day for 7 days.
        • Second consolidation course:
          • Age <=60 years and low risk (WBC <10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
          • Age <50 years and high risk (WBC >=10,000/mm3): IV: 2,000 mg/m2 every 12 hours for 5 days (10 doses).
          • Age 50 to 60 years and high risk (WBC >=10,000/mm3): IV: 1,500 mg/m2 every 12 hours for 5 days (10 doses).
          • Age >60 years and high risk (WBC >=10,000/mm3): IV: 1,000 mg/m2 every 12 hours for 4 days (8 doses).
    • Chronic lymphocytic leukemia (off-label use): OFAR regimen: IV: 1,000 mg/m2/dose over 2 hours days 2 and 3 every 4 weeks for up to 6 cycles (in combination with oxaliplatin, fludarabine, and rituximab).
    • Hodgkin lymphoma, relapsed or refractory (off-label use):
      • DHAP regimen: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) for 2 cycles (in combination with dexamethasone and cisplatin).
      • ESHAP regimen: IV: 2,000 mg/m2 day 5 (in combination with etoposide, methylprednisolone, and cisplatin) every 3 to 4 weeks for 3 or 6 cycles.
      • Mini-BEAM regimen: IV: 100 mg/m2 every 12 hours days 2 to 5 (total of 8 doses) every 4 to 6 weeks (in combination with carmustine, etoposide, and melphalan).
      • BEAM regimen (transplant preparative regimen): IV: 200 mg/m2 twice daily for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
    • Non-Hodgkin lymphomas (off-label use):
      • BEAM regimen (transplant-preparative regimen): IV: 200 mg/m2 twice daily for 3 days beginning 4 days prior to transplant (in combination with carmustine, etoposide, and melphalan) or 100 mg/m2 over 1 hour every 12 hours for 4 days beginning 5 days prior to transplant (in combination with carmustine, etoposide, and melphalan).
      • Burkitt lymphoma:
        • CALGB 9251 regimen: Cycles 2, 4, and 6: IV: 150 mg/m2/day continuous infusion days 4 and 5.
        • CODOX-M/IVAC regimen:
          • Adults <=60 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
          • Adults <=65 years of age: Cycles 2 and 4 (IVAC): IV: 2,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
          • Adults >65 years of age: Cycles 2 and 4 (IVAC): IV: 1,000 mg/m2 over 3 hours every 12 hours days 1 and 2 (total of 4 doses/cycle) (IVAC is combination with ifosfamide, mesna, and etoposide; IVAC alternates with CODOX-M).
        • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
          • Adults <60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) plus rituximab (in cycles 1 to 4) and CNS prophylaxis.
          • Adults >=60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 2 and 3 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate and leucovorin) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) with rituximab (in cycles 1 to 4) and CNS prophylaxis.
      • Mantle cell lymphoma:
        • R-DHAP regimen: Adults <=65 years of age: IV: 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle) every 3 weeks (in combination with rituximab plus dexamethasone and cisplatin) for 4 cycles or 2,000 mg/m2 every 12 hours on day 2 (total of 2 doses/cycle; in combination with rituximab plus dexamethasone and cisplatin) alternating with R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) for 6 cycles (3 cycles each of R-CHOP and R-DHAP).
        • RBAC regimen: IV: 500 to 800 mg/m2 over 2 hours (starting 2 hours after bendamustine) on days 2 through 4 every 28 days for up to 6 cycles (in combination with rituximab and bendamustine).
        • Nordic regimen:
          • Adults <=60 years of age: IV: 3,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP (dose-intensified CHOP) for 3 cycles (total of 5 cycles).
          • Adults >60 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours for a total of 4 doses (in combination with rituximab) for 2 cycles alternating with Maxi-CHOP for 3 cycles (total of 5 cycles).
        • Hyper-CVAD alternating with high-dose methotrexate/cytarabine regimen:
          • Adults <=60 years of age: Cycles 2, 4, 6, and 8: IV: 3,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab), alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
          • Adults >60 years of age: Cycles 2, 4, 6, and 8: IV: 1,000 mg/m2 every 12 hours days 3 and 4 (total of 4 doses/cycle) of a 21-day cycle (in combination with methotrexate, leucovorin, and rituximab) alternating with Hyper-CVAD administered on odd-numbered cycles (cyclophosphamide, vincristine, doxorubicin, dexamethasone, and rituximab).
      • Relapsed or refractory non-Hodgkin lymphomas:
        • DHAP regimen:
          • Adults <=70 years of age: IV: 2,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
          • Adults >70 years of age: IV: 1,000 mg/m2 over 3 hours every 12 hours day 2 (total of 2 doses/cycle) every 3 to 4 weeks for 6 to 10 cycles (in combination with dexamethasone and cisplatin).
        • ESHAP regimen: IV: 2,000 mg/m2 over 2 hours day 5 every 3 to 4 weeks for 6 to 8 cycles (in combination with etoposide, methylprednisolone, and cisplatin).
    • Primary CNS lymphoma (off-label use): IV: 2,000 mg/m2 over 1 hour every 12 hours days 2 and 3 (total of 4 doses) every 3 weeks (in combination with methotrexate and followed by whole brain irradiation) for a total of 4 courses or 3,000 mg/m2 (maximum dose of 6,000 mg) over 3 hours on days 1 and 2 every 4 weeks for 2 cycles (administer cytarabine after 5 to 7 cycles of the induction R-MPV regimen [rituximab, methotrexate, leucovorin, vincristine, and procarbazine] and whole brain radiation therapy) or 2,000 mg/m2 over 2 hours every 12 hours days 1 to 4 (total of 8 doses) as consolidation therapy (in combination with etoposide); cytarabine/etoposide is administered following remission induction with methotrexate, leucovorin, temozolomide, and rituximab.
    • Meningeal leukemia: Intrathecal therapy: Note: Optimal intrathecal chemotherapy dosing should be based on age rather than on body surface area (BSA); CSF volume correlates with age and not to BSA. Dosing provided in the manufacturer’s labeling is BSA-based.
    • Off-label uses or doses for intrathecal therapy:
      • CNS prophylaxis (ALL): Intrathecal: 100 mg weekly for 8 doses, then every 2 weeks for 8 doses, then monthly for 6 doses (high-risk patients) or 100 mg on day 7 or 8 with each chemotherapy cycle for 4 doses (low risk patients) or 16 doses (high-risk patients) or 70 mg on day 1 of remission induction cycle 1 (adults <40 years of age).
        • or as part of intrathecal triple therapy (TIT): Intrathecal: 40 mg days 0 and 14 during induction, days 1, 4, 8, and 11 during CNS therapy phase, every 18 weeks during intensification and maintenance phases.
      • CNS prophylaxis (APL, as part of TIT): Intrathecal: 50 mg per dose; administer 1 dose prior to consolidation and 2 doses during each of 2 consolidation phases (total of 5 doses).
      • CNS prophylaxis (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1 and 3 of cycles 1 and 3 (CODOX-M cycle).
      • CNS prophylaxis (Burkitt lymphoma; component of Hyper-CVAD alternating with cytarabine/methotrexate regimen): Intrathecal: 100 mg on day 7 of each 21-day treatment cycle.
      • CNS leukemia treatment (ALL, as part of TIT): Intrathecal: 40 mg twice weekly until CSF cleared.
      • CNS lymphoma treatment: Intrathecal: 50 mg twice a week for 4 weeks, then weekly for 4 to 8 weeks, then every other week for 4 weeks, then every 4 weeks for 4 doses.
      • CNS treatment (Burkitt lymphoma; component of CODOX-M/IVAC regimen): Intrathecal: 70 mg on days 1, 3, and 5 of cycles 1 and 3 (CODOX-M cycle) and 70 mg on days 7 and 9 of cycles 2 and 4 (IVAC cycle).
      • Leptomeningeal metastases treatment: Intrathecal: 25 to 100 mg twice weekly for 4 weeks, then once weekly for 4 weeks, then a maintenance regimen of once a month or 40 to 60 mg per dose.
    • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance.

FLAG-IDA for acute myeloid leukemia — 2023-07-04 - https://aml-hub.com/medical-information/flag-ida-for-acute-myeloid-leukemia

FLAG-Ida for Acute Myeloid Leukaemia (AML) — 2023-07-04 - https://media.leukaemiacare.org.uk/wp-content/uploads/FLAG-Ida-for-Acute-Myeloid-Leukaemia-AML-Web-Version.pdf

FLAG (fludarabine + high-dose cytarabine + G-CSF): an effective and tolerable protocol for the treatment of ‘poor risk’ acute myeloid leukemias — https://pubmed.ncbi.nlm.nih.gov/7526088/

  • Twenty-eight patients with poor prognosis acute myeloid leukemia (AML) received therapy with two courses of fludarabine 30 mg/m2/day + ara-C 2 g/m2/day (days 1-5) and G-CSF 5 mg/kg/day (FLAG) (from day 0 to polymorphonuclear recovery).

==========

2023-08-31

[Posanol (posaconazole) initial dose may be insufficient]

For prophylactic treatment against invasive fungal infections, the package insert recommends administering Posanol (posaconazole) at a dose of 300 mg twice on the first day, followed by 300 mg daily thereafter.

Failing to administer the medication twice on the initial day could potentially compromise or delay its intended effects.

2023-08-01

[pancytopenia]

Rydapt (midostaurin 25 mg) 2# PO Q12H has been initiated since 2023-07-28. The package insert recommends taking the medication with food. Please ensure that the patient takes the medication with food Q12H.

The following adverse drug reactions and incidences are associated with midostaurin:

  • Hematologic and oncologic:
    • Anemia (60%; grade >=3: 38%)
    • Leukopenia (61%; grade >=3: 19%)
    • Lymphocytopenia (66%; grade >=3: 42%)
    • Neutropenia (49%; grade >=3: 22%)
    • Thrombocytopenia (50%; grade >=3: 27%)
  • Hepatic:
    • Hyperbilirubinemia (29%)
    • Increased gamma-glutamyl transferase (35%)
    • Increased serum alanine aminotransferase (31%)
    • Increased serum alkaline phosphatase (39%)
    • Increased serum aspartate aminotransferase (32%)

Since pancytopenia had already developed before this drug administration, it would be difficult to distinguish to what extent the subsequent pancytopenia would gradually be attributed to midostaurin (if any).

2023-07-27

[pancytopenia]

Both fludarabine and cytarabine, which are components of the FLAG regimen, are known to cause bone marrow suppression, especially fludarabine.

The patient received two cycles of the FLAG regimen, one on 2023-06-21 and the other on 2023-07-19. The first cycle resulted in a 5-day period (2023-06-28 to 2023-07-02) of WBC < 1K/uL, and the second cycle resulted in WBC < 1K/uL since 2023-07-24, which has not yet returned to levels above 1K/uL. Thrombocytopenia was previously mentioned in the pharmacist’s note. The HGB levels show a similar trend to the PLT levels. In addition, the patient has received several blood transfusions this year on different dates (2023-01-02, 2023-01-06, 2023-01-11, 2023-01-18, 2023-01-22, 2023-01-26, 2023-01-28, 2023-01-30, 2023-02-03, 2023-03-03, 2023-03-07, 2023-03-11, 2023-03-17, 2023-04-14, 2023-04-18, 2023-04-22, 2023-04-26, 2023-04-30, 2023-06-19, 2023-06-28, 2023-07-17, 2023-07-21, 2023-07-25) and also received G-CSF in the first quarter of this year.

2023-07-07

The FLAG regimen was initiated on 2023-06-21. However, the current thrombocytopenia event had started even before the regimen was administered. Visually estimating the platelet count before and after the FLAG administration, the values were approximately within the range of 50 +- 25 K/uL, and there was no clear downward trend. This is because the patient had received multiple transfusions to maintain PLT a certain level.

2023-07-06 PLT 55 x10^3/uL
2023-07-04 PLT 25 x10^3/uL
2023-07-02 PLT 48 x10^3/uL
2023-06-30 PLT 23 x10^3/uL
2023-06-28 PLT 62 x10^3/uL Blood Transfution
2023-06-26 PLT 37 x10^3/uL
2023-06-25 PLT 47 x10^3/uL
2023-06-24 PLT 73 x10^3/uL
2023-06-23 PLT 28 x10^3/uL Blood Transfution 2023-06-22 PLT 40 x10^3/uL
2023-06-21 PLT 54 x10^3/uL FLAG 2023-06-20 PLT 47 x10^3/uL
2023-06-19 PLT 19 x10^3/uL Blood Transfution 2023-06-08 PLT 70 x10^3/uL
2023-05-04 PLT 247 x10^3/uL
2023-05-02 PLT 176 x10^3/uL
2023-05-01 PLT 137 x10^3/uL Blood Transfution (2023-04-30)

The risk of bleeding generally increases with platelet counts below 40 to 50 K/uL, but there isn’t a strong linear correlation between platelet count and bleeding risk. If major or life-threatening bleeding occurs, platelet transfusions should be administered without delay.

2023-07-04

[FLT3 inhibitors]

  • Laboratory data from 2023-01-12 and 2023-06-28 indicated the presence of FLT3/ITD mutation.

  • There are two FDA approved FLT3 inhibitors for AML included in the National Health Insurance Medication Reimbursement Regulations, namely:

    • Midostaurin (such as Rydapt)
      • This is reserved for use in combination with standard induction and consolidation chemotherapy in adult patients newly diagnosed with FLT3 mutation positive AML.
      • Patients with acute promyelocytic leukemia (APL) must be excluded.
      • For first-time use during the standard induction period, pre-examination is not required, and it is limited to two courses. If complete remission is not achieved after two courses, further use is prohibited.
      • For continuous use, it must be approved after pre-examination. Applications must include the results and date of the FLT3 mutation positive test, the record of chemotherapy prescription, and the evaluation of treatment effect. Each renewal application is limited to two courses and must include the evaluation results from the previous treatment to confirm no disease progression. The total treatment courses are capped at six per patient.
      • If a patient undergoes hematopoietic stem cell transplantation, this drug will no longer be covered.
    • Gilteritinib (such as Xospata)
      • This is restricted to use in adult patients with FLT3-mutated relapsed or refractory acute myeloid leukemia (R/R AML) who are planning to undergo hematopoietic stem cell transplantation. It is limited to use before transplantation, with a maximum of six treatment courses per patient. Patients must have received at least one chemotherapy course including an anthracycline drug.
  • Currently, Rydapt is a temporarily procured drug at our hospital, and Xospata does not have a built drug code yet. If any of these two drugs is considered further use, a temporary procurement procedure must be carried out.

2023-04-19

[neutropenia follow-up]

  • The patient received daunorubicin for a 3-day course and cytarabine for a 5-day course at a dosage of 2000mg/m2 with 4000mg every 12 hours, on 2023-04-07. The patient’s WBC count dropped below 1000/uL beginning on 2023-04-14. As a result, lenograstim at 250ug and filgrastim at 150ug have been given daily from that date onwards. However, the patient’s WBC count has not yet returned to normal levels at this time.
    • 2023-04-18 WBC 0.10 x10^3/uL
    • 2023-04-16 WBC 0.15 x10^3/uL
    • 2023-04-14 WBC 0.56 x10^3/uL
    • 2023-04-12 WBC 1.51 x10^3/uL
  • The patient is in good spirits and has no chills. His diet and sleep are satisfactory, and his diarrhea symptoms have improved as of the morning of 2023-04-19.
  • Please remain vigilant for any signs of infection.

2023-04-12

[leukopenia]

  • On 2023-01-09, the patient started a regimen containing anthracycline and cytarabine (idarubicin for 3 days + cytarabine for 7 days), which led to more than 2 weeks of leucopenia with a WBC count of less than 1000/uL. More than 5 weeks later, on 2023-02-23, the second dose was shifted to daunorubicin for 3 days and cytarabine for 7 days. This time, the duration of WBC less than 1000/uL was approximately halved to 1 week. Although the patient was administered G-CSF (filgrastim 150ug) and Granocyte (lenograstim 250ug) on 2023-03-03, WBC count did not appear to increase soon after.

  • On 2023-04-07, the patient received daunorubicin for 3 days and cytarabine for 5 days at a more intensive dose of 2000mg/m2 amounting to 4000mg every 12 hours. After the administration, the WBC count has not dropped below 1000/uL and there has been a reduction in the severity of leukopenia to date.

  • WBC lab data

    • 2023-04-12 WBC 1.51 x10^3/uL
    • 2023-04-10 WBC 4.54 x10^3/uL
    • 2023-04-06 WBC 13.52 x10^3/uL
    • 2023-03-24 WBC 6.18 x10^3/uL
    • 2023-03-17 WBC 7.11 x10^3/uL
    • 2023-03-15 WBC 8.61 x10^3/uL
    • 2023-03-13 WBC 1.41 x10^3/uL
    • 2023-03-11 WBC 0.49 x10^3/uL
    • 2023-03-09 WBC 0.54 x10^3/uL
    • 2023-03-07 WBC 0.48 x10^3/uL
    • 2023-03-05 WBC 0.83 x10^3/uL
    • 2023-03-03 WBC 0.73 x10^3/uL
    • 2023-03-01 WBC 1.58 x10^3/uL
    • 2023-02-27 WBC 2.56 x10^3/uL
    • 2023-02-23 WBC 5.71 x10^3/uL
    • 2023-02-20 WBC 8.15 x10^3/uL
    • 2023-02-08 WBC 6.31 x10^3/uL
    • 2023-02-03 WBC 13.64 x10^3/uL
    • 2023-02-01 WBC 18.52 x10^3/uL
    • 2023-01-30 WBC 3.21 x10^3/uL
    • 2023-01-28 WBC 1.06 x10^3/uL
    • 2023-01-26 WBC 0.56 x10^3/uL
    • 2023-01-24 WBC 0.66 x10^3/uL
    • 2023-01-22 WBC 0.34 x10^3/uL
    • 2023-01-20 WBC 0.24 x10^3/uL
    • 2023-01-18 WBC 0.28 x10^3/uL
    • 2023-01-16 WBC 0.63 x10^3/uL
    • 2023-01-14 WBC 0.44 x10^3/uL
    • 2023-01-13 WBC 1.02 x10^3/uL
    • 2023-01-11 WBC 43.50 x10^3/uL
    • 2023-01-10 WBC 83.37 x10^3/uL
    • 2023-01-09 WBC 89.32 x10^3/uL
    • 2023-01-08 WBC 90.19 x10^3/uL
    • 2023-01-06 WBC 90.16 x10^3/uL
    • 2023-01-04 WBC 93.88 x10^3/uL
    • 2023-01-02 WBC 163.72 x10^3/uL

2023-01-13

  • There was neutropenia of grade 2 (2023-01-13 1.02K/uL) as well as suspected tumolysis syndrome (2023-01-11 P 7.3mg/dL, Ca 2.0mmol/L, uric acid 8.3mg/dL) in this patient. please consider whether G-CSF is necessary in the next few days.
  • Rolikan (sodium bicarbonate) has been prescribed since 2023-01-13. The role of urinary alkalinization with either acetazolamide and/or sodium bicarbonate is unclear and controversial. In the past, alkalinization to a urine pH of 6.5 to 7 or even higher was recommended to increase uric acid solubility, thereby diminishing the likelihood of uric acid precipitation in the tubules. However, this approach has fallen out of favor for the following reasons: 1. There are no data demonstrating the efficacy of this approach. In addition, the only available experimental study suggested that hydration with saline alone is as effective as alkalinization in minimizing uric acid precipitation.; 2. Alkalinization of the urine has the potential disadvantage of promoting calcium phosphate deposition in the kidney, heart, and other organs in patients who develop marked hyperphosphatemia once tumor breakdown begins. (ref: https://www.uptodate.com/contents/tumor-lysis-syndrome-prevention-and-treatment).
  • Febuxostat is administered to this patient currently. The level of uric acid has decreased to 3.8 mg/dL as of 2023-01-13.

700295999

231103

[exam findings]

  • 2023-08-21 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Ovary, left, debulking surgery — Mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor), and Ovarian abscess
      • Ovary, right, debulking surgery — Mixed carcinoma, and Ovarian abscess
      • Fallopian tube, bilateral, debulking surgery — Negative for malignancy
      • Cervix, debulking surgery — Endocervical polyp
      • Endometrium, debulking surgery — Negative for malignancy
      • Myometrium, debulking surgery — Adenomyosis, and multiple leiomyomas
      • Serosa, debulking surgery — Serous carcinoma seeding (revise)
      • Appendix, debulking surgery — Serous carcinoma seeding
      • Omentum, debulking surgery — Negative for malignancy
      • Lymph node, left iliac, dissection — Negative for malignancy
      • Lymph node, left obturator, dissection — Negative for malignancy
      • Lymph node, right iliac, dissection — Negative for malignancy
      • Lymph node, right obturator, dissection — Metastatic carcinoma
      • Lymph node, left paraaortic, dissection — Negative for malignancy
      • Lymph node, right paraaortic, dissection — Negative for malignancy
      • AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
    • Gross description:
      • Procedure (select all that apply)
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy + appendectomy)
        • Specimen size:
          • Left ovary: 10x 8 x 6 cm in size, 220 gm in weight
          • Right ovary: 10x 9 x 5 cm in size, 240 gm in weight
          • Uterus: 9x 7.5 x 4.5 cm cm in size, 120 gm in weight
          • Appendix: 5.5 cm in length and 0.4 cm in greatest diameter
          • Omentum: 42x 14x 2 cm in size
          • Note: For information about lymph node sampling, please refer to the Regional Lymph Node section.
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.
        • Specimen Integrity of Right Ovary (if applicable): ruptured
        • Specimen Integrity of Left Ovary (if applicable): ruptured
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site:
        • Note: Please select the primary tumor site only
        • Bilateral ovaries
      • Ovarian Surface Involvement (required only if applicable)
        • Present (Left)
      • Fallopian Tube Surface Involvement (required only if applicable)
        • Absent
      • Tumor Size
        • Note: For bilateral tumors, please report maximum dimension for each primary tumor, specifying by laterality.
        • Greatest dimension (centimeters), left side: 8 cm
          • Additional dimensions (centimeters): 6 x 5 cm
        • Greatest dimension (centimeters), right side: 8 cm
          • Additional dimensions (centimeters): 7 x 4 cm
      • Sections are taken and labeled as:A1:left iliac, A2:left obturator, A3:right iliac, A4-5:right obturator, A6:left paraaortic, A7:right paraaortic, A8:CX, A9:right adnexae, A10-12:corpus and myomas, A13-16:left ovarian tumor, A17-19:right ovarian tumor, A20:serosa, A21:appendix, A22:omentum
    • Microscopic Description:
      • Histologic Type:
        • Mixed carcinoma (composed of 70% of low-grade serous carcinoma component and 30% of Malignant Brenner tumor component)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System: Not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Note: Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.
        • Present (specify sites): appendix and serosa
      • Other Tissue/ Organ Involvement (select all that apply):
        • Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable)
        • Microscopic
      • Peritoneal/Ascitic Fluid
        • Malignant (positive for malignancy); N2023-03213
      • Regional Lymph Nodes:
        • Lymph node, left iliac: Negative for metastasis ( 0 / 3 )
        • Lymph node, left obturator: Negative for metastasis ( 0 / 7 )
        • Lymph node, right iliac: Negative for metastasis ( 0 / 3 )
        • Lymph node, right obturator: Positive for Metastasis (1/ 12)
        • Lymph node, left paraaortic, dissection— Negative for metastasis ( 0 / 5 )
        • Lymph node, right paraaortic, dissection— Negative for metastasis ( 0 / 7 )
      • Additional Pathologic Findings
        • Adenomyosis
        • Intramural, submucosal and subserosal leiomyomas
        • Endocervical polyp
      • Immunostains - Napsin A (-), WT-1 (focal+), p53 wild-type, p16 (-), GATA3 (+), CK20 (-), vimentin (focal+).
  • 2023-08-21 Body fluid cytology - ascites
    • Malignancy - positive for malignancy present;
    • GROSS DESCRIPTION: 40 ml turbid
    • MICROSCOPIC DESCRIPTION: few clusters of adenocarcinoma, many red blood cells, lymphocytes and mesothelial cells present.
  • 2023-08-17 CT, CTA - chest
    • Indication: advance ovary cancer
    • Chest CT with and without IV contrast ehnancement shows:
      • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
      • Suggest clinical correlation
    • Imp:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Some fluid accumulation at abdominal cavity is found. Dirty appearance of the mesentery is also noted. Suggest correlate with tumor marker.
  • 2023-08-15 SONO - abdomen
    • Diagnosis:
      • Hepatic cyst
      • Renal cyst, right
      • Renal lesion, left, rule out angiomyolipoma, rule out renal stone
    • Suggestion:
      • Please correlate with other image study
  • 2023-08-14 Gynecologic Ultrasonography
    • Findings
      • Uterus Position : AVF
        • Size: 80 * 49 mm
      • Endometrium:
        • Thickness: 7.3 mm
      • Adnexae:
        • ROV: Mass: 117 * 75 mm
        • LOV: Mass: 96 * 74 mm
      • CUL-DE-SAC: No fluid
    • IMP:
      • R/O Bilateral Ovarian mass
  • 2023-07-03 Patho - soft tissue tumor, extensive resection (Y1)
    • DIAGNOSIS:
      • Tissue, labeled as “epiploic appendages”, LSC biopsy — Invasive carcinoma
      • NOTE: The differential diagnosis includes serous carcinoma, endometrioid carcinoma,and etc.
    • Microscopically, it shows nests of invasive carcinoma with psammoma bodies, stromal fibrosis and mixed inflammatory infiltrate.
    • Immunohistochemical stain reveals CK (+), p53: wild-type (focal patchy+, < 10%), WT-1 (focal+), PAX8 (-), calretinin (-).
    • ADDENDUM: IHC stain — CK7 (+), CK20 (-), GATA3 (focal+), Napsin A (-), ER (focal weak+). Correlation with image and clinical findings is advised.
  • 2023-06-24 CT - abdomen
    • Clinical history: 57 y/o female patient with watery discharge noted for a year, pinkish discharge today, received chinese medicine, covid (+) last May.
    • With and without contrast enhancement CT of abdomen–whole:
      • There are heteregeneous tumors in bilateral adnexa(4.6cm in right adnexa and 5.2cm in left adnexa), r/o malignancy.
      • Uterine tumor, 2.4cm, r/o uterine myoma.
      • Cystic tumor, 3.1x1.6cm in right subhepatic region, r/o peritoneal seeding.
      • Small left renal cysts.
      • There are small aortocaval region lymph nodes.
      • Minimal ascites.
      • There are small peritoneal nodules, r/o carcinomatosis.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3c(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIIc__(Stage_value)
    • Impression:
      • Bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0.
      • Small aortocaval region lymph nodes.
  • 2023-04-26 Clinical Dementia Rating
    • CDR score: 0.5
  • 2023-04-26 Mini-Mental State Examination
    • MMSE score: 28
  • 2023-02-22 CT - brain
    • No evidence of intracranial lesion.
  • 2023-01-09 Mammography
    • BI-RADS category 1, Negative.
  • 2023-08-14 Gynecologic Ultrasonography
    • Uterine myoma

[MedRec]

  • 2023-08-31 Psychosomatic Medicine Chen WenJiang
    • Prescription x3 (doubling of doses to date since 2022-08-15)
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Valdoxan (agomelatine 25mg) 0.5# HS
  • 2023-08-11 ~ 2023-08-29 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Ovarain cancer -> mixed carcinoma (composed of 70% of low-grade serous carcinoma and 30% of Malignant Brenner tumor) AJCC 8th edition pathology stage: pT3aN1a (if cM0); FIGO stage IIIA1i; Prognostic stage IIIA2
      • Bilateral tubo-ovarian abscess
      • Abdominal pain
    • CC
      • for fever and abdominal pain since 8/11
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
      • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey. She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07. C1 neoadjuvant Taxel + Carbo on 2023/07/24.
      • This time, she has fever and abdominal distention with tenderness, so she was brought to our ED for help on 2023/8/11. There were no nausea/vomiting, no cough,no dysuria, no abdominal pain, no diarrhea, but vegina discharge got more.
      • At ER, vital signs: BP:132/61mmHg, PR:123bpm, BT:39’C, RR:20/min, Con’s:E4V5M6, SpO2:94%. Lab revealed WBC 8970/uL, with neutrophil predominant: 73%. CRP:13.7mg/dL, HGB = 9.4 g/dL.
      • Under the impression of Malignant neoplasm of unspecified ovary, the patient was admitted to our hema ward for further evaluation and treatment.
      • CA125                       
        • 2023-06-23 4621.9 U/mL                
        • 2023-08-07 7804.2 U/ml        
    • Course of inpatient treatment
      • The patient was admitted the hematology and oncology ward. Consultation GYN arrange sonography show right ovarian mass 117x75 mm side. The tumor marker CA125 4621.9 -> 8/7 7804.2 (U/mL), D-dimer > 10000, with Clexan 60 mg Q12H.
      • She and underwent GYN cancer debulking surgery (Abdominal Total Hysterectomy + bil salpingo-oophoretom + BPLND+ infracolic omentectomy + appendectomy) on 08/21/2023. Her postoperative course was uneventful. Her Eating and urination by self voiding was smooth. The vital sign was stable after surgery. JP drain was removed then on 08/25 and 08/28 morning. The Gyn tumor conference was arranged thursday.
      • She is discharged on 008/29/2023 pm and her followup appointment is scheduled on next week.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Bokey (aspirin 100mg) 1# QD
      • Acetal (acetaminophen 500mg) 1# Q4H
      • Through (sennoside 12mg) 2# HS
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • cephalexin 500mg 1# QID
  • 2023-07-23 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725
    • CC
      • for first chemotherapy
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness. Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side. The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23. The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
      • She underwent exploratory laparoscopy for biopsy on 2023/07/03, the pathology showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6. Port-A insertion on 2023/07/07.
      • This time, she was admitted for first chemotherapy on 2023/7/23.
    • Course of inpatient treatment
      • After admission, she received dexamethasone 5# q6h on 7/24 2300 and 7/25 0500.
      • Baraclude 0.5mg/tab 1# qdac for postive of anti-HBc.
      • C1 Taxel + Carboplatin on 2023/7/25.
      • Primepram 1# tidac for prevent vomit.
      • Under the stable condition, she can be discharged on 2023/7/26. OPD follow up is arranged.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Through (sennoside 12mg) 2# HS
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNTID
      • Emend (aprepitant 125mg) 1# PRNQDAC
  • 2023-07-02 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Bilateral ovarian cancer (for pelvic tissue biopsy report ) post Laparoscopic tumor biopsy on 2023/07/03
      • Abdominal pain
      • Myoma uteri
    • CC
      • Lower abdominal fullness for 2 months
    • Present illness
      • This 57 years old female with history of asthma and anxiety under medication control. She was menopaused at 51 years old. She had previous followed up at our GYN OPD for urine incontinence and vaginal itchness.
      • Since May 2023, lower abdominal fullness and FLANK SORENESS WAS noted and she came to our GYN OPD on 2023/05/18, the GYN echogram revealed left ovarian mass 2.5x2.2cm and mild adenomyosis. Intermittent right lower abdominal pain WAS also occurred. She went to GI OPD for help and symptomatic treatment given. The colonscopy arranged. Pink vaginal discharge noted on 06/21 and the vaginal sonography found bilateral ovarian mass, 5.5x4cm at right side and 5x3.1cm at left side.
      • The abdominal CT on 06/26 revealed bilateral ovarian tumors with peritoneal tumors, r/o ovarian malignancy with carcinomatosis, cstage T3cN0M0. The tumor marker CEA 19.87 ng/mL and CA125 4621.9 U/mL on 06/23.
      • After discussed with the patient, she was admitted for laparoscopic ovarian biopsy WILL BE arrange on 2023/07/03.
    • Course of inpatient treatment
      • The patient was admitted on 2023/07/02.The Upper G-I panendoscopy and Colon fiberoscopy were arranged for work up and tumor survey.
      • She underwent exploratory laparoscopy for biopsy on 2023/07/03. We gave her Cefazolin IV form for 2 day and then shifted her antibiotics to Cephalexin oral form.
      • Post-operation wound was dry and clean without dehiscence, discharge, or oozing. Her lab data on 2023/07/04 also showed no specific positive findings.
      • The pathology reported showed invasive carcinoma.
      • Due to high D-dimer (> 10000) with Clexan 60 mg injection on 7/5 and 7/6.
      • After GYN tumor conference on 2023/07/06 and the neo-adjuvant will be arrange. We was consulted GS/GU for port-A insertion and breast echo and cystoscopic on 2023/07/07.
      • Since all her general conditions were all improved and relatively stable, we arranged discharge on 2023/07/07 and Gyn/HemOnc OPD follow up of her recovery status and surgical wound conditions.     
    • Discharge prescription
      • Bokey (aspirin 100mg) 1# QD
      • MgO 1# QID
      • Acetal (acetaminophen 500mg) 1# QID
      • cephalexin 500mg 1# QID
  • 2022-08-15 Psychosomatic Medicine Chen WenJiang
    • Prescription x2
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Valdoxan (agomelatine 25mg) 0.5# HS
  • 2022-08-15 Chest Medicine Su WenLin
    • Prescription x2
      • Actein (acetylcysteine 600mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Symbicort Turbuhaler (budesonide, formoterol) 2 puff BID INHL
      • Trisonin Nasal Spray (triamcinolone acetonide micronized 55ug/dose, 120dose/bt) 2 puff QD

[consultation]

  • 2023-08-18 Urology
    • Q
      • For arrange insert ureteral catheter
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation. She will accept the debulking surgery + HIPEC on 08/21/2023 on call. We need your expertise to evaluate this patient. Thank you very much!
    • A
      • Due to advance pelvic tumor, DBJ may be inserted during pelvic surgery
  • 2023-08-16 Obstetrics and Gynecology
    • Q
      • The 57 y/o woman has advance of ovarian cacner /p neoadjuvant chemo as C1 Taxel + Carbo on 2023/7/24. We need your help for surgical intervention next Monday.
    • A
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to rapid tumor progression, we were consulted for evaluation.
      • ObGyn history
        • G2P2, NSD X 2
        • Menopause (+, 51y/o)
        • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
        • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
        • 2023/07/25 Paclitaxel + Carboplatin C1D1
      • Lab
        • CA125 06/23: 4621.9 -> 8/7: 7804.2 -> 8/15: 13679.2 (U/mL)
        • 2023-08-16
          • WBC 8.95K
          • Hb 8.9g/dL
          • BCS WNL
          • CRP 14.0 mg/dL
          • D-dimer > 10000
      • Impression
        • Advanced ovarian cancer with tumor progression
      • Suggestion
        • Please give LPpRBC 3U transfusion for anemia.
        • Please give Clexane for elevated D-dimer.
        • We plan to transfer her to the GYN ward on W5 08/18. Bowel prepare on W5.
        • We will arrange surgery on W1 08/21: debulking surgery with self-paid HIPEC.
  • 2023-08-16 General and Gastrointestinal Surgery
    • Q
      • The 57 y/o woman has advance of ovarian cacner. We need your help for surgical intervention tomorrow. Thanks!
    • A
      • I’ll arrange combined opeartion for her (CRS + HIPEC).
  • 2023-08-14 Obstetrics and Gynecology
    • Q
      • The 57 y/o woman has Invasive carcinoma of bilateral ovarian, c-stage T3cN0M0, cstage IIIc post 1st neoadjuvant chemotherapy on 20230725. She has fever with abdominal and vagina discharge. We need your help for management.
    • A
      • This is a 57y/o, G2P2 (NSD X 2), menopause (+, 51y/o) woman with invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc, s/p laparoscopic tumor biopsy and 1st neoadjuvant chemotherapy in 2023/07.
      • This time, she was hospitalized due to symptoms of abdominal pain. Due to increased vaginal discharge, we were consulted for evaluation.
      • CC
        • Abdominal pain and increased vaginal discharge for/since
      • ObGyn history
        • G2P2, NSD X 2
        • Menopause (+, 51y/o)
        • Invasive carcinoma of bilateral ovaries, cstage T3cN0M0, cstage IIIc
        • 2023/07/03 Exploratory laparoscopy for tumor biopsy and cell block
        • 2023/07/25 Paclitaxel + Carboplatin C1D1
      • Lab
        • CA125 06/23: 4621.9 -> 8/7: 7804.2 (U/mL)
        • 2023-08-11
          • WBC 8.97K
          • Hb 9.4g/dL
          • BCS WNL
          • CRP 13.7 mg/dL
          • U/A clear
      • PV
        • Mild amount of light yellow discharge -> s/p culture
        • No active bleeding
        • smooth cervix
      • Sono
        • Uterus: AVF, 80*49mm
        • EM: 7.3mm
        • RT mass: 117*75mm
        • LT mass: 96*74mm
        • CDS: no fluid
      • Impression
        • Advanced ovarian cancer
      • Suggestion
        • keep current neoadjuvant chemotherapy for bilateral ovarian cancer
        • please treat side effect of chemotherapy as your expertise
        • pending vaginal culture report
  • 2023-07-06 Urology
    • Q
      • For cystoscopy
      • Patient underwent Exploratory laparoscopy for biopsy on 07/03/2023. pathology report showed Invasive carcinoma. After GYN tumor conference.(cystoscopy is suggested). We need consult you for further management. Thank a lot!
    • A
      • We will arrange CUS on 2023/07/06 pm.

[chemotherapy]

  • 2023-11-03 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-10-10 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-09-18 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-07-25 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

701503831

231103

  • 2023-10-31 CXR
    • Increased infiltration in both lung fields
    • Partial atelectasis of left lung
    • s/p port A insertion
  • 2023-10-31 CT - brain
    • No definite intracranial lesion
  • 2023-10-31 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia

==========

2023-11-03

[tube feeding]

All of the oral medications on the active medication list can be administered through a feeding tube.

700787059

231101

[exam findings]

  • 2023-10-07 CT - abdomen
    • Indication: Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, hold Glimet F.C 2mg & 500mg/tab (10/5~10/7)
    • With and without contrast enhancement CT of abdomen shows:
      • Colon and rectal CA, s/p operation. Nodular lesions in RUQ, in progression.
      • A cystic lesion, 2.6cm, in liver dome.
      • Some lymph nodes in para-aortic region.
    • Impression
      • Colon and rectal CA, s/p operation
      • Peritoneal nodules in RUQ, in progression
      • Para-aortic lymph nodes
  • 2023-06-29 CT - abdomen
    • History and indication:
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I s/p CCRT and chemotherapy with FOLFOX, s/p Low AR + loop ileostomy and Right hemicolectomy and chemotherapy with FOLFOX
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon operation. Some nodules at bil. lungs.
      • A poor enhancing lesion (2.5cm) at liver dome.
      • Renal cysts (up to 3.6cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • S/P colon operation. Some nodules at bil. lungs.
      • A poor enhancing lesion (2.5cm) at liver dome.
  • 2023-06-24 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Tortous aorta with calcification is noted.
    • Faint aveolar opacity over left upper lobe is found.
    • Emphysematous change over both lungs.
  • 2023-06-21 Joint soft tissue sonography
    • Left shoulder supraspinatus calcific tendinopathy
  • 2023-06-16 Shoulder Lt
    • Normal bone alignment
    • moderate decreased left shoulder joint space
    • moderate left subacromial spur formation.
    • a nodular lesion in the left upper lung field
  • 2023-04-04, -03-21, -03-17, -03-14 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Old fracture of right clavicle shows mild angulation deformity but good union.
  • 2023-03-27 Ga-67 Whole body inflammation scan with SPECT
    • The whole-body gallium-67 inflammation scan with SPECT was performed at the 24th and 48th hour after injecting 6 mCi of Ga-67 to the patient. The images showed increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields and in both kidneys.
    • IMPRESSION:
      • Increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hilar regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. Please correlate with other clinical findings for further evaluation.
      • Mildly increased radiotracer uptake in both kidneys. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-03-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (97.3 - 25.3) / 97.3 = 74.00%
      • M-mode (Teichholz) = 74.0
    • Conclusion:
      • Thickened AV with no AR
      • Thickened MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Normal LV wall motion
      • No PR, trivial TR, normal IVC size
  • 2023-03-11 CTA - chest
    • Findings
      • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
      • S/P operation. Minimal ascites.
      • Renal cysts (up to 3.6cm).
      • S/P Port-A infusion catheter insertion.
    • IMP
      • Bil. pleural effusion with adjacent lung collapse. Ground glass opacities at bil. lungs.
  • 2023-03-11 ECG
    • Sinus tachycardia
    • Left bundle branch block
  • 2023-03-10 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-02-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, ascending colon, R’t hemicolectomy (s/p CCRT) — Mucinous adenocarcinoma
      • Resection margins, bilateral, ditto — Free of tumor invasion
      • Lymph node, mesocolic, dissection — Free of tumor metastasis (0/18)
      • Appendix — Free of tumor invasion
      • AJCC pathologic stage — ypT3N0, if cM0, stage IIA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: R’t hemicolectomy
      • Specimen site: Ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 27.7 cm in length, up to 8.4 cm in circumference, (b) Terminal ileum: 2.3 cm in length, 2.3 cm in diameter and (c) Appendix: 2.2 cm in length, 0.7 cm in diameter
      • Tumor size: 4.7 x 3.8 cm
      • Tumor location: ascending colon, 14.8 and 9 cm away from bilateral resection margins
      • Tumor appearance: protruding mass
      • Depth of invasion grossly: pericolonic fat
      • Representative sections as follows: A1: ileum + colonic resection margin, A2: appendix, A3-A6: tumor, A7-A10: lymph nodes
    • MICROSCOPIC EXAMINATION
      • Histology: mucinous adenocarcinoma
      • Histology Grade: G2, moderately differentiated
      • Depth of invasion: pericolonic fat
      • Angiolymphatic invasion: not identified
      • Perineural invasion: not identified
      • Discontinuous extramural tumor extension: not present
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: free of tumor metastasis (0/18)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: N/A
      • Pathological TNM Stage: ypT3N0
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: mucin production
      • TNM descriptors: Y
      • Tumor regression grading S/P CCRT: grade 5
  • 2023-02-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, rectum, laparoscopic LAR (s/p CCRT) — Adenocarcinoma
      • Resection margins, ditto — Free of tumor invasion
      • Lymph nodes, mesocolic, dissection — Tumor metastasis (1/6)
      • AJCC pathologic stage — ypT4aN1a, if cM0, stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic LAR
      • Specimen site: rectum
      • Specimen size: 7.7 cm in length, 3.1 cm in diameter
      • Tumor size: 1.5 x 1.3 cm with perforated hole 2.6 x 0.9 cm
      • Tumor location: 4.5 cm and 0.5 cm away from bilateral resection margins
      • Tumor appearance: subserosal nodule and perforated hole
      • Depth of invasion grossly: visceral peritoneum
      • Proximal margin: 3.2 x 1.2 x 0.9 cm
      • Distal margin: 1.8 x 1.3 x 0.9 cm
      • Representative sections as follows: A1-A3: perforated hole (ink) + subserosal tumor, A4-A6: perforated hole (ink) + mucosa, A7-A9: LNs, B: Proximal margin and C: distal margin
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: G2, moderately differentiated
      • Depth of invasion: visceral peritoneum (<0.1 cm from serosa layer)
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: absent
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: Tumor metastasis (1/6)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: not involved (0/1)
      • Pathological TNM Stage: ypT4aN1a
      • Type of polyp in which invasive carcinoma arose: N/A
      • TNM descriptors: Y
      • Tumor regression grading S/P CCRT: G3
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 34) / 105 = 67.62%
      • M-mode (Teichholz) = 68
    • Conclusion
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Prominent posterior mitral annulus calcification with mild MR; mild aortic valve sclerosis .
      • Mild aortic root calcification with sessile atheromas.
  • 2023-01-31 Sigmoidoscopy
    • Rectal cancer s/p CCRT , significant tumor regression
  • 2023-01-26 CT - abdomen
    • History and indication:
      • Locally advanced rectal cancer with large pelvic LNs A-colon cancer with intussusception (no obstruction sign) –> Suggest pre-op CCRT for better resectability and local control, 20221205 RT finish
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
      • Renal cysts (up to 3.6cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Much regression of rectal and A-colon cancer and metastatic LAP. A tiny nodule at RML.
  • 2022-10-28 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GAT, p.G12D)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-10-24 CXR
    • Ground glass opacity in RLL.
  • 2022-10-17 CT
    • Indication: synchronous rectal cancer and A-colon cancer
    • Findings
      • Chest:
        • Small lymph nodes are found at both sides of the mediastinum.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Visible abdomen:
        • DIffuse wall thickening at rectum about 4.2cm in length with regional lymphadenopathy is found. Rectal cancer is considered. Regional lymphadenopathy is found.
        • Annular lesion at ascending colon near hepatic flexure about 3cm is found. suspected colon cancer with intussusception.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Non-specific bowel gas at abdominal cavity is found.
        • There is no evidence of destructive bone lesion.
        • No definite inguinal or pelvic sidewall LAP
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • Suggest clinical correlation
    • IMp:
      • Rectal cancer with regional lymphadenopathy, T4N2M0
      • Ascending colon cancer. T2N0M0.
  • 2022-10-17 ECG
    • Normal sinus rhythm
    • Left axis deviation
  • 2022-10-06 Patho - colorectal polyp
    • Colorectum, ascending colon, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-10-06 Patho - colorectal polyp
    • Colorectum, rectum about 11 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-10-06 Colonoscopy
    • Colon cancer, rectum, s/p biopsy
    • Colon polyp, sigmoid colon, s/p polypecotmy + cliping
    • Colon polyp, descending colon, s/p polypectomy + cliping
    • Colon cancer, ascending colon, s/p biopsy
    • Internal hemorrhoid

[MedRec]

  • 2023-05-16 SOAP Metabolism and Endocrinology
    • Diagnosis
      • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# BID
      • Trajenta (linogliptin 5mg) 1# QL
  • 2023-03-11 POMR Cardiology
    • Discharge diagnosis
      • Severe sepsis with septic shock
      • Bacteremia with Serratia marcescens on 2023/03/11 and pan-drug resistant (PDR) Klebsiella pneumoniae on 2023/03/22
      • Port A catheter infection with pan-drug resistant (PDR) Klebsiella pneumoniae (by tip culture on 2023/03/24), status post removal on 2023/03/24
      • Urinary tract infection with urosepsis by urine culture grewed Enterobacter cloacae complex on 2023/03/11
      • Non-ST elevation myocardial infarction, favor Type 2 myocardial infarction by infection related
      • Type 2 diabetes mellitus
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 112/02/14
      • Iron deficiency anemia
      • Gastrointestinal (GI) bleeding (stool occult blood 1+)
      • Hypokalemia, resolved
      • Hypomagnesemia, resolved
      • Hypocalcemia, improving
      • Constipation
    • CC: fever and chillness at 20230311 night
    • Present illness
      • This 79 y/o male patient has the past history of
        • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
        • Type 2 diabetes mellitus with OHA control
        • Postoperative Ileus
      • the patient regular follow up at our OPD and just admitted at our proctology service from 2023/02/14 to 2023/03/09 for his adenocarcinoma of the rectum operation.
      • According to the statement of the patient’s families and ER medical record. This time, the patient suffered from fever and chillness at 22:00, so he was sent to our ER on 20230310. At MER, his GCS was E4V5M6 and vital signs showed BP:149/76 mmHg; HR:120 BPM; BT:38.4’C; RR:20 BPM; SpO2:95%. Covid-19 rapid test showed negative. The patient complained upper back pain at 00:05. However, consciousness changed to GCS:E4V1M4 at 00:22 combined with cold sweating, air hunger and blood pressure couldn’t measure, so bosmin 1mg iv stat was given.
        • The laboratory disclosed increased in cardiac enzyme Troponin I:46.8->3918.7->14527.3pg/mL, CK:163ng/mL, D-dimer:7591.06ng/mL, Lactic acid:4.8mmol/L, CPR:1.15mg/dl, band:5.0%, urine analysis (NIT:2+, WBC:>=100 and bacteria:3+) and ABG showed hypoxia (PO2:31.7, SpO2:63.7%). CXR revealed presence of ileus. The first EKG showed sinus tachycardia, the secondary EKG (post Bosmin) showed ST depression in V4~V6, suspect AMI and the third and fourth EKG restored to normal sinus rhythm. Arranged chest CTA disclosed bilateral pleural effusion with adjacent lung collapse, ground glass opacities at bilateral lungs. Cardiology was consulted and who suggested that the subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction, not true MI. Also, KUB revealed presence of ileus and degeneration and spondylosis of L-S spine. Under the impression of Urinary tract infection with urosepsis, NSTEMI, he was admitted to MICU for further evaluation and management on 2023/03/11.
    • Course of inpatient treatment
      • After admitted to MICU, we administered empirical antibiotic with IV Cravit (03/11~03/15) according to his previous (2023/03/01) urine culture grew Enterobacter cloacae complex for infection control and IV hydration for favor poor intake with dehydration and septic shock status, DAPT with Bokey and plavix for AMI and PPI with Nexium for prevent stress ulcer.
        • Echocardiography was done on 03/13 disclosed LVEF: 74%, 1.Thickened AV with no AR; 2.Thickened MV with mild MR; 3.Normal LV chamber size and wall thickness; 4. Preserved LV and RV systolic function; 5.Normal LV wall motion; 6. No PR, trivial TR, normal IVC size. Later, hypokalemia and hypomagnesemia were found, thus 0.298%KCL in NaCL and MgSO4 were given. The blood culture x 2 set grew Serratia marcescens and urine culture grew Enterobacter cloacae complex, single dose of tapimycin was used first on 3/13 and INF was consulted to adjust antibiotic for his infection control. Hb drop from 9.5 to 7.7 g/dl was also found, LPRBC transfusion was given to correct anemia. His condition was relative stable, he was transferred to cardiology general ward for further care on 03/14.
      • At ordinary ward, his consciousness was alert but weakness and vital signs were stable, no dyspnea or chest discomfort was complained, respiratory pattern smooth under nasal cannula support. Cravit was changed to Tapimycin (03/13, 03/15) for his bacteremia with Serratia marcescens and UTI with Enterobacter cloacae complex. Continue to use other current medication to control the underlying disease and closely monitor his vital signs and clinical symptoms.
        • The INF recommend antibiotic treatment with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 days, thus Tapimycin was shifted to Tienam used on 03/16. We also arrange thallium scan for CAD survey and stool OB, ion profiles examination for his anemia surveyed. Then stool OB was 1+ and iron profiles reported Fe 19 ug/dL, TIBC 272 ug/dL, UIBC 253 ug/dL, so we kept Nexium used and added Foliromin F.C. 50mg/tablet (Sodium Ferrous Citrate). The thallium scan was done on 2023/03/17, and reported probably mild myocardial ischemia at the inferoapical wall and inferolateral wall. Medical treatment was prescribed first.
      • Another episode of fever with chills developed at 23:21 on 03/21, Cravit was added. Gallium whole body inflammation scan was arranged for fever survey. The tracking initial blood culture on 03/22 report GNB. Tienam plus Cravit was changed to Doripenem (03/23~03/26) after contacting the infection doctor. Due to recurrent bacteremia, suspected to be related port-A infection, we consulted with a general surgeon, and port-A was removed on 03/24 with the signed consent of the family.
        • The 2023/03/22 blood culture officially reported as PDR-Klebsiella pneumonia, so Doripenem was changed to Tygacil plus UFO (fosfomycin) after contacting the infectious department. Later, port-A TIP culture on 03/24 also grew PDR-Klebsiella pneumonia. All Abx was shifted to Zavicefta since 03/28 by ID suggestion. Gallium inflammation scan on 2023/03/29 reported increased radiotracer uptake in a focal area in the left supraclavicular fossa, in a focal area in the left anterior upper chest wall, in the right upper anterior mediastinum, in bilateral pulmonary hailer regions and in the posterior aspect of bilateral lower lung fields. Infection/inflammation involving these regions should be watched out. We followed his blood culture results after 3 days of Zavicefta treatment (03/31) and results are pending.
        • During 7-day treatment course of Zavicefta, he had no fever or other infection signs. On 4/4, lab data were all within acceptable range. Blood culture on 3/31 also showed negative findings. Under the stable hemodynamic status, he was discharged on 4/6.
  • 2023-01-03 SOAP Hemato-Oncology
    • S: 2022-11-14 RAS G12D
  • 2022-12-14 Radiation Oncology
    • O
      • RT (2022-10-27 ~ 2022-12-05): 4500cGy/25 fractions (15MV photon) of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed area.
  • 2022-11-24 Radiation Oncology
    • A/P
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2022-10-25
        • CCRT (Concurrent Chemoradiotherapy) first, then surgery.
        • For the liver nodule, it is suggested to evaluate with abdominal sonography for staging purposes.
  • 2022-10-28 POMR Hemato-Oncology
    • Discharge diagnosis
      • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I
      • Malignant neoplasm of rectum
      • Type 2 diabetes mellitus with unspecified complications
      • Unspecified viral hepatitis B without hepatic coma
      • Other constipation
    • Present illness
      • This time, he admitted for concurrent chemoradiotherapy with 5-Fu on 2022/10/28 and 2022/10/31-2022/11/03 (5 days).
    • Course of inpatient treatment
      • After admission, CCRT with 5-Fu (225mg/m2 -> 350mg) x 5days on 2022/10/28, stop 2022/10/31-2022/11/03 treatment, change to FOLFOX regimen (Oxalip 85mg/m2 -> 110mg, Leucovorin 400mg/m2 -> 600mg, 5-Fu 2400mg/m2 -> 3700mg) from 2022/10/31 (well treatment for two site tumor), and explain to family (wife and son) and patient.
        • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
        • Type 2 diabetes mellitus with Monitor blood sugar QDAC
        • Glimet F.C 2mg/500mg/tab 1# PO BID.
        • Viral hepatitis B (Anti-HBc (+)) with Baraclude 0.5mg/tab 1# PO QDAC.
        • Constipation (suspect EMEND related, next cycle DC) with Bisacodyl supp 10mg/pill 2 supp RECT ST on 2022/11/02, Through 12mg/tab 1# PO HS, no stool passage add to 2# for MBD.
      • He can tolerance chemotherapy. The patient was discharged on 2022/11/03 under stable condition. ONC OPD follow up was advised.
  • 2022-10-20 SOAP Radiation Oncology
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed.
  • 2022-10-20 SOAP Colorectal Surgery
    • A
      • Locally advanced rectal cancer with large pelvic LNs
      • A-colon cancer with intussusception (no obstruction sign)
    • P
      • Suggest pre-op CCRT for better resectability and local control
  • 2017-01-07 SOAP Metabolism
    • Diagnosis
      • NIDDM with unspecified complication, not stated as uncontrolled [E11.8]
      • Dyslipidemia; other and unspecified hyperlipidemia [E78.5]
    • Prescription
      • Pitator (pitavastatin 2mg) 1# QD
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# TID

[consultation]

  • 2023-08-09 Dermatology
    • Q
      • This 79-year-old man patient is a case of Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC s/p concurrent chemoradiotherapy and chemotherapy with FOLFOX from 2022/10/31~2023/06/09(for 9 cycles) with tumor dense invasion/adhesion to anterior pelvic wall, lymph node enlarged narropw pelvis s/p Low anterior resection + loop ileostomy and Right hemicolectomy on 2023/02/15 with bil.lung and liver metastases s/p chemotherapy of FOLFIRI from 2023/06/30 and Avastin from 2023/07/13. He was admitted for chemotherapy with Avastin(C3)/FOLFIRI(C2D15).
      • This time, for left toe wound of injuried. Now, for evaluate left toe wound medication therapy. Thank you.
    • A
      • The patient had sufferred from thicekening nail bed with scales and erosive wound formation.
      • Under the impression of onychomycosis and onycholysis with wound formation
      • The following suggestion:
        • for wound lesion, Tetracyclie onit 1 tube topical bid use.
        • for tinea unguium, Exelderm lotion 1 bot. topical bid use over nail-fold (to put the drug into the affected area between the nail seams).
  • 2023-03-15 Infectious Disease
    • Q
      • for Serratia bacteremia
      • This 79 y/o male patient has the past history of
        • Synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy status post low anterior resection with loop ileostomy, ypT4aN1aM0, stage IIIB and right hemicolectomy, ypT3N0M0, stage IIA on 2023/02/14
        • Type 2 diabetes mellitus with OHA control
        • Postoperative Ileus
      • This time,the impression of
        • Urinary tract infection with urosepsis (20230301 urine culutre yeild Enterobacter cloacae complex)
        • NSTEMI
        • Syncope, suspect dehydration related
      • He was admitted to MICU for further evaluation and management on 2023-03-11. We gave empirical antibiotic with Cravit (since 20230311) used. His Blood culture (20230311) yeild serratia marcescens. We really need your experience for treatment suggestion, thanks!!!
    • A
      • Hx review as mentioned above and Lab data check
      • Suggestion:
        • Recommend antibiotic Rx with Tienam or Mepem for S. marcescens bacteremia and E. cloacae UTI for 7 to 10 D
        • Repeat B/C
        • Monitor CRP
  • 2023-03-11 Cardiology
    • A
      • This patient presented with sepsis syndrome in advanced colon C, not acute coronary syndrom
        • The CXR didnot show medistianl wideing, the aortic dissection is less likely
        • The subsequent ECG change is associated with bosmin effect, which will lead to transient vasoconstriction
        • not true MI
      • please treat underlying diseae, maintain optimal Bp
        • f/u echocardiography for wall motin assessment
  • 2023-03-07 Dermatology
    • Q
      • For bilateral perianal skin rash
      • This is a 79-year-old male with past history of synchronous adenocarcinoma of the rectum, cT4N2M0 stage IIIC, and adenocarcinoma of the ascending colon, cT2N0M0 stage I post neoadjuvant concurrent chemoradiotherapy.
        • He went through low anterior resection, loop ileostomy and right hemicolectomy on 20230215.   
        • During the surgery, advanced rectal cancer s/p CCRT , tumor dense invasion/adhesion to anterior pelvic wall, LN enlarged Narropw pelvis was found.
        • After surgery, ileus was noted and NG decompression was applied. Now NG has been removed.
      • However, he experienced bilateral multiple perianal rash for 2 days.
        • The rash was painless but pruritus.
        • No vesicles were noted.
        • Mycomb was applied for now.
      • We need your expertise for further evaluation. Thank you so much for your help.
    • A
      • The patient had sufferred from annular lesions with peripheral active borders on the bilateral thigh and genital area.
      • Under the impression of tinea cruris et intertrigo eczema.
      • The following suggetion:
        • Exelderm cream 1 tube topical QN use over large area of lesions after body clean and Mycomb cream 1 tube topical PRN Bid use over regional erythema itchy area.
        • keep body dry, clean and avoid further friction or compression.

[radiotherapy]

  • 2022-10-27 ~ 2022-12-05 - 4500cGy/25 fractions (15MV photon) of the pelvic, and 4680cGy/26 fractions of the rectal tumor bed area. (20221201 OPD)

[chemoimmunotherapy]

  • 2023-10-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-18 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-09 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-30 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-09 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-12 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-06 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-21 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-07 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-25 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-14 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-31 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-10-28 - fluorouracil 225mg/m2 350mg NS 250mL 10min D1-5 (CCRT)
    • [dexamethason 4mg + NS 250mL] D1-5

==========

2023-11-01

[hyperglycemia]

During this hospital stay, the patient’s blood glucose levels have consistently been elevated (216 -> 376 -> 294 mg/dL).

It is advisable to introduce acarbose 50mg PO TIDCC, with the patient instructed to take each dose at the beginning of every main meal.

2023-09-19

On 2023-08-08, our endocrinologist provided a repeat prescription for Glimet (glimepiride, metformin) and Trajenta (linagliptin), which the patient is currently taking without discrepancies. However, the patient’s blood glucose levels have been consistently high, >= 285 mg/dL for these 2 days. As a recommended addition to his treatment plan, the prescription of Dibose (acarbose 100mg) is advised to be taken as 0.5# TID, with the first bite of each main meal.

2023-07-28

Glimet (glimepiride, metformin) and Trajenta (linagliptin) were refilled on 2023-07-05 as a repeat prescription prescribed by our endocrinologist on 2023-05-16. Both medications have been added to the active medication list without any identified issues.

At 20:14 on 2023-07-27, there was a spike in blood glucose to 269 mg/dL. If this elevation persists, it may require re-evaluation and possible modification of the antidiabetic treatment plan.

There appears to be an upward trend in liver enzyme levels. Given this situation, the addition of BaoGan (silymarin) could be considered as an optional measure if there are no other specific concerns.

  • 2023-07-25 S-GPT/ALT 73 U/L

  • 2023-07-13 S-GPT/ALT 50 U/L

  • 2023-07-13 S-GPT/ALT 51 U/L

  • 2023-06-28 S-GPT/ALT 31 U/L

  • 2023-06-15 S-GPT/ALT 28 U/L

  • 2023-07-25 S-GOT/AST 49 U/L

  • 2023-07-13 S-GOT/AST 34 U/L

  • 2023-07-13 S-GOT/AST 33 U/L

  • 2023-06-28 S-GOT/AST 26 U/L

  • 2023-06-15 S-GOT/AST 27 U/L

2023-06-29

According to the PharmaCloud database, our hospital has been the sole provider of the patient’s medical services for the past three months. On 2023-06-24, our Thoracic Department issued a 7-day prescription for Curam (amoxicillin, clavulanic acid), Actein (acetylcysteine), Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), and MgO. Due to changes in the patient’s condition, Curam and MgO are not currently on the active formulary, indicating that these medications may no longer be needed. Therefore, no evidence of medication reconciliation discrepancies was identified.

701496820

231101

[lab data]

2023-09-20 Anti-HBc Reactive
2023-09-20 Anti-HBc Value 3.40 S/CO
2023-09-20 Anti-HBs 191.16 mIU/mL
2023-09-20 Anti-HCV Nonreactive
2023-09-20 Anti-HCV Value 0.12 S/CO
2023-09-20 HBsAg Nonreactive
2023-09-20 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-09-28 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 94 dB HL, moderate to profound mixed type HL
      • L’t : 54 dB HL, mild to profound SNHL.
  • 2023-09-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (70 - 24) / 70 = 65.71%
      • M-mode (Teichholz) = 71.1
    • Conclusion:
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, AR
  • 2023-09-05 Nasopharyngoscopy
    • Finding: NPC
    • NpScope: right NP crusting and exudate coating

[MedRec]

  • 2023-10-11 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Granocyte (lenograstim 250ug) QD SC 3D
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 2# TID
      • Smecta (dioctahedral smectite 3g) 1# PRNQ8H
      • NS 500mL ST IVD
  • 2023-09-25 ~ 2023-10-06 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Malignant neoplasm of nasopharynx, unspecified
      • Nonkeratinizing, undifferentiated nasopharyngeal carcinoma, cT3N1M0, Stage III, s/p CCRT with proton (6996cGy/33 Fx, from 2022/09/19~2022/11/07), s/p chemotherapy with gemcitabine plus cisplatin (from 2022/08/10~2022/10/19), recurrence in 2023/05, rT4N0M0, Stage IVA, s/p docetaxel plus cisplatin from 2023/06/07~2023/08/30, progression with involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA
      • Anemia, unspecified
      • Hypomagnesemia
      • Chronic viral hepatitis B without delta-agent
      • Enlarged prostate with lower urinary tract symptoms
      • Other insomnia not due to a substance or known physiological condition
    • CC
      • for scheduled chemotherapy        
    • Present illness
      • This 70 y/o man was quite robust before. He had the initial presentation with right side hearing loss for one more months.
      • He visited CGMH where the diagnosis of nonkeratinizing, undifferentiated NPC was made by the biopsy on 2022-07-20. The initial stage was cT3N1M0, Stage III.
      • Then he received the CCRT with proton (6996cGy/33 Fx, from 2022-09-19 to 2022-11-07) and biweekly gemcitabine plus cisplatin (from 2022-08-10 to 2022-10-19).
      • The follow-up nasopharyngoscopic examination found a suspicious lesion and the biopsy was done on 2023-05-02.
      • The result of biopsy confirmed the recurrence. On 2023-05-26, the follow-up MRI showed the disease was in progression, with a clinical stage of rT4N0M0, Stage IVA.
      • On 2023-06-16, the PET-CT confirmed the local residual tumor. Then he received the salvage chemotherapy with biweekly docetaxel plus cisplatin from 2023-06-07 to 2023-08-30.
      • On 2023-08-18, the follow-up MRI disclosed the tumor still in progression, involving with right nasopharyngeal space, parapharyngeal space, skull base and very close to ICA, which was unresectable.
      • Denied TOCC history in recent three months. Then he visited our hospital for further management.
    • Course of inpatient treatment
      • After admission, collect 24hr Ccr on 2023/09/26 showed 83.7 mL/min and arrange 2D echo for survey, on 2023/09/27 showed LVEF:71.1%, Adequate LV, RV systolic function with normal wall motion, Impaired LV relaxation, Mild MR, AR.
      • PTA was done on 2023/09/28 showed R’t : 94 dB HL, moderate to profound mixed type HL、L’t : 54 dB HL, mild to profound SNHL.
      • Anemia was noted, BT LRBC 2unit on 2023/09/27.2023/09/28, then get improved.
      • Hypomagnesemia with MgO 250mg/tab 2# PO TID for support.
      • He received chemotherapy with MEPFL (Mitomycin-C 8mg/m2、Epirubicin 60mg/m2、Cisplatin 60mg/m2 on D1 / Leucovorin 30mg/m2、5-Fu 450mg/m2 on D8) from 2023/09/28 (C1D1), 2023/10/05(C1D8).
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Enlarged prostate with lower urinary tract symptoms, TONE 25mg/tab 1# PO BID, Betmiga 50mg/tab 1# PO QDAC was given for relief.
      • Insomnia with Stilnox 10mg/tab 0.5# PO HS, Modipanol 1mg/tab 2# PO HS.
      • For chemotherapy, Baraclude 0.5mg/tab 1# PO QDAC was given for Anti-HBc:reactive.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/10/06 and OPD followed up later.   
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • MgO 250mg 2# TID
      • Smecta (dioctahedral smecitite 3g) 1# PRNQ6H
  • 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
    • S: s/p CCRT (Proton) with Gem/Platinum
      • Due to recurrence, s/p docetaxel/Platinum
    • A/P:
      • Suggest admission for salvage C/T with MEPFL.
      • Admission for echocardiography, 24 hours CCr, audiometry
  • 2023-09-08 SOAP Ear Nose Throat Huang YunCheng
    • O: r/o r T3N0M0, suggest repeat CCRT or proton therapy?
      • He has received chemotherapy + proton therapy, but still recurrence tumor noted, He looked for 2nd opinion.
    • A: salvage sugery is not indicated due to near ICA
  • 2023-09-05 SOAP Ear Nose Throat Huang YunCheng
    • S: NPC, s/p CCRT at LinKou ChangGung Hospital?
    • O: NpScope: right NP crusting and exudate coating
    • P: Apply course of treatment from LinKou ChangGung

[chemotherapy]

  • 2023-10-31 - mitomycin-C 6mg/m2 10mg NS 100mL 30min + epirubicin 50mg/m2 80mg NS 250mL 30min + cisplatin 50mg/m2 80mg NS 500mL 24hr (MEPFL C2D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-05 - leucovorin 30mg/m2 50mg NS 250mL 1hr + fluorouracil 450mg/m2 700mg NS 250mL 2hr (MEPFL C1D8)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-09-28 - mitomycin-C 8mg/m2 12mg NS 100mL 30min + epirubicin 60mg/m2 90mg NS 250mL 30min + cisplatin 60mg/m2 90mg NS 500mL 24hr (MEPFL C1D1)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Induction Chemotherapy With Mitomycin, Epirubicin, Cisplatin, Fluorouracil, and Leucovorin Followed by Radiotherapy in the Treatment of Locoregionally Advanced Nasopharyngeal Carcinoma - https://sci-hub.se/10.1200/JCO.2001.19.23.4305

  • Neoadjuvant Chemotherapy
    • Serotonin antagonist and corticosteroids were routinely given for prophylaxis of nausea and vomiting.
    • The MEPFL chemotherapy consisted of intravenous (IV) administration of
      • D1
        • mitomycin 8 mg/m2,
        • epirubicin 60 mg/m2, and
        • cisplatin 60 mg/m2 on day 1 with hydration and diuresis.
      • D8
        • Fluorouracil 450 mg/m2 and
        • leucovorin 30 mg/m2 were given on day 8.
    • This cycle was repeated every 3 weeks if hemogram measurements were adequate (leukocyte count >= 3,500/L and platelet count >= 100,000).
    • If the leukocyte count was between 3,000 and 3,500/L or the platelet count was between 75,000 and 100,000/L on day 28, the subsequent cycle was modified by a 20% reduction in the dosage of mitomycin and epirubicin.
    • Three cycles were planned unless severe side effects occurred.
  • Radiotherapy
    • Curative radiotherapy began within 3 weeks after completion of the last cycle of chemotherapy.
    • Megavoltage photons (6 MV) were used and the irradiation fields were designed according to the extension of the tumor.
    • The initial treated target volume was the gross target volume with a 2-cm margin in all directions and shrinkage to avoid excessive irradiation to the pons and spinal cord after 46 Gy.
    • All patients, except those with stage N3b disease, were treated with bilateral opposing portals to cover the primary tumor and neck; the fraction size was 2 Gy.
    • After 36 Gy, the primary and neck were treated by the split-field technique.
    • The primary was irradiated with shrinkage bilateral opposing fields, using 2.5 Gy as the fraction size, and an additional 10 Gy was given.
    • The intracranial lesion was excluded from the treatment portal after 46 Gy.
    • An additional 24 Gy in 10 fractions to the nasopharynx was delivered via bilateral anterior oblique infraorbital portals.
    • The accumulated radiation dose to nasopharynx was 70 Gy in 32 fractions, whereas the accumulated dose to intracranial lesion was 46 Gy in 22 fractions.
    • For patients with nasal or ethmoid involvement, the three-field technique (anterior field and bilateral opposing fields) was used instead of infra-orbital portals, with 24 Gy in 12 fractions.
    • The neck was treated using anterior-posterior opposing portals after 36 Gy in 18 fractions for patients with N0 to N3a disease, with the spinal cord shielded.
    • For N3b cases, the neck was treated using anterior-posterior opposing portals initially and blocked spinal cord after 40 Gy in 20 fractions.
    • The accumulated dose was 50 Gy in 25 fractions to uninvolved neck and 60 Gy in 30 fractions to involved regions.
    • An additional 5 Gy in two fractions was given to residual neck masses after 60 Gy.

==========

2023-11-01

Access to the patient’s PharmaCloud records is currently unavailable.

Following the initial cycle of the MEPFL regimen, leukopenia was noted for several days. Prompt intervention with G-CSF effectively alleviated this episode.

  • 2023-10-31 WBC 4.60 x10^3/uL 10/31 MEPFL C2D1
  • 2023-10-18 WBC 7.17 x10^3/uL
  • 2023-10-11 WBC 0.99 x10^3/uL *** 10/11,12,13 Granocyte (lenograstim)
  • 2023-10-04 WBC 2.53 x10^3/uL * 09/28 MEPFL C1D1, 10/05 MEPFL C1D8
  • 2023-09-25 WBC 4.55 x10^3/uL
  • 2023-09-19 WBC 4.55 x10^3/uL

The second cycle of the MEPFL regimen incorporated a “scaled-down” version of the “MEP” components (mitomycin 6mg/m2, epirubicin 50mg/m2, cisplatin 50mg/m2) compared to the first cycle (mitomycin 8 mg/m2, epirubicin 60 mg/m2, cisplatin 60 mg/m2), as per the original trial (https://doi.org/10.1200/jco.2001.19.23.4305). This modification aimed to mitigate the recurrence of such episodes.

There is no discrepancy found in the medication.

700307466

231031

[MedRec]

  • 2022-09-05 ~ 2022-09-09 POMR General and Gastrointestinal Surgery Zhang YaoRen
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast cancer with right axillary lymph nodes metastatic, cT4bN1M0. stage IIIB, ER (2+, 90%), PR (-) and HER2 (+, Dako score 3+) status post port implantation on 2022/09/06. ECOG:0
      • For neo-adjuvant chemotherapy with 1th Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg.
      • Hypertension
    • CC
      • for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg)
    • Present illness
      • This 62-year-old female patient had past history of 1) hypertension 2) peritonitis s/p for 20+ years at TaiNan ChiMei Hospital. She denied any TOCC histories in recent 3 months.
      • She noted a mass at right breast for 1 years ago, it grew larger quickly recently. She came to DaLin TzuChi Hospital for help first. Breast sono guide biopsy, pathology showed invasive carcinoma, IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10. She tranferred to our hospital for sencond opinion. She denid of local edema, nipple bloody discharge or nipple retraction. After examination, palpabled a 5x4x2.5 xm firm mass with skin invasion over right breast. Sono guide biopsy of right axillary lymph nodes was performed. Pathology showed metastatic carcinoma. The tumor marker showed CA-153:16.684 U/ml, CEA:1.793 ng/ml. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
      • Under the impression of right breast invasive carcinoma with axillary LN metastsis, cTbN1M0, stage IIIB. After well explain including pathology and the possible treatment modality were well explained to the patient. She was admitted for for implantation port-a catheteriplatation and arrange neo-adjuvant chemotherapy with 1st TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
    • Course of inpatient treatment
      • After admittion, follow up breast MRI for further survry. Breast MRI showed right breast malignancy with skin invasion and lymph node metastasis and left breast oval shaped tumor. After fully explaination the finally pathology. She underwent of Port-A catheter implatation on the left side on 2022/09/06. Arrange heart echo for cardiac toxicity of herceptin, data showed no obvious lesion for pre-chemo survey. We prescribed 1st neo-adjuvant chemotherapy with TCPH (Taxotere 75mg/m2 + Carboplatin 450mg + Herceptin 600mg SC + Perjeta 420mg).
      • Arrange whole bady PET scan for cancer survry on 2022/09/08. The whole bady PET scan report showed glucose hypermetabolism in the right breast with skin invasion, compatible with primary breast malignancy with skin invasion, some right axillary lymph nodes. Metastatic lymph nodes may show this picture and mild glucose hypermetabolism in a focal area in the medial aspect of left breast. During the process, she complain of vomiting, cold sweats and itchy rashes on limbs. Therefore, extended chemotherapy injection time. Under the stable condition, she was discharged today and and OPD follow up was suggested next week.
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Parmason Gargle Solution (chlorhexidine) BID GAR
      • Exforte (amlodipine 5mg, valsartan 160mg) 1# QD
      • Saline (nicametate citrate 50mg) 1# BID
      • Vit B6 (pyridoxine 50mg) 1# BID
      • Stilnox (zolpidem 10mg) 1# PRNHS
  • 2022-08-31 SOAP General and Gastrointestinal Surgery Zhang YaoRen
    • S: breast lump. Rt breast ca proved by CNB on 2022-08-18 at DaLin TzuChi Hospital.
    • O
      • postmenopausal 50 y/o
      • menarche 15 y/o
      • G2P2
      • FH of breast ca (-)
      • HRT(-)
      • A 5x4x2.5 xm firm mass with skin invasion over rt breast
      • rt axillary papale LN
      • 2022-08-18 DaLin TzuChi Hospital
        • The specimen submitted consists of 4 strips of breast tissue, measuring up to 1.2x0.2x0.2 cm, fixed in formalin.
        • Grossly, the tissue is gray fleshy and soft. All for section.
        • Microscopically, the section shows an invasive carcinoma with focal duct differentiation. The tumor demonstrates moderate cellular atypia, in solid nests, Indian filing pattern, relative hyperchromatic nuclei, nucleoli, not infrequent mitoses, >10/10HPF and infiltrative pattern with marked tissue desmoplasia.
        • Immunohistochemically, the tumor cells positive for ER (100% tumor nuclei stained) and E-Cadherin, negative for PR (0% tumor nuclei stained), with a Ki-67 proliferating index of 10% in hot area. The stain for HER2/neu is positive (3+, complete intense circumferential membranous staining in >10% of invasive tumor cells).
        • The morphological picture is invasive carcinoma of no special type, grade II, score 6 (tubule formation: 2, nuclear pleomorphism; 2, mitotic count: 2).
        • Results of the IHC staining: ER (positive, 100% tumor nuclei stained), PR (negative, 0% tumor nuclei stained), HER2/neu (positive, 3+) and Ki-67 index: 10% in hot area.
        • IHC stains (Bondmax, Leica, Australia): ER (SP1/Zeta, 50X), PR (1E2/Ventana, 4X), HER2/neu (CB11/Leica, 200X), Ki-67 (GM010/Genemed, 300X) and E-cadherin (GM016/Genemed, 50X).

[surgical operation]

  • 2023-06-13
    • Surgery
      • Dx: suspected epidermal cyst over posterior side of right ear
      • OP: excision
    • Finding
      • 1.5cm, egg-shaped, capsulated, subcutaneous tumor over posterior side of right ear
  • 2023-01-10
    • Surgery
      • right breast MRM        
      • Intraop ICG reverse mapping of axillary lymphatic duct
    • Finding
      • breast tumor, 1.5cm, 8”/3cm
      • axillary multiple LN

[immunochemotherapy]

  • 2023-09-13 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-08-23 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-07-31 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-07-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-06-12 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-05-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-04-27 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-04-06 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-03-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-02-22 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-01-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2023-01-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min
  • 2022-12-21 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 124mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-30 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-09 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-19 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-07 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 60min + docetaxel 75mg/m2 123mg NS 250mL 1hr + carboplatin AUC 2 450mg NS 250mL 2hr (pertuzumab loading)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

==========

2023-10-31

[grade 3 diarrhea]

Based on the bowel movement records from the HIS5’s TPR panel, the patient has not had any instances of bowel movements reaching seven times in a day during her last three hospital stays.

It has been documented that the occurrence of diarrhea is linked with trastuzumab (7% to 25%), pertuzumab (46% to 67%), and neratinib (diarrhea at 95%; severe diarrhea: 2%). Given that the use of trastuzumab and pertuzumab started in Sep 2022 and has been continuous since then, and neratinib was only introduced in mid-Sep 2023, and its likelihood of causing diarrhea is higher than the former two, it is plausible that the recent episode of grade 3 diarrhea is more likely attributed to neratinib.

The prescription of Smecta and loperamide is an appropriate measure.

The patients should be reminded to maintain a fluid intake of approximately 2 L/day to prevent dehydration. Once the diarrhea improves to grade 1 or returns to baseline, it is recommended to initiate loperamide at 4 mg with each subsequent dose of neratinib.

700301909

231030

[lab data]

2023-09-20 HBsAg (NM) Negative
2023-09-20 HBsAg Value (NM) 0.422
2023-09-20 Anti-HBc (NM) Positive
2023-09-20 Anti-HBc Value (NM) 0.01
2023-09-20 Anti-HCV (NM) Negative
2023-09-20 Anti-HCV Value (NM) 0.042
2023-09-20 Anti-HBs (NM) Positive
2023-09-20 Anti-HBs value (NM) 46.4 mIU/mL

[exam findings]

  • 2023-09-15 All-RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene.
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-09-14 Patho - peritoneum biopsy
    • Peritoneum, biopsy — Adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
    • Section shows pieces of fibroadipose tissue with metastatic adenocarcinoma.
    • The immunohistochemical stains reveal CK7(-), CK20(+), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
  • 2023-09-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 41) / 125 = 67.20%
      • M-mode (Teichholz) = 68
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; mild MR.
      • Mildly dilated aortic root with mild calcification.
  • 2023-08-22 Flow Volume Chart
    • r/o mild restrictive ventilatory defect
  • 2023-08-14 Patho - colon biopsy
    • Colorectum, cecum base involving ileocecal junctioon (130 cm above anal verge), biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-08-04 CT - abdomen
    • Findings:
      • There is a heterogeneous poor enhancing mass in right lateral pelvis with directly attached the terminal ileum, cecum and rectosigmoid junction, measuring 7.7 cm (the largest dimension).
        • Adenocarcinoma of the terminal ileum is highly suspected.
        • The differential diagnosis includes lymphoma, malignant GIST and colon cancer with exophytic growing. Please correlate with colonoscopy.
        • In addition, this mass causes marked right hydroureteronephrosis and delayed contrast excretion of right kidney that is c/w Right pelvic mass with direct invasion M/3-L3 ureter induce obstructive uropathy.
      • There are seven enlarged lymph nodes in the sigmoid mesocolon and right internal iliac chain that are c/w metastatic nodes.
      • There are multiple soft tissue nodules in the omentum at RUQ and LUQ abdomen that are c/w carcinomatosis.
      • There is a homogeneous enhancing mass 2.3 cm in S6 of the liver that may be hemangioma. Please correlate with MRI.
      • In addition, there are three cysts on S5, S4, and S3 (the largest one 1.9 cm in S5).
    • Impression:
      • Adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected.
      • The differential diagnosis includes lymphoma, malignant GIST, and colon cancer with exophytic growing.
  • 2023-07-28 SONO - abdomen
    • Diagnosis:
      • suspicious, colonorectal tumor or pelvic tumor
      • Liver cyst, S8
      • Hydronephrosis, right
      • Renal stone, left
      • pancreatic body and tail masked by gas.
    • Suggestion:
      • arrange abd + pelvic CT
      • consider refer to Urology.

[MedRec]

  • 2023-09-26 SOAP Urology Li MingWei
    • A
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
      • Right PCN was done on 2023/09/15
    • Prescription
      • Harnalidge (tamsulosin 0.4mg) 1# QN
  • 2023-09-26 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission for C/T with FOLFIRI +/- avastin
  • 2023-09-26 SOAP Colorectal Surgery Chen ZhuangWei
    • A: Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
    • P: refer to oncoligist for palliative chemotherapy, may bypass or ileistomy if obstructed symptoms got worse
  • 2023-09-12 ~ 2023-09-18 POMR Colorectal Surgery Chen Zhuang Wei
    • Discharge diagnosis
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis status post diagnostic laparoscopy on 2023/09/14, cT4bN2bM1c, stage IVc
      • Right hydronephrosis status post right ureteral catheterization on 2023/09/14 and right percutaneous nephrostomy on 2023/09/15
    • CC
      • peri-umbilical tenderness for 2 weeks with difficult defecation
    • Present illness
      • This is a 67 y/o male with past history of ICH on 2020/3. This time he was admitted due to peri-umbilical tenderness for 2 weeks with difficult defecation.
      • According to the patient statement, he suffered from peri-umbilical tenderness for 2 weeks with difficult defecation. He denied diarrhea, melena or hematocheizia. Due to above symptoms, he went to our GI OPD for help on 7/25. Abdominal ultrasound showed right hydronephrosis, suspicious S-colon/rectal lesion. And abdominal CT on 8/4 showed adenocarcinoma of the terminal ileum with lymph nodes metastases and carcinomatosis is highly suspected. Colonoscopy showed 1. Ulcerative tumor lesion was noted in the cecum base (130cm AAV) involving ileocecal junction 2. Mucosal chnage with external compression-like effect was found at RS-colon. Pathology showed adenocarcinoma. Under impression of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc, this time he was admitted for further evaluation and surgical intervention.
    • Course of inpatient treatment
      • This 67 years old male patient was a case of cecal adenocarcinoma. After admission, he complained right testicular region tenderness for two weeks. Right epididymitis was suspected and cravit was given. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14. However, due to right ureteral catheterization failed with suspected tumor invasion of right upper ureter, right PCN was done on 2023/09/15. And Port-A was also done on 9/15 for palliative chemotherapy. The post-operative course was relatively smooth without complication. The bowel function, urinary function were normal and the wound pain was tolerable. He was discharged on 2023-09-18 and will follow up in our out-patient department next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQID
      • Cravit (levofloxacin 500mg) 1.5# QDAC
      • Harnalidge (tamsulosin 0.4mg) 1# HS
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS
  • 2020-04-21 SOAP Neurosurgery
    • S: spontaneous ICH, conservative treatment 2020/03
    • Prescription x2
      • Depakine (valproic acid 500mg) 1# BID

[consultation]

  • 2023-09-16 Radiation Oncology
    • Q
      • For right side PCN
      • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with carcinomatosis and right hydronephrosis, stage IVc.
      • He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
      • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) Right lower ureter stricture, suspected tumor invasion of right upper ureter; 3) Suspected tumor invasion of right upper ureter, URS and guidewire can not pass through.
      • Due to right ureteral catheterization failed, we needs your expert experience for further evaluation and management. Thanks a lot !!
    • A
      • According to the clinical condition and imaging findings, right PCN is indicated.
  • 2023-09-14 Hemato-Oncology
    • Q
      • For palliative chemotherapy
      • This is a 67 y/o male was a case of newly found cecal adenocarcinoma, locally advanced with possible carcinomatosis, stage IVc. He underwent diagnostic laparoscopy and right ureteral catheterization on 2023/09/14.
      • Op finding: 1) Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum; 2) We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination; 3) Right lower ureter stricture, suspected tumor invasion of right upper ureter.
      • After fully explained of the condition, palliative chemotherapy was suggested. So we needs your expert experience for further evaluation and management. Thanks a lot !!
    • A
      • Dear doctor: This 67 year old man is a case of cecal adenocarcinoma with carcinomatosis. We are consulted for pallative chemtoherapy.
      • For metastasis colon adenocarcinoma (Pending All RAS/BRAF), chemotherapy+/- target therapy is indicated. We had well explaint to patient and his wife. Please arrange our OPD after discharge.
      • Check HBsAg, Anti HBc, Anti HBs, Anti HCV and arrange port A insertion before chemotherapy.

[surgical operation]

  • 2023-09-14
    • Surgery: Diagnostic laparoscopy     
    • Finding
      • Diagnostic laparoscopy was performed and whole peritoneal cavity was inspected.    
      • Locally advanced cecal cancer was identified with densely direct invasion of surrounding strucrues and diffuse carcinomatosis over the whole peritoneal cavity including abdominal wall and omentum    
      • We got three pieces of seeding tumors over abdomen wall and omentum for pathology examination.
      • Right ureter catherter was performed by urologist but is difficult to be done smoothly due to tumor effect.    
      • We had informed above condition to his son during the operation, further management such as right PCN and port-A are needed. 

[immunochemotherapy]

  • 2023-10-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-28 - irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-02

PharmaCloud data indicates that the patient has only been to our hospital within the last three months. Our urologist prescribed a refill of Harnalidge (tamsulosin) on 2023-09-26, and the medication is currently being used without any issues.

701306367

231030

[exam findings]

  • 2023-08-01 Neck soft tissue
    • Placement of nasogastric tube and tracheostomy.
    • Straightening alignment of cervical spine.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-08-01 CXR
    • Normal heart size with tortuous aorta.
    • Placement of tracheostomy and nasogastric tube.
    • Multiple right ribs fracture, old.
    • Fibrocalcified nodules at RUL.
    • Bilateral clear costophrenic angles.
    • L2 compression fracture status post vertebroplasty.
  • 2023-07-27 CXR
    • Tortuosity of the aorta with atherosclerotic change.
    • Fibrocalcified change over right apical lung, may be old TB.
    • Old fracture of multiple ribs.
    • S/P tracheostomy.
    • S/P N-G tube insertion.
  • 2023-07-20 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine and L2-4 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilaterla rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips, knees, right ankle and right foot, compatible with benign joint lesions.
  • 2023-07-19 CT - neck
    • Right tongue squamous cell carcinoma, moderately differentiated, for cancer work up
    • With and Without contrast Neck CT showed
      • The neck airway was unremarkable.
      • heterogeneous enhancing tumors in the oral cavity, oropharynx and bilateral hypopharynx.
      • multipe necrotic lymph nodes in the left carotid space, riht submandibular space and right posterior cervical space
      • The major salivary glands were unremarkable.
      • The skull base and C-spine alignment were unremarkable
    • IMP: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck.
  • 2023-07-18 EGD
    • Suboptimal study due to poor intolerance
    • Reflux esophagitis LA Classification grade C
    • Esophageal mucosal lesion, EC junction, s/p biopsy
    • Hiatal hernia
    • Superficial gastritis
    • Gastric erosions, antrum
  • 2023-07-10 Patho - tongue biopsy
    • Tongue tumor, R’t, biopsy — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the tongue tumor tissue characterized by solid tumor nests infiltration with keratin formation, hemorrhage and necrosis.
    • Immunohistochemistry shows CK(+), P40(+), P16(-) and HPV(-) for tumor.
  • 2023-07-08 Embolization (TAE) - neuro
    • The procedure was performed under general anaesthesia via right femoral artery approach with a Fr#8 angiocatheter sheath and guiding catheter.
    • Bilateral carotid angiograms reveal tumor stains over oropharyngeal space, supplied by bilateral lingual artery. .
    • Transarterial embolization of the tumor was then performed by infusion of particles (Embospheres).
    • Post embolization bilateral carotid angiograms show total embolization of this tumor.
  • 2023-07-08 Carotid angiography bilat.
    • Tumor stains over oropharyngeal space, supplied by bilateral lingual artery.
  • 2023-07-08 Aortography - thoracic
    • Type II aortic arch.
    • No critical stenosis of bilateral proximal carotid and vertebral arteries.
    • The whole procedure was smoothly done without apparent immediate complication and the patient stood it well under local anesthesia.
  • 2023-07-08 CT, CTA - brain
    • Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries.
    • Several necrotic nodes over left-side of the neck.
    • S/P tracheostomy.
  • 2023-04-11 Patho - doudenum biopsy
    • Duodenum, bulb, GC/PW, biopsy — Brunner’s gland hyperplasia
  • 2023-04-11 EGD
    • Reflux esophagitis LA Classification grade C
    • Duodenal polyps, bulb, s/p biopsy
    • Hiatal hernia
    • Superficial gastritis
  • 2023-04-03 EEG
    • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere with left side more severe. There were no obvious photic driving response.
    • This EEG suggest moderate diffuse cortical dysfunction left side more severe. Advise clinical correlation.
  • 2023-03-30 CT - brain
    • Small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
    • Traumatic head injury with right frontal scalp and face swollen change.
    • Depressed left hemicranium with thickening dura. Compressed left cerebral hemisphere with large area of old infarction.
    • S/P V-P shunt insertion.

[MedRec]

  • 2023-08-08 SOAP Hemato-Oncology
    • P: Arrange admission for CCRT with weekly CDDP
  • 2023-08-04 SOAP Radiation Oncology
    • S: Diagnosis: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. cT4aN2cM0 at least.
    • O: 2023/07/27~ RT to the oral cavity and bil. neck lymphatic drainage area: 12 Gy/ 6 fx.
    • P: Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx.
  • 2023-07-08 ~ 2023-08-28 POMR Ear Nose Throat
    • Discharge diagnosis
      • Malignant neoplasm of overlapping sites of tongue, stage IV
      • Oropharyngeal tumor bleeding with hypovolemic shock
      • Hemoptysis
      • Acute hypoxemic respiratory failure post intubation
    • CC
      • cough with much blood sputum today, and poor intake fo 2 days
    • Present illness
      • This 51-year-old man has past history of 1.) old CVA with right weakness, 2.) alcoholism 3.) Traumatic brain injurys/p craniectomy 4.) Epilepsy 5.) s/p abdomen operation (colon).
      • According to statement of his ex-wife, he suffered from cough with much blood sputum today, and poor intake fo 2 days. He was brough to our hospital for help. At ER, Con’s:E4V5M6, TPR:37.1/112/18, BP:94/55mmHg; SpO2:99%, sudden massive blood from oral and desaturation, bradycardia, hypotension were noted, s/p Bosmin injection, difficult oral endotrachea tube installation, emergency tracheostomy with ventilator support was performed at ER. Laboratory studies showed leukocytosis, increase of segment, Imbalance electrolyte as hyperkalemia, hyponatremia. The chest film disclosed Fibrocalcified change over RUL.
      • Due to massive oral bleeding, so we arrange brain CT, which revealed 1. Presence of huge lobulated mass lesion over oropharyngeal space, mainly at posterior tongue, with invasion of anterior part of the tongue and the epiglottis. Large necrotic area of this tumor. The tumor was mainly supplied by bilateral lingual arteries. 2. Several necrotic nodes over left-side of the neck. Angiography was arranged and embolization was done. Empirical antibiotics, IV fluid challenge, and blood transfusion for hypovolemic shock were given. Under the impression of 1.) Acute hypoxemic respiratory failure post intubation 2.) oropharyngeal tumor bleeding with hypovolemic shock, he was admitted to MICU for further treatment.
      • He did not received vaccice included covid-19 and Influenza
    • Course of inpatient treatment
      • MICU 7/08-7/17
        • After admitted to MICU, on cricothyrotomy with ventilator support. Arrange tracheostomy on 7/9. Unstable hemodynamics under IVF hydration and levophed titration infusion.
        • Empiric antibiotic with tapimycin Tapimycin (7/8-) and Targocid (7/9-7/11) for infection treat. Give MgSO4, KCL IVD, Ca. gluconate and high P diet were given for correct imbalance electrolyte.
        • Transamin IV and Bosmin inhalation were given for hemoptysis. AEDs with dilantin IV shift to oral form and ativan PRN IVD for seizure control. Contact ENT for biopsy of right tongue tumor: Squamous cell carcinoma. Try T-mask overnight since 7/15 for weaning ventilator. He wil transfer to ENT ward for further care.
      • ENT ward 7/17-7/28
        • Under relative stable condition, we remove foley catheter and shift tracheostomy to shiley 6 # smoothly on 7/18.
        • Cancer work up was arranged, which revealed tongue tumor with extensive invasion the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck. Operation was not indicated due to massive invasion. Radiotherapy will be arranged from 7/27, and he will be discharged under relative stable condition.
    • Discharge prescription
      • Zalain Cream (sertaconazole nitrate 2%) BID TOPI
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
      • Phenytoin (diphenylhydantoin 100mg) 1# TID
      • Ulstop (famotidine 20mg) 1# BID
      • Parmason Gargle Soln (chlorhexidine) BID GAR
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-03-31 ~ 2023-04-12 POMR Infectious Disease
    • Discharge diagnosis
      • Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
      • Hypostatic pneumonia, unspecified organism
      • Contusion of unspecified part of head, initial encounter
      • Contusion of eyeball and orbital tissues, right eye, initial encounter
      • Altered mental status, unspecified
      • Unspecified adrenocortical insufficiency
      • Gastritis, unspecified, without bleeding
      • Gastro-esophageal reflux disease with esophagitis
    • CC
      • Drowsy conscious and poor appetite in recent three days.
    • Present illness
      • This is a 51 year-old male patient, who has underlying histories of alcoholism, Left TBI s/p craniectomy, s/p abd op (colon), is admitted for drowsy conscious and poor appetite in recent three days.
      • According to his ex-wife, he suffered from drowsy conscious and poor appetite after fall down with hit the head before three days ago. He also accompanying symptoms of headache, right eye swelling and ecchymosis.There is no TOCC or trauma hisory. He had no previous allergy to food or drug. There is no URI or UTI symptom in recent days.
      • He was brought to our ED for help.
      • At ED, vital signs showed tachycardia (BP:129/88; HR:104; BT:35.5; RR:18). PE showed ecchymosis, swelling, local heat, painful and tenderness over right eye, sclera congestion, pupils has light reflex. Laboratory data showed leukocytosis (13200/uL), elevated Hb (Hb:18.1 g/dl), CRP (7.06mg/dL), glucose (Glu:190 mg/dl), and normal liver and renal function. Blood gas (vein) showed respiratory acidosis with metabolic compensation. Urinalysis showed elevated urobilinogen (8 mg/dl), bilirubin (1+), no pyuria. CXR showed clear both lung field. Brain CT revealed small amount of chronic subdural effusions along right convexity. Minimal amount of acute SDH over right temporal fossa.
      • Under the impression of hypostatic pneumonia, dehydration, SDH, he is admitted to the Infection ward for evaluation and management on 2023-03-31.    
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral cefuroxime for empirical treatment of hyposttaic pneumonia. Consciousness was monitor due to post head injury. Raise the head of the bed up 30 degree. Neurology consulted for treatment of SDH and headache. This EEG suggest moderate diffuse cortical dysfunction left side more severe. The adequate fluid hydration due to dehydration. The Foley catheter indwelling is for monitor and record urine amount. Oncology was consulted for suspect polycythemia. Patient received JAK2, BCR ABL, therapeutic phlebotomy (maintain the hematocrit < 45 percent) and bone marrow aspiration and biopsy.
      • Patient’s ex-wife complained of no stool passage above three days and abdominal distension. KUB revealed stool impaction. Laxative, antiflatulent were given. Hiccup is noted, we also addition prokinetic treatment. Patient’s ex-wife complained of dark green stool noted, stool is submitted for stool OB. We also give recheck Hb level and adrenal function survey. No bacterial growth on blood culture is noted. Mild decreased ACTH is noted, adrenocortical insufficiency was considered.
      • We give addition systemic steroid. Panendoscopy was arrange due to anemia and stool OB 4+. Panendoscopy revealed Reflux esophagitis LA Classification grade C
      • Duodenal polyps, bulb, s/p biopsy. Hiatal hernia. Superficial gastritis. PPI was given after panendoscopy examination. Voiding is smooth after removal foley catheter. No bacterial growth on blood culture is noted. Laboratory examinaiton revealed improve. No more fever occurs. Conscious clear. Respiratory pattern is smooth. Under stable condition, he is discharged on April 12, 2023.
    • Discharge prescription
      • cortisone acetate 25mg 0.5# QD
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Mopride (mosapride citrate 5mg) 1# TID
      • Through (sennoside 12mg) 1# HS
  • 2021-07-27 SOAP Neurosurgery
    • S
      • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
      • Postoperatively, his symptom has been relieved.
    • P
      • Porlia infusion
    • Prescription
      • Prolia (denosumab 60mg) ST SC
  • 2021-07-15 ~ 2021-07-16 POMR Neurosurgery
    • Discharge diagnosis
      • Wedge compression fracture, L2 post vertebroplasty on 2021/07/16
    • CC
      • Lower back pain for 3 weeks
    • Present illness
      • This is a 49 year-old male with alcoholism, Left TBI s/p craniectomy, s/p abd op (colon).
      • This time he was suffered from lower back pain after fell down when work since 6/28. The pain became worse so he came to our NS OPD for help on 7/5.
      • At OPD, PE showed MP RUE 3 RLE 3, LUE 4 LLE, SLRT -/- Lasguest test(+). L-spine X-ray showed L2 compresion fracture. MRI of L spine revealed: L2 subacute compression fracture. After discussion with the patient, surgery would be arranged.
      • Under the impression of L2 compression fracture, he was admitted for further management.
    • Course of inpatient treatment
      • After admission, we did pre-OP prepare. L2 body bone cement augmentation was arranged on 7/16. The patient’s condition and vital sign was stable after the surgery and his symptoms was mild improved. After assessment, he will discharge on 7/16 and OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine Aq Soln (povidone iodine) QD EXT for L-spine wound

[consultation]

  • 2023-10-19 Ear Nose Throat
    • Q:
      • PH extensive tumors in the oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck; cT4aN2cM0 at least.
    • A
      • S
        • Hemoptysis since last night by family
        • Fair saturation (SpO2: 97-99% under room air) but lip with cyanotic change when visiting
        • Cuff inflation (8 ml) for airway protection before visiting
        • PHx: extensive tumors in the oral cavity, oropharynx andhypopharynx with necrotic LAP in the bilateral neck
          • s/p CCRT with weekly CDDP ( 7000 cGy / 35 Fx, from 2023/07/27~2023/09/14)
      • O
        • Portable scope: no active bleeding over trachea after cuff inflation, bloody mucus over trachea
        • Local finding: no active bleeding or oozing over tracheostomy
        • much blood clot over left tongue necrotic wound, s/p bosmin gauze compression
      • A
        • Hemoptysis, favor oral cancer bleeding related
      • P
        • S/p bosmin gauze compression -> no active oral bleeding
        • Keep Cuff inflation for airway protection
        • If active oral bleeding, angiography for embolization may be indicated -> however, patent refused futher aggresive treatment (The patient is conscious and alert. The patient was informed that there is a life-threatening risk if bleeding continues and embolization is not performed. The patient nodded in understanding. When asked if they would accept the treatment, the patient shook their head to indicate refusal. The patient’s ex-wife was also informed of the same content. She understood and expressed respect for the patient’s wishes.)
  • 2023-08-17 Family Medicine
    • Q
      • This 52 year-old man patient is a case of Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB s/p concurrent chemoradiotherapy from 2023/07/27. Concurrent chemotherapy with CDDP was on 2023/08/17. This time, for PS:4 with weakness and sign DNR. Now, for evaluate hospice combined care. Thank you.
    • A
      • Cons:E4V5M6. ECOG:4
      • We will arrange hospice combine care and follow up his condition.
      • Indication: Tongue cancer with bilateral neck LAP metastasis, cT4aN2cM0, stage IVB
      • Plan: Hospice combined care
  • 2023-07-24 Dermatology
    • Q
      • Itching papule over peri-inguinal region was noticed for days. We need your expertise for further evaluation and treatment.
    • A
      • This patient suffered from erytehamtous patches on L’t thigh for days.
      • Imp: Tinea corprois
      • Suggestion:
        • Mycomb * 2 tubes/bid
        • Zalain cream * 2 tubes/bid
  • 2023-07-21 Hemato-Oncology
    • Q
      • Operation may not be indicated due to masive tumor invasion. We need your expertise for concurrent or induction chemotherapy arrangement.
      • The patient’s caregiver is his ex-wife, and they have a 14-year-old underage daughter together.
    • A
      • This 51 year old man is a case of Tongue base squamous cell carcinoma, moderately differentiated, p16(-), HPV (-) with tumor bleeding, status post angiography embolization on 2023/07/08, status post tracheostomy on 2023/07/09.
      • Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck. We are consulted for CCRT. Please arrange port A insertion.
      • Check Anti HBc, HBsAg, Anti HCV. Arrange 24 urine CCR. Please arrange our OPD after discharge.
  • 2023-07-21 Radiation Oncology
    • A
      • This time, he was admitted to our ward for oropharyngeal tumor bleeding. Biopsy over tongue revealed squamous cell carcinoma, moderately differentiated, p16(-), HPV (-). Neck CT revealed tumor invasion over oral cavity, oropharynx and hypopharynx with necrotic LAP in the bilateral neck.
      • CCRT is indicated. CT-simulation will be arranged on 7/24. Plan to deliver 50 Gy/ 25 fx to the oral cavity, oropharynx, and bil. neck lymphatic drainage area. Then boost the gross tumor and LAPs to 70 Gy/ 35 fx. RT will start around 7/27. Thank you very much.
  • 2023-07-19 Oral and Maxillofacial Surgery
    • Q
      • tongue cancer patient, for oral cavity evaluation
      • This is a 51-year old man with past history
        • Old cerebrovascular accident with right side weakness
        • Alcoholism 
        • Traumatic brain injury status post left craniectomy more than 20 years ago
        • Epilepsy under phenytoin
        • Unknown colon lesion status post operation
      • This time, he was admitted to our ward for massive tumor bleeding. Emergent tracheostomy with tongue tumor biopsy was perfromed smoothly, and pathology report showed moderately differentiated squamous cell carcinoma. As part of cancer evaluation, we need your expertise for oral cavity evaluation.
    • A
      • After examing the intraoral condition, poor oral hygiene and multiple deep caries were noticed.
      • As the patient is unwilling to open his mouth and refuse to accept further dental evaulation.
      • Extraction of hopeless teeth might be difficult.
  • 2023-07-08 Ear Nose Throat
    • A1
      • If massive bleeding occurs again, you can pack the mouth with Bosmin gauze (4x4 unfolded gauze pieces tied together in a string).
    • A2 Supplementary Consultation Response: 2023-07-08 21:02:07
      • The procedure performed this time was a cricothyrotomy (non-tracheostomy procedure), and tracheostomy surgery will be needed in the coming days.
  • 2023-04-05 Hemato-Oncology
    • Q
      • This 51 y/o man admitted due to hypostatic pneumonia. History of smoking and trauma s/p V-P shunt. Hb:18.1 g/dl, suspect polycythemia. So we need your help for further suggestion. Thanks.
    • A
      • Please check JAK-2, BCR ABL, and arrange theraputic phlebotomy (maintain the hematocrit <45 percent).
      • Bone marrow aspiration and biopsy is indicated. Thanks for your consultation.
  • 2021-06-29 Neurosurgery
    • Q
      • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
      • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
      • Allergy: denied
    • A
      • The patient had lower back pain and general weakness.
        • Recent Hx of chest trauma: undetectable
        • CT scan of the abdomen showed old fracture of right lower ribs with chronic pleural change.
        • Patient hand no chest pain and dyspnea
      • Suggestion:
        • OPD FU for CS condtion
        • Consult NS
  • 2021-06-29 Neurosurgery
    • Q
      • CC: fell down 3 days ago? and low back pain and generalized weakness; decreased appetite; slurred speech as usual (according to the ex-wife)
      • PH: alcoholism, Left TBI s/p craniectomy on 1995, s/p abd op (colon?)
      • Allergy: denied
    • A
      • This patient suffered from back pain after a fall 3 days ago. At ER, his L spine films showed L2 compression fracture. Conservative therapy, including back brace, is suggested. OPD f/u is advised.

[radiotherapy]

[chemotherapy]

==========

2023-10-30 (not posted)

[patient’s weight is too light]

A dosage of 1# QD could be considered appropriate for this patient with a less severe condition, given his body weight of 37 kg. This dosage is approximately equivalent to 1.5# QD for a patient weighing 57 kg.

2023-08-11

[reconciliation]

The patient obtained a 28-day refill of the repeat prescription for Dilantin Kapseals (phenytoin) for his “absence epileptic syndrome, not intractable, with status epilepticus” from Taipei City Hospital on 2023-08-04. However, the patient is currently not taking phenytoin (according to the active medication list). It is recommended to assess whether the patient’s neurological symptoms persist and to determine the continued necessity of the drug.

701490021

231030

[lab data]

2023-09-14 Anti-HBc Reactive
2023-09-14 Anti-HBc-Value 1.30 S/CO
2023-09-14 Anti-HBs 127.72 mIU/mL

[MedRec]

  • 2023-09-13 ~ 2023-09-18 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31
      • Malignant neoplasm of head of pancreas
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for chemotherapy
    • Present illness
      • This 69 y/o female patient denied underlying diseases, diagnosis was Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1, stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31.
      • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion. Cholangiography MRI on 2032/07/11 showed a poor enhancing lesion (3.0x3.3x4.3cm) at pancreatic head with adjacent duodenal and CBD invasion causing biliary dilatation, some small LNs at retroperitoneum. Distention of gallbladder and stomach, a poor enhancing nodule (8mm) at S4-8 junction of liver、renal cysts (up to 2.3cm). Pancreatic Carcinoma T3N2M1, stage IV.
      • Endoscopic retrograde cholangiopancreatography on 2023/07/11 showed duodenal tumor with duodenum stricture: at SDA: post biopsy (failed cannulation), duodenal ulcer. Pathology showed intestine, small, duodenum, SDA, biopsy — Adenocarcinoma, IHC reveals CK7(+), CA19-9(-), CK20(1). Abdominal echo on 2023/07/12 showed probable liver parenchymal disease (incomplete exam of liver), suspected pancreas tumor (head portion), mild dilatation of pancreatic duct, gallbladder obscured, mild dilatation of CBD and bilateral IHD, right renal cyst, right pleural effusion: minimal amount.
      • Pathology showed Labeled as “pancreatic neck”, EUS needle biopsy — adenocarcinoma. IHC stains (using block S2023-13884): CA19-9 (-), CK7 (+), CK20 (-), CK19 (+), CEA (+). She received whipple op with partial gastrectomy, S4b/5 partial hepatectomy, LNstation 5,6,8,12,13 dissectio on 2023/07/31, pathology showed Liver, S4b, partial hepatectomy — Metastatic pancreatic adenocarcinoma; 1. Pancreas, Whipple operation with partial gastrectomy — Ductal adenocarcinoma, moderately differentiated; 2. Pathologic Staging: pT3N2M1, stage IV.
      • This time, she was admitted to our ward for chemotherapy with FOLFIRINOX (C1D1).
    • Course of inpatient treatment
      • After admission, she received chemotherapy with FOLFIRINOX (Oxalip 50mg/m2, Campto 100mg/m2, LV 300mg/m2, 5FU 300mg/m2 and 2400mg/m2) (C1D1) from 2023/09/14~2023/09/16 (hold 5-Fu due to fever was noted 2023/09/16, after Acetal 500 mg/tab 1# PO ST, then improving, keep continue 5-Fu).
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Protase 1# po TID was given for pancreatic insufficiency.
      • Post chemotherapy with Oxalip given Hydroxocobalamin “T.F.” 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies.
      • Blood-stinged was noted on toilet paper after urination today. No hematuria or other symptoms. consulted for GYN evaluation. Postmenopausal spotting, keep observation. Cervical polyp, keep observation. May arrange GYN OPD f/u after discharged, for recheck endometrial thickness (might consider to arrange endometrial sampling or D&C if persistent vaginal spotting or EM thickening).
      • Chronic viral hepatitis B with (Anti-HBc:reactive) with Vemlidy 25 mg/tab 1# PO QD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/18 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Protase (pancrelipase 280mg) 1# TIDCC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ12H
  • 2023-09-05 SOAP Hemato-Oncology Xia HeXiong
    • P: Check Anti-HBs, Anti-HBc and Anti-HCV during admission. Already told the regimen:
      • GASL
      • GA
      • mFOLFOX
  • 2023-07-10 ~ 2023-08-18 POMR General and Gastrointestinal Surgery Wu ChaoCun
    • Discharge diagnosis
      • Ductal adenocarcinoma of pancreatic head with liver metastasis, pT3N2M1; Stage IV status post whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and lymph noder dissection on 2023/07/31. ECOG:1
      • Pancreatic head cancer, with adjacent duodenal invasion and obstructive jaundice status post percutaneous transhepatic gallbladder drainage on 2023/07/12
      • Cholangitis
      • Obstruction of bile duct
    • CC
      • Frequent postprandial vomiting for about 2 weeks
    • Present illness
      • This 69 y/o female patient denied underlying diseases, like hypertension or type 2 diabete mellitus.
      • Accroding to her statement, she had upper abdominal fullness and frequent postprandial vomiting for several times about these half month. Body weight loss wa noted (72kg -> 69kg for 1 month). There was no fever, no dyspnea, no diahrrea, no tarry/bloody stool passage. She went to ChiMei Hospital and image study showed 2-3 cm pancreatic head tumor. Lab data showed elevated AST/ALT, ALP, rGT and Total bilirubin level. She then went to our hospital for second opinion.
      • Lab data on 7/10 showed no naemia, no CEA(3.2) CA199(1.07) level elevation, AST(337), ALT(652), Tbil(2.27), rGT(624), cholestasis type abnormal liver function and jaundice, suspected obstrution. Physical exam showed no fever, no dyspnea, no jaundice, no abdominal tenderness, normoactive bowel movement, no lower limbs pitting edema.
      • Under the impression of pancreatic head lesion causing obstructive jaundice and cholangitis, she was admitted to our ward for evaluation and management.
    • Course of inpatient treatment
      • After admitted, MRCP on 7/11 showed r/o pancreatic head tumor (2.2cm) with adjacent duodenal and CBD invasion causing biliary dilatation. Distension of gallbladder and stomach. A poor enhancing nodule (0.8cm) at S4/8 junction of liver. ERCP revealed duodenal tumor at bulb to SDA, s/p biopsy ; failed canulation.
      • PTGBD was also performed on 7/12 for bile drainage. EUS with FNB was performed on 7/12, for pancreatic mass-lesion biopsy.
      • The pathology of duodenal mass lesion showed adenocarcinoma and pancreatic mass fine needle biopst revealed malignancy.
      • GS was consulted then she was referred to GS service for further surgical intevention preparing.
      • TPN for nutrition supplement was given since 7/14.
      • Then she received whipple’s operation with partial gastrectomy and S4b/5 partial hepatectomy and LN dissection was processed successfully on 7/31.
      • Post operaively, we observed patient recovery and keep empiric antibiotic, albumin with lasix therapy, and analgesic agent were administered and the wound management was performed.
      • However, post operation with bile leakage via JP (no.2) was noted. Then we keep sandostatin support and keep well JP drainage.
      • Fever was noted on 8/4 and CXR showed ground glass opacity in bilateral lower lungs.
      • A+B inhalation and Aerobika for promote lung expansion since 8/4.
      • She try to introduced liquid diet with step by step after well flatus passage and can tolerate well for soft diet.
      • Leukocytosis was persisted then we check ascites culture on 8/7, then final report showed staphylococcus, then Zyvox support was used. However, high fever was noted on 8/16 then suspect of CVC infection and CVC removed then follow up tip culture and blood culture and removed of JP tube were done smoothly. Add antibiotic with Brosym and flucon support then fever was subside for 2 days. Recheck blood examination with no leukocytosis and CRP showed 4.8mg/dl. Under stated improvement of clinical symptoms, she was allowed to discharge today and OPD follow up was arranged.
    • Discharge prescription
      • Celebrex (celecoxib 200mg) 1# BID
      • Diovan (valsartan 160mg) 1# QD
      • LoraPsudo 24H SR FC (loratadine 10mg, pseudoephedrine 240mg) 1# QD
      • Megest (megestrol 40mg/mL) 10mL QD
      • Mopride (mosapride citrate 5mg) 1# TID
      • Rich (lansoprazole 30mg) 1# QDAC
      • Through (sennoside 12mg) 2# HS
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Flu-D (fluconazole 150mg) 1# QD
      • Ceficin (cefixime 100mg) 2# BID
  • 2023-07-10 SOAP Gastroenterology Chen JiangHua
    • S
      • 70 y/o
      • 2023/07/10 vice president Dr. Hsu’s VIP, A 2-3 cm panc head tumor referred for management
      • PI: Bw loss (+/-), GOT/GPT=841/1065, ALP=77, GGT=686, Bil(T)=1.9 mg/dl, Albumin=3.8 g/dl
      • She went to XinYing ChiMei Hospital where she is told to have panc tumor
      • PHx : HTN (-) DM (-) Op (-)
      • Drug allergy : (-)
    • O
      • PE: soft abdomen and anicteric sclera

[surgical operation]

  • 2023-07-31
    • Surgery
      • whipple op with partial gastrectomy
      • S4b/5 partial hepatectomy
      • LNstation 5,6,8,12,13 dissection
    • Finding
      • 4 x 3.5 x 3.5 cm head tumor at pancreatic head
      • regional LN enlarge at 12
      • 1.2 x 1.2 x 1.0cm tumor at S4b/5
      • ascite(-)
      • seeding(-)

[chemotherapy]

  • 2023-10-27 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-10-09 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX, DC 5-FU bolus, due to neutropenia was noted, post last time C/T)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-14 - oxaliplatin 50mg/m2 85mg D5W 250mL 2hr + irinotecan 100mg/m2 170mg D5W 250mL 90min + leucovorin 300mg/m2 500mg NS 250mL 2hr + fluorouracil 300mg/m2 500mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

700948807

231027

[exam findings]

  • 2023-08-31 C-spine AP + Lat
    • Disc space narrowing and posterior spur at C3-4-5-6-7
  • 2023-08-02 CT - abdomen
    • History and indication: D-colon cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Colon cancer s/p operation.
      • A nodule (5mm) at LLL.
      • Duodenal diverticulum.
      • Increased density of bil. breasts and lungs.
      • Liver and renal cysts (up to 1.6cm).
      • Retroversion of uterus.
      • Atherosclerosis of aorta, iliac arteries.
      • Disc space narrowing at L4/5.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Colon cancer s/p operation.
      • A nodule (5mm) at LLL.
  • 2023-06-07, -03-22 CXR
    • Atherosclerotic change of aortic arch
    • S/P metalic autosuture at right upper lung with lung volume decrease.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 All-RAS + BRAF mutation
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-02-23 CXR
    • s/p right chest tube in place, its tip directed medially, projecting over 6th intercostal space
    • atelectasis of RUL
  • 2023-02-21 Patho - lung total/lobe/segmental
    • PATHOLOGIC DIAGNOSIS
      • Lung, RUL, VATS RS2 segmentectomy — Metastatic adenocarcinoma, colorectal origin
      • Lymph node, LN 7, right, dissection — Negative for malignancy ( 0 / 3 )
      • Lymph node, LN 11, right, dissection — Negative for malignancy ( 0 / 6 )
      • Lymph node, LN 12, right, dissection — Negative for malignancy ( 0 / 4 )
      • AJCC 8th edition pathology stage (for colon cancer): pTxN0M1a; AJCC stage IVA
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): VATS RS2 segmentectomy
      • Specimen Type:
        • Location: Right upper lobe
        • Lymph node dissection: yes (specify): LN7, LN 11, LN 12
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: 10x 5 x 2.5 cm
      • Tumor Site: Right upper lobe
      • Tumor number: Multiple (Number:2 )
      • Tumor Size: Greatest dimension: 0.6 cm and 0.2 cm, respectively
      • Gross tumor patterns:poorly defined
      • Gross Tumor Extension (specify) : Not identified
      • All for sections are taken and labeled as: F2023-70FS:tumor, F2023-70A1:tumor, F2023-70A2-13”RUL, A:LN7, B:LN11, C:LN 12
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Metastatic adenocarcinoma, colorectal origin
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: not identified
      • Margins: Margins free, Distance from closest margin: 2 cm
      • Visceral Pleura Invasion: not identified
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Regional lymph Nodes:
        • Number examined: 13
        • Number involved: 0
      • Ancillary Studies: IHC stain — CK20(+), TTF-1(-), Napsin A(-), CK7(-)
  • 2023-02-19 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Blunting of left costophrenic angle due to pleural thickening
    • a small nodular opacity over medial RUL
    • extensive increased opacity over Lt and Rt lower lung zonesdue to breast shadows
    • partial atelectasis with bronchiectasis of inferior lingular segment
  • 2023-02-09 SONO - abdomen
    • Propable liver cyst, left
    • Suspected fatty infiltration of pancreas
  • 2023-02-07 CT - chest
    • a well-defined RUL solid nodule, increase in size (from 6mm to 8mm), and statonary of bronchiectasis and bronchiolitis at lingula, and several subpleural reticular opacities at LLL as compared with previous CT on 2022/11/03.
  • 2022-11-09 Barium Enema
    • Double contrast study of LGI series revealed:
      • The contrast medium passage from anus to terminal ileum smoothly without obstruction.
      • S/P operation.
      • Colonic diverticula.
    • IMP: S/P operation. Colonic diverticula.
  • 2022-11-03 CT - abdomen
    • History and indication: Colon cancer at splenic flexure
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Colon cancer s/p operation.
      • A nodule (6mm) at RUL.
      • Duodenal diverticulum.
      • Increased density of bil. breast.
      • Liver and renal cysts (up to 1.6cm).
      • Atherosclerosis of aorta, iliac arteries.
      • Disc space narrowing at L4/5.
    • IMP:
      • Colon cancer s/p operation.
      • A nodule (6mm) at RUL.
  • 2022-05-05 SONO - abdomen
    • Diagnosis:
      • Propable liver cyst,left
      • Suspected fatty infiltration of pancreas
      • Propable left renal cyst
    • Suggestion:
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2021-11-04 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, splenic flexure colon, SILS left hemicolectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Negative for malignancy (0/12)
      • Lymph node, IMA / SMA, dissection —- N/A.
      • Pathology stage: pT3N0(if cM0); AJCC stage IIA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: SILS left hemicolectomy
      • Specimen site:splenic flexure colon
      • Specimen size: colon: 15 cm in length
      • Tumor size: 2.5 cm
      • Tumor location: 3.5cm away from the closest resection margin
      • Depth of invasion grossly: perirectal soft tissue
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled: A1-2:bilateral margins, A3-6:LNs, A7-10:tumor
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: pericolorectal tissue
      • Angiolymphatic invasion: Present
  • 2021-11-01 CT - chest
    • LLL curvilinear opacity (11 mm), focal atelectasis or a primary nodule, no lung metastasis, suggest f/u CT at 6 to 12 months later.
    • lingular bronchiectasis.
  • 2021-11-01 SONO - abdomen
    • Liver cyst.
    • Hypoechoic nodule, 0.98x0.81cm in right lobe liver. Suggest follow up.
    • Right renal cyst.
  • 2021-10-28 ECG
    • Sinus bradycardia
    • Low voltage QRS of limb leads
    • Borderline ECG
  • 2021-10-20 CT - abdomen
    • History: diarrhea and abdominal pain for 3 ms. blood in stool (+). stool 3-4/day. cramp (+). fullness esp post meal. 2021/10/13 colonoscopy: One huge ulcerative tumor at just proximal to splenic flexure colon
    • Indication: colon cancer, splenic flexture, CT for staging
    • Findings:
      • There is soft tissue mass measuring 2 cm in the splenic flexure colon that is compatible with adenocarcinoma.
        • In addition, there are two lymph nodes in the adjacent mesocolon that may be metastatic nodes.
      • There is an ill-defined small poor enhancing nodule 5 mm in S8 of the liver that may be flow artifact, cyst or tumor. Please correlate with sonography.
      • A hepatic cyst measuring 1.6 cm in S2 is noted.
      • Two renal cysts 0.8 cm and 1 cm in left upper pole are noted.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2021-10-14 Patho - colorectal polyp
    • Colon tumor, 45-42 cm from anal verge, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with focal necrosis and desmoplasia.
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
  • 2021-10-13 Colonoscopy
    • Colon polyp, A-colon, s/p biopsy removal (A)
    • Highly suspect colon cancer, just proximal to splenic flexure(occupied 45 to 42cm from AV), s/p biopsy (B)
    • Colon polyp, S-colon, s/p hot snare polypectomy (C)
    • Internal hemorrhoid

[MedRec]

  • 2022-02-10 SOAP Colorectal Surgery
    • 20220210 UFT discotinue due to general malaise and poor appetite

[surgical operation]

  • 2023-02-20
    • Surgery
      • VATS RS2 segmentectomy + LND.
    • Finding
      • One nodular lesion was noted over RS2 of RUL, size about 1.5cm in diameter.
      • Frozen section: adenocarcinoma.
      • One 20 Fr. straight chest tube was inserted via right 5th ICS.
  • 2021-11-03
    • Surgery
      • SILS left hemicolectomy        
    • Finding
      • splenic flexure tumor, T3N1bMx Stage: IIIB
      • Anastomosis by GIA 75/4.8mm *2

[immunochemotherapy]

  • 2023-10-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-17 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-26 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-21 - irinotecan 150mg/m2 200mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-30 - irinotecan 120mg/m2 180mg D5W 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-11-22 ~ 2021-12-27, 2022-02-07 ~ 2022-06-09 - UFT (tegafur 100mg, uracil 224mg) 2# BID

==========

2023-10-27

Upon reviewing both PharmaCloud and HIS5 records, no medication discrepancies were detected. However, PharmaCloud indicates that the patient visited MinSheng Hospital and received a diagnosis of an unspecified UTI on 2023-10-18. It may be prudent to verify that the UTI has been resolved.

2023-08-08

Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf

  • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration. Patients with total enteral nutrition Dipeptiven is continuously infused over 20-24 hours per day.

2023-06-27

  • Based on the information in the PharmaCloud database, our hospital has been the exclusive provider of all necessary medical services and medications for this patient for the past three months. All current medications have been prescribed by our hemato-oncology department. Therefore, no medication reconciliation issues have been identified.

  • The recent lab results indicate a decreasing trend in the patient’s CEA level, potentially suggesting that the current regimen of FOLFIRI plus Avastin is effective. On the other hand, the gradually increasing CA199 level could imply a condition related to the pancreas, which aligns with the abdomen sonography conducted on 2023-02-09 suggesting suspected fatty infiltration of the pancreas? The latest lab results from 2023-06-26 showed normal readings in CBC, electrolytes, and renal and liver functions. The dosage of irinotecan in the FOLFIRI regimen has been increased to a regular dose (180mg/m2) during this hospitalization. No adjustments to the medication dosage are currently required.

    • 2023-06-16 CEA 2.54 ng/mL
    • 2023-05-05 CEA 3.14 ng/mL
    • 2021-10-20 CEA 10.61 ng/mL
    • 2023-06-16 CA199 109.70 U/mL
    • 2023-05-05 CA199 91.76 U/mL

700948877

231027

{Left overain cacner, High grade serous carcinoma, with liver mrtastasis, s/p Debulking surgery}

[lab data]

2022-05-15 HCV Genotyping Test HCV Not Detected
2022-05-13 HCV RNA-PCR (quantative) Target Not Detected IU/mL

2022-05-12 HBsAg Nonreactive
2022-05-12 HBsAg (Value) 0.41 S/CO
2022-05-12 Anti-HBc Reactive
2022-05-12 Anti-HBc-Value 6.22 S/CO
2022-05-12 Anti-HBs 0.79 mIU/mL
2022-05-12 Anti-HCV Reactive
2022-05-12 Anti-HCV Value 15.23 S/CO

[exam findings]

  • 2023-08-16 SONO - abdomen
    • Diagnosis:
      • Fatty liver, mild
      • Liver tumor, S8, r/o hemangioma or metastasis
      • GB stone
      • suspicious, Renal stone, right
    • Suggestion:
      • encourage exercise and diet adjustment.
      • correlate with other image study.
  • 2023-07-01 CT - abdomen
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • Liver tumors in S7 and S8, r/o liver metastasis, mild progression.
      • R/O lymphocele in right pelvic cavity.
      • Gallbladder stones.
      • Small lung nodule in right lower lung, stationary.
  • 2023-04-15 Gynecologic Ultrasonography
    • No obvious uterine or ovarian lesion
  • 2023-04-01 CT - abdomen
    • Findings
      • s/p hyesterectomy and salpingo-oophorectomy.
      • A poor enhancing lesion, 0.9cm, in S8 of liver.
      • Para-aortic lymph node metastasis, stationary.
      • No evidence of bowel obstruction.
      • A cystic lesion, 3.6cm, in right inguinal region, stationary.
      • No bony destructive lesion on these images.
    • Impression
      • Ovarian cancer, s/p operation
      • Liver and lymph node metastasis with stable disease
  • 2022-12-23 CT - abdomen
    • Findings: Comparison prior CT dated 2022/05/04.
      • S/P hysterectomy, oophorectomy, and omentum resection.
      • Prior CT identified two metastases 3 cm in S7 and 1.4 cm in S8 of the liver capsule area are noted again, decreasing in size that are c/w liver metastases S/P C/T with partial response.
        • In addition, prior CT identified a metastasis 0.7 cm in S8 of the liver dome is noted again, become calcification that is c/w metastasis S/P C/T with complete response.
      • Prior CT identified several metastatic nodes in para-aortic space are noted again, decreasing in size that are c/w metastatic nodes C/T with partial response.
      • There is mild wall thickening of left rectus sheath muscle at middle pelvis (Srs:303 Img:106) that may be tumor seeding or post-operative change. Follow up is indicated.
      • There is a cystic lesion 4 cm in right pelvis that may be lymphocele.
      • There is are few gallstones.
      • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
    • Impression:
      • Liver and LNs metastases S/P C/T show partial response.
      • There is mild wall thickening of left rectus sheath muscle at middle pelvis that may be tumor seeding or post-operative change. Follow up is indicated.
      • Lymphocele 4 cm in right pelvis is highly suspected.
  • 2022-12-23 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
    • Suggestion:
      • PPI use
  • 2022-09-14 Gynecologic Ultrasonography
    • ATH + BSO
    • IMP: Suspect RT adnexal cyst: 49x29mm
  • 2022-06-29 SONO - abdomen
    • Liver tumor, S4 and S7, suspected hemangioma
    • GB stone
  • 2022-06-16 Pure tone audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL; LE 31 dB HL.
    • R’t normal to moderately severe SNHL.
    • L’t normal to moderate SNHL. - 2022-06-13 CXR
    • Blunted right costophrenic angle.
  • 2022-05-19 Patho - ovary (tumor)
    • Diagnosis:
      • Lymph node, right iliac, dissection — Negative for malignancy (0/4)
      • Soft tissue, right iliac, excision — Metastatic serous carcinoma
      • Lymph node, right obturator, dissection — Negative for malignancy (0/5)
      • Lymph node, left iliac, dissection — Negative for malignancy (0/4)
      • Uterus, corpus, total hysterectomy — Negative for malignancy — Leiomyoma
      • Uterus, cervix, total hysterectomy — Negative for malignancy
      • Uterus, endometrium, total hysterectomy — Negative for malignancy
      • Ovary, right, oophorectomy — Metastatic serous carcinoma seeding on serosa
      • Fallopian tube, right, salpingectomy — Metastatic serous carcinoma seeding on serosa
      • Ovary, left, oophorectomy — High grade serous carcinoma
      • Fallopian tube, left, salpingectomy — Serous tubal intraepithelial carcinoma
      • Peritoneum, excision — Metastatic serous carcinoma
      • Omentum, infracolic omentectomy — Metastatic serous carcinoma
      • AJCC 8th edition: pStage IIIC, pT3cN0(if cM0), FIGO Stage: IIIC
        • or pStage IVB, pT3cN0(if cM1b), FIGO Stage: IVB
    • Microscopic Description:
      • Histologic Type:
        • Left ovary: High-grade serous carcinoma; The immunohistochemical stains reveal CK(+), PAX8(+), p53(aberrant expression (complete loss of expression)), WT-1(+), PR(-), and Napsin A(-).
        • Left fallopian tube: Serous tubal intraepithelial carcinoma (STIC) (0.2 x 0.1 mm)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not available
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not available
      • Other Tissue/ Organ Involvement (select all that apply): bilateral ovaries and fallopian tubes, peritoneum, omentum, right iliac soft tissue
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm)
      • Peritoneal/Ascitic Fluid: N2022-01890: Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: right iliac: 0/4; right obturator: 0/5; left iliac: 0/4
      • Additional Pathologic Findings: Leiomyomas are seen.
  • 2022-05-19 Patho - colorectal polyp
    • Colon, D-colon, s/p hot snare polypectomy — Tubulovillous adenoma with low grade dysplasia.
  • 2022-05-19 Patho - stomach biopsy
    • Stomach, low body, GC, s/p biopsy removal — Hyperplastic polyp
  • 2022-05-11 Gynecologic Ultrasonography
    • Pelvis mass: (1) 146x108mm, (2) 34.20mm
  • 2022-05-05 Gynecologic Ultrasonography
    • Multiple huge pelvic mass, the largest one is about 11.4x9.4cm without flow
  • 2022-05-04 CT - liver, spleen, biliary duct, pancreas
    • Findings:
      • There is a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus.
        • Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • There is ascites and smudggy appearance of the omentum that may be carcinomatosis? Please correlate with ascites cytology.
      • There are two well-defined poor enhancing masses measuring 3 cm in S7 and 1.4 cm in S8 of the liver capsule area with capsule defect that may be tumor seeding with indentation the liver capsule.
        • The differential diagnosis include liver metastases.
      • There is are several enlarged nodes in para-aortic space that may be metastatic nodes.
      • S/P Chest tube insertion, right.
        • Mild left side Pleura effusion is noted.
    • Impression:
      • Leiomyosarcoma of the uterus is highly suspected.
        • The differential diagnosis include ovarian cancer.
        • Please correlate with CA125.
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
      • Tumor seeding in S7 & S8 of the liver capsule are suspected.
        • The differential diagnosis include liver metastases.
      • Metastatic nodes in para-aortic space are suspected.
  • 2022-05-04 CXR
    • resolution of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-03 SONO - abdomen
    • IMP: Gallbladder stones (0.74cm, 0.76cm, 0.70cm).
  • 2022-05-02 Patho - lung wedge biopsy
    • Pleura, right, excision — chronic inflammation
    • Pleura, right, cyst, excision — cyst with chronic inflammation
    • Lung, RLL, wedge resection — pleural fibrosis and chronic inflammation
  • 2022-05-02 CXR
    • signficiant regression of Rt pleural effusion s/p chest tube and pigtail drain placement
    • small Lt pleural effusion
  • 2022-05-01 CXR
    • progression of moderate Rt pleural effusion as compared with previous image
    • thoracic aortic arch calcified atheriosclerotic plaque
    • small Lt pleural effusion
  • 2022-04-22 CT - lung/mediastinum/pleura
    • Massive right pleural effusion and mild left pleural effusion with consolidation over right lower lobe and left lower lobe
    • Hepatic low density lesion.
  • 2022-04-13 CXR
    • regression of Rt pleural effusion as compared with previous image
    • Linear band subsegmental atelectasis at Lt lung base
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-04-06 Cell block cytology
    • pathologic diagnosis
      • Dense inflammation, reactive change
    • macroscopic examination
      • 50 cc red turbid right pleural effusion
    • microscopic examination
      • Immunocytochemistry shows TTF-1(-), Napsin-A(-), P40(-), CK7(-) and calretinin(-) for carcinoma.
  • 2022-04-06 CXR
    • moderate Rt pleural effusion
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
    • mild levoscoliosis of the spine
  • 2022-04-06 SONO - chest
    • pleural effusion, moderate to massive, right
    • consolidation, RLL
  • 2022-04-01 Bronchodilator test, BT
    • Moderate restrictive lung defect without significant reversibility
  • 2022-03-30 SONO - abdomen
    • parenchymal liver disease
    • liver hemangioma, S8
    • GB stone
    • pancreatic head masked by gas
    • ascites, minimal
    • pleural effusion, bilateral
  • 2022-03-22 Thyroid Ultrasound
    • Goiter
  • 2022-03-03 SONO - chest
    • pleural effusion, trivial amounts
    • high risk of pneumothorax during chest tapping
    • hold chest tapping procedure
  • 2022-03-02 CXR
    • Rt subpulmonary effusion or Linear band subsegmental atelectasis at lung base
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • mild levoscoliosis of the spine
  • 2021-09-29, 2021-03-01, 2020-08-03, 2020-02-23 SONO - abdomen
    • Diagnosis
      • GB stones
      • Hepatic tumor, suspect hemangioma, S8
      • Probable parenchymal liver disease
      • Suspect renal stones, right
    • Suggestion
      • Please follow sonography in 3-6 mon
      • Please check tumor, hepatitis markers and LFTs q3-6 mon
  • 2018-08-28 CT - abdomen
    • Small heaptic lesion at surface up to 1.9cm with marginal enhancement and filling in change is found. Hemangioma is considered.
  • 2019-07-29, 2019-01-28, 2018-07-30, 2018-01-10 SONO - abdomen
    • Parenchymal liver disease
    • Liver tumor, nature?
    • Fatty infiltration of pancreas
    • GB stones
  • 2017-06-26 SONO - abdomen
    • Diagnosis
      • suspect liver parenchyma disease, incomplete exam of liver
      • liver tumor suspected hemangioma
      • gallstones
  • 2017-01-09 SONO - abdomen
    • Suspected, Parenchymal liver disease
    • GB stone
    • Suspected, Parenchymal renal disease

[MedRec]

  • 2023-08-16 SOAP Gastroenterology
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
  • 2022-06-08 SOAP Hemato-Oncology Xia HeXiong
    • Plan
      • Arrange Port-A insertion
      • Admission for 24 houirs CCr, audiometry and then C/T with TP
  • 2022-05-17 ~ 2022-05-23 POMR Obstetrics and Gynecology Zeng LunNa
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Left ovarian serous carcinoma, pT3cN0(if cM1b), FIGO Stage: IVB post Debulking surgery on 2022/05/19
      • Acute posthemorrhagic anemia due to blood lose about 1200 ml
    • CC
      • Accidentally found the pelvic mass, during last hospitalization   - Present illness
      • This is a 69 y/o woman with G3P3 and LMP at 54y/o. She had past history of (1) pleural effusion s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy for pleural effusion with benign pathology report. Spotting was noted once 2 weeks ago and no bleeding was mentioned. Other associated symptoms included urinary frequency, weight loss and right lower abdominal dullness. There were no pale conjunctiva, dyspnea, general malaise, orthostatic hypotension ,nausea, vomiting, no tarry/bloody stoool and brittle nails noted.
      • During last hospitalization, abdominal CT done on 2022.05.04 and leiomyosarcoma of the uterus was highly suspected. Therefore, she was tranferred to our GYN OPD for help. The GYN echo done on 2022.05.11 revealed pelvic mass (1) 14.6cmx10.8cm and (2) 3.4x2.0cm. Tumor marker was examinated on the same day and showd CA125 = 678.3 U/mL; CA199 = 5.98 U/mL; CEA = 0.42 ng/mL.
      • Under the impression of leiomyosarcoma, she was admitted on 2022.05.17 for debulking surgery.
    • Course of inpatient treatment
      • The patient was admitted on 2022/05/17 and underwent debulking surgery with abdominal hysterectomy+bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy on 2022/05/19. Due to blood loss 1200 ml and blood transfusion LP-RBC 4U and FFP 4U were given during operation.
      • We provided cefazolin IV form for 2 day and then shifted her antibiotics to cephalexin oral form. Post-operation wound was dry and clean without dehiscence, discharge, nor oozing. Her lab data on 2022/05/20 also showed no specific positive findings. Since all her general conditions were all improved and relatively stable, she discharged and she will have her OPD follow up next week.     
    • Discharge prescription
      • Keto (ketorolac 10mg) 1# QID
      • MgO 250mg 1# QID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# QID
      • cephalexin 500mg 1# QID
      • Cough Mixture (platycodon) 10mL QID
      • Anxiedin (lorazepam 0.5mg) 1# HS
  • 2022-05-01 ~ 2022-05-05 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Right pleural effusion status post three dimensional video-assisted thoracic surgery right lower lung wedge resection and pleurodesis and pleural biopsy on 2022-05-02
    • CC
      • Chest pain and exertional dyspnea for several months
    • Present illness
      • This is a 69 y/o woman who has no known systemic disease. She was a smoker who has been smoking cigarrete 1/2 ppd for 10 years. Chest pain and exertional dyspnea were noted in the past few months. The patient denied dyspnea, cough, running nose, fever nor chillness. As a result, she came to our hospital for help.
      • At the OPD of Chest Medicine, physical examination revealed decreased breathing sound in right lung field and regular heart sound. Chest X-ray showed RUL nodule and right pleural effusion. Chest sonography showed right trivial pleural effusion. Thoracentesis was done and pleural fluid analysis revealed exudate lymphocyte predominant. Pulmonary function test revealed FVC55%, compatable with lung restriction.
      • Under the impression of right pleural effusion, the patient was admitted to our ward for 3D VATS RLL wedge resection + pleurodesis + pleural biopsy.
    • Course of inpatient treatment
      • During admission, her vital signs were stable. 3D VATS RLL wedge + pleurodesis + pleural biopsy was done on 2022/05/02. She tolerated the procedure well and no discomfort was complained afterwards. Under stable condition, she will be discharged on 2022/05/05 and will be followed up at OPD.        

[consultation]

  • 2022-05-04 Obstetrics and Gynecology
    • Q
      • This 69 y/o woman with past hx of uterine myoma was admitted due to right pleural effusion. Three dimensional video-assisted thoracic surgery with right lower lung wedge resection, pleurodesis and pleural biopsy was done on 2022-05-02.
      • Urinary frequency was noted inrecent months. Body weight loss 5 kg was noted in 2 months. She denied abdominal pain, fullness, nor vaginal bleeding.
      • Abdominal CT on 2022-05-04 revealed a well-defined lobulated heterogeneous mass in the uterine fossa, measuring 14.2 cm in size (the largest dimension), and non-visualization of the normal uterus. Leiomyosarcoma of the uterus is highly suspected. The differential diagnosis include ovarian cancer.
      • Under the impression of suspected leiomyosarcoma of the uterus and ovarian cancer, we would like to consult you for evaluation.
    • A
      • S
        • 69 y/o, female, G4P3 (NSDx3)
        • Admitted on 2022/05/01 for VATS (Video-Assisted Thoracic Surgery)
        • Hx: s/p 3D VATS RLL wedge + pleurodesis + pleural biopsy on 2022/05/02
      • O
        • Abdominal CT on 5/4 revealed a well-defined lobulated heterogeneous mass in the uterine fossa
        • weight loss 5kg in 2months
        • WBC: 7510, Hb: 12.1
        • CT:
            1. Leiomyosarcoma of the uterus is highly suspected.
            • The differential diagnosis include ovarian cancer.
            • Please correlate with CA125.
            1. Carcinomatosis is highly suspected.
            • Please correlate with ascites cytology.
            1. Tumor seeding in S7 & S8 of the liver capsule are suspected.
            • The differential diagnosis include liver metastases.
            1. Metastatic nodes in para-aortic space are suspected.
            • sono: Multiple huge heterogenous pelvic mass, the largest is about 11.4x9.4cm without flow
          • CDS: no fluid
        • IMP:
          • Suspect uteine malignancy or ovarian cancer
        • P:
          • Please check CA125, CA199, CEA, SCC
          • OPD follow after 1 week

[surgical operation]

  • 2022-05-19
    • Surgery
      • Diagnosis
        • Ovarian tumor suspected malignancy with intraperitoneal seeding and liver metastasis
      • Operation
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)   - Finding
      • Ovarian tumor, suspected malignancy.
      • Frozen: not performed
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, dense contact with bladder
      • Adnexa:
        • LOV: 14x10cm, capsule intact, adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents and necrotic tissue.
        • ROV: 5x4 cm, capsule not intact,adhesion to bowels and posterior uterine wall; intraoperative rupture (+) with papillary contents
        • Fallopian tube: bilateral engorged
      • CDS: invisible due to tumor mass occupied, totally obliterated
      • Ascites: bloody, about 300 ml, cytology was performed
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
        • s/p dissection of right iliac LNs, right obturator LNs and left iliac LNs
      • Omentum: infracolic omentectomy was done.
      • Liver: miliary tumor seeding(+), bean sized over liver surface
        • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • Appendix: not seen
      • After the operation, suboptimal debulking surgery was achieved.
      • Residual tumor: multiple tumor seeding over rectum, peritoneal wall s/p partial excision; suspected liver and subdiaphragmatic miliary tumor seeding
      • Partial intestine bowels adhesion
      • Due to the intestine was soaking in the ascites fluid, inflammation was noticed
      • Estimated blood loss: 1200ml (neovascular oozing)
      • Blood transfusion:s/p blood transfusion with pRBC 2u
      • Complication: none       
      • abdominal drainage tube x1 at right CDS
  • 2022-05-02
    • Surgery
      • 3D VATS RLL wedge + pleurodesis + pleural biopsy.
    • Finding
      • One nodualr lesion was noted over RLL, suspected intrapulmonary LN. A mount of pleural effusion was also noted over right pleural cavity, about 1450mL.
      • One 24 Fr. straight chest tube and 14 Fr. pig-tail was inserted via right 8th ICS.

[chemotherapy]

  • 2023-10-26 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-31 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-03 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-15 - paclitaxel 140mg/m2 200mg NS 500mL 3hr + carboplatin AUC 4 450mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-06-16 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-05-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-04-27 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-03-31 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-03-08 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-02-17 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2023-01-30 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-12-23 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-12-02 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-11-11 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-10-24 - bevacizumab 15mg/kg 600mg NS 400mL 1.5hr (Avastin maintenance)
    • dexamethasone 4mg + NS 250mL
  • 2022-09-29 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-09-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-09-19 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-08-02 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-08 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-06-17 - bevacizumab 15mg/kg 600mg NS 100mL 90min + paclitaxel 175mg/m2 210mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-27

After reviewing the PharmaCloud and HIS5 records, no concerns were found.

The CA125 levels have been within the normal range since 2022-09-09. Following a CT scan on 2023-07-01 that indicated mild progression of liver metastasis, paclitaxel and carboplatin were reintroduced at a reduced dosage compared to their administration (x6) in 2022 Jun to Sep. The latest lab results are generally within normal limits.

701208485

231027

{pancreatic cancer T4N1M0 stage III}

[exam findings]

  • 2023-08-28 MRI - pancreas

    • History and indication: Pancreatic cancer
    • With and without contrast MRI of pancreas revealed:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
      • Tiny liver cysts.
      • Mild splenomegaly. Small caliber of intrahepatic portal vein.
    • IMP:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with distal p-duct dilatation.
      • Mild splenomegaly.
  • 2023-08-17 EGD

    • ERBD, Bonastent(SEMS), insitu
    • Post status IHD plastic stent removal
    • Duodenal shallow ulcers
  • 2023-08-13 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • Biliary stricture s/p removal of SEMS & s/p ERBD (Bonastent(SEMS) placement in right IHD, plastic stent in left IHD)
    • Chronic cholangitis
  • 2023-05-26 MRI - pancreas

    • Findings:
      • S/P metalic stent implantation at CHD and CBD, causing artifact in the surrounding area.
        • The distal end of this stent may be retracted from the duodenum into the distal CBD. please correlate with clinical condition.
      • There is mild dilatation of IHDs. please correlate with clinical condition.
      • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
        • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
      • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
      • A renal cyst measuring 0.8 cm in right upper pole is noted.
    • Impression:
      • Prior MRI identified adenocarcinoma of the pancreatic head and body is noted again, stationary. Follow up contrast enhanced dynamic CT 3 months later is indicated.
  • 2023-02-13 MRI - pancreas

    • Findings
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with p-duct stenting.
      • Tiny liver cysts.
    • IMP:
      • S/P CBD stenting with artifact. Mild dilatation of IHD.
      • Pancreatic head cancer (2.3cm) with p-duct stenting.
  • 2023-02-10 PET scan

    • Mild glucose hypermetabolism in the head and body of the pancreas. Residual malignancy should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the central portion of the uterus. Either hyperemia or inflammation may show this picture.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-01-09 T - L spine AP + Lat.

    • S/P metalic stent implantation from IHD to duodenum.
  • 2022-12-26 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • Biliary stricture s/p removal of SEMS & s/p Kaffet stent placement (8mm x 50mm)
    • Choledocholithiasis s/p retrieval balloon removal
    • Chronic cholangitis
  • 2022-12-23 CT - abdomen

    • Findings
      • S/P metalic stent implantation at CHD and CBD.
        • The distal end of this stene may be retracted from the duodenum into the distal CBD.
        • In addition, There is moderate dilatation of IHDs and CHD.
        • Obstruction of the stent is highly suspected.
      • S/P pigtail catheter implantation at the gallbladder
      • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
        • Total encasement of splenic vein and the trifurction of splenic vein, superior mesenteric vein, and portal vein is still noted.
      • The trifurcation of celiac trunk, common hepatic artery and splenic artery shows small size that is c/w tumor encasement.
      • A renal cyst measuring 0.8 cm in right upper pole is noted.
    • Impression:
      • Obstruction of the stent in the CHD and CBD is noted.
      • Prior CT identified adenocarcinoma of the pancreatic head and body is noted again, stationary.
  • 2022-12-22 Percutaneous transhepatic gallbladder drainage, PTGBD

  • 2022-12-22 SONO - abdomen

    • Pancreatic cancer in resolution, neck part (proved by EUSFNB)
    • CBD obstruction s/p SEMS
    • Parenchymal liver disease
    • splenomegaly
  • 2022-12-07 KUB

    • S/P metalic stent implantation from IHD to duodenum.
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.
    • Fecal material store in the colon.
  • 2022-12-06 ECG

    • Sinus tachycardia
    • Right axis deviation
  • 2022-10-29 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.1cm, mild regression).
      • S/P CBD stenting. Wall thickening of gallbladder. Dilatation of bil. IHDs.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.1cm, mild regression).
      • S/P CBD stenting. Dilatation of bil. IHDs. Wall thickening of gallbladder.
  • 2022-08-23 CT - abdomen

    • Findings
      • S/P biliary stenting. Stationary pancreatic head tumor as compare with CT study on 2022-06-23.
      • Right renal cyst, 0.8cm.
      • Cystic lesion, 2.8cm in left adnexa, r/o left ovarian cyst.
    • Impression:
      • Pancreatic head cancer, s/p stenting, with stationary.
      • Right renal cyst.
      • R/O left ovarian cyst.
  • 2022-06-23 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.8cm, stable).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.8cm, stable).
      • S/P CBD stenting. Left portal vein thrombosis.
  • 2022-05-24 KUB

    • S/P metalic stent implantation from IHD to duodenum.
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition or CT.
  • 2022-04-11 CT - abdomen

    • Findings
      • Pancreatic head cancer (2.8cm).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
      • Right renal cyst (0.9cm).
      • Left liver cyst (0.3cm).
    • IMP:
      • Pancreatic head cancer (2.8cm).
      • S/P CBD stenting. Wall thickening of gallbladder. Left portal vein thrombosis.
  • 2022-02-21 KUB

    • S/P metalic stent implantation from IHD to duodenum.
  • 2022-02-16 KUB

    • S/P biliary stenting?
    • Non-specific bowel gas pattern.
    • Calcifications in the pelvic cavity, could be due to phleboliths.
    • Mild lumbar spondylosis.
  • 2022-01-24 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • biliary obstruction s/p SEMS
    • chronic cholangitis
  • 2022-01-14 CT - liver, spleen, biliary duct, pancreas

    • There is filling defects at left lobe portal vein that is c/w thrombosis and the etiology may be thrombophlebitis.
    • Adenocarcinoma of the pancreatic head-body with portal vein, splenic vein, and celiac trunk encasement is suspected.
  • 2022-01-12 Patho - pancreas biopsy

    • Pancreas, head, EUSFNB — adenocarcinoma, moderately differentiated
    • Section shows pancreas tissue with infiltration of neoplastic glands in fibrous stroma.
    • IHC: CK(+)
  • 2022-01-10 ERCP (Endoscopic Retrograde CholangioPancreatography)

    • biliary obstruction s/p brushing cytology & plastic stent placement
    • chronic cholangitis
    • reflux esophagitis

[MedRec]

  • 2023-08-22 SOAP Radiation Oncology Wang YuNong
    • Plan
      • CT-simulation will be arranged according to CCRT date.
      • Plan to deliver 45 Gy/ 25 fx to the pancreatic tumor and adjacent lymphatic drainage area.
  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • Plan
      • Add IV Lorazepam and Olan. Shift Atropine to 0.5 mg SC
      • CCRT with weekly CDDP and pembrolizumab during 2023-09-05 admission

[chemotherapy] (not completed)

  • 2023-10-28 - pembrolizumab 200mg NS 100mL 1hr
    • diphenhydramine 30mg + NS 250mL
  • 2023-10-04 - carboplatin AUC 1.5 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)
    •                       NS 250mL D1   + dexamethasone 4mg    + palonosetron 250ug                       + aprepitant 150mg PO + lorazepam 1mg
  • 2023-09-26 - pembrolizumab 200mg NS 100mL 1hr D1 + carboplatin AUC 3 150mg NS 250mL 2hr D2 (carbo AUC 1.5, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
  • 2023-09-12 - cisplatin 40mg/m2 60mg NS 500mL 3hr D1 (CDDP, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1 + dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 150mg PO D1-3
  • 2023-09-05 - pembrolizumab 200mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 500mL 3hr D2 (CDDP, CCRT)
    • diphenhydramine 30mg D1 + NS 250mL D1-2 + dexamethasone 4mg D2 + palonosetron 250ug D2 + lorazepam 1mg D2 + aprepitant 125mg PO D2
  • 2023-08-09 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + atropine 0.5mg SC D1 + lorazepam 1mg ST D1 Q12H D2 + aprepitant 125mg PO D1-3 + NS 250mL D1 + NS 500mL Q8H D2-3
  • 2023-07-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
  • 2023-06-13 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL] D1 + aprepitant 125mg PO D1-3
  • 2023-05-02 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-04-10 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 120mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-03-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 675mg NS 250mL + fluorouracil 2400mg/m2 4050mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-02-20 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 117mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2023-01-11 - pembrolizumab 200mg NS 100mL 1hr + oxaliplatin 70mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg IVD + NS 250mL] D1
  • 2022-11-29
  • 2022-11-08
  • 2022-10-18
  • 2022-09-26
  • 2022-08-15
  • 2022-07-25
  • 2022-07-12
  • 2022-06-27
  • 2022-06-13
  • 2022-05-23
  • 2022-05-04
  • 2022-04-20
  • 2022-03-30
  • 2022-03-16
  • 2022-03-02
  • 2022-02-10 ~ undergoing - FOLFIRINOX + pembrolizumab

==========

2023-10-27

[leukopenia]

The WBC count hit its lowest point in 2023 on 2023-10-26 at 1.97K/uL. The latest administration of the chemotherapy drug carboplatin took place on 2023-10-04, while the most recent radiotherapy session was on 2023-10-06. Both chemotherapy and radiotherapy can lead to leukopenia.

  • 2023-10-26 WBC 1.97 x10^3/uL *
  • 2023-09-25 WBC 4.07 x10^3/uL
  • 2023-09-18 WBC 6.05 x10^3/uL
  • 2023-09-11 WBC 5.99 x10^3/uL
  • 2023-09-05 WBC 5.88 x10^3/uL

Granocyte (lenograstim) has been prescribed to address the leukopenia, which is an undisputed intervention measure.

[timely medication switch resolves creatinine spike]

There was an increase in serum creatinine levels in late Sep compared to earlier baseline data. The cisplatin administered on 2023-09-12 was changed to carboplatin on 2023-09-26. Currently, a decrease in creatinine levels is being observed, indicating that the change in medication appears to have been a timely decision.

  • 2023-10-26 Creatinine 0.72 mg/dL
  • 2023-09-25 Creatinine 1.12 mg/dL *
  • 2023-09-18 Creatinine 0.90 mg/dL
  • 2023-09-11 Creatinine 0.58 mg/dL
  • 2023-09-05 Creatinine 0.51 mg/dL
  • 2023-08-22 Creatinine 0.44 mg/dL
  • 2023-08-13 Creatinine 0.43 mg/dL
  • 2023-08-09 Creatinine 0.44 mg/dL

2023-09-27

After reviewing both the PharmaCloud database and the HIS5 records, no reconciliation issues were identified.

After the initiation of FOLFIRINOX + pembrolizumab in 2022-02, the CEA level had been remained in the single digits between 2022-06 and 2023-02.

Then platinum-based CCRT was initiated in early 2023-09, and there was a slight decrease in the double-digit CEA level.

  • 2023-09-15 CEA (NM) 14.341 ng/ml
  • 2023-08-25 CEA (NM) 14.737 ng/ml
  • 2023-07-04 CEA (NM) 12.402 ng/ml
  • 2023-06-20 CEA (NM) 10.795 ng/ml
  • 2023-04-13 CEA (NM) 11.154 ng/ml
  • 2023-02-22 CEA (NM) 12.664 ng/ml
  • 2023-02-10 CEA (NM) 7.731 ng/ml
  • 2023-01-13 CEA (NM) 8.882 ng/ml
  • 2023-01-13 CEA (NM) 9.221 ng/ml
  • 2022-11-02 CEA (NM) 7.296 ng/ml
  • 2022-08-29 CEA (NM) 6.091 ng/ml
  • 2022-06-29 CEA (NM) 3.417 ng/ml
  • 2022-06-28 CEA (NM) 4.084 ng/ml
  • 2022-04-12 CEA (NM) 12.119 ng/ml
  • 2022-02-11 CEA (NM) 37.004 ng/ml

Based on the lab results from 2023-09-25, both AST and ALT readings are < 2x ULN (silymarin in use), with an eGFR of 55. Therefore, there is no need for medication dose adjustment.

2023-09-06

Our gastroenterologist prescribed a two-month supply of Nexium (esomeprazole) on 2023-08-17, however the drug is currently absent from the active medication list. Please verify whether this drug is no longer needed for the patient’s condition.

2022-03-31

  • Pancreatic adenocarcinoma with or without BRCA1/2 or PALB2 mutations, FOLFIRINOX is preferred; this patient has been receiving this regimen since 2022-02-10.
  • Results of liver and kidney function tests reported on 2022-03-30 were normal, CBC readings were slightly lower, the latter should not be likely to affect treatment in this hospital stay.
  • No issue with current medication.

700335852

231026

[lab data]

2023-08-03 RPR/VDRL Nonreactive
2023-08-03 HBsAg Nonreactive
2023-08-03 HBsAg (Value) 0.31 S/CO
2023-08-03 Anti-HCV Nonreactive
2023-08-03 Anti-HCV Value 0.11 S/CO
2023-08-03 HIV Ab-EIA Nonreactive
2023-08-03 Anti-HIV Value 0.09 S/CO
2023-08-03 Anti-HBc Nonreactive
2023-08-03 Anti-HBc-Value 0.11 S/CO

[exam findings]

  • 2023-10-24 Aortography - thoracic
    • Diagnostic aortography was performed
    • Imaging findings:
      • Type I aortic arch.
      • No critical stenosis of bilateral proximal carotid and vertebral arteries.
  • 2023-10-24 Carotid angiography Bilat, Vertebral angiography
    • Diagnostic intraarterial angiography of brain vasculature by way of bilateral internal carotid and left vertebral arteries was performed
    • Imaging findings:
      • Short segmental moderate stenosis of left distal ICA (petrous-cavernous segment) with wall irregularity. Compatible with encasement by tumor. Suggest placement of one stent.
      • One wide-neck saccular aneurysm (neck:5.5mm, diameter:6.8mm, depth:3.3mm) over right distal ICA (petrous segment). Suggest stent-assisted coiling.
  • 2023-10-24 CT - brain
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
      • Mass lesion (5.0cm) over left nasopharyngeal space. Compatible with nasopharyngeal cancer. Invasion of left carotid space by this tumor. Encasement of left ICA by this tumor. Suggest check cerebral angiography and stenting.
  • 2023-10-24 ECG
    • Atrial fibrillation with rapid ventricular response
    • Incomplete right bundle branch block
    • Nonspecific ST abnormality
  • 2023-09-20 Transrectal Ultrasound of Prostate, TRUS-P
    • Prostate
      • Size of prostate: 4.5 (T) cm x 2 (L) cm x 4.4 (AP) cm = 22 cc
      • Size of adenoma: 3.5 (T) cm x 1.6 (L) cm x 2.8 (AP) cm = 8.3 cc
    • Seminal vesicles
      • Symmetricity:
        • Size: L’t 1.1 x 0.4 cm
        • Size: R’t 1.3 x 0.4 cm
  • 2023-09-17 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left ventricular hypertrophy
    • Nonspecific T wave abnormality
  • 2023-08-11 CT - chest
    • no neoplastic LAP in chest and abdomen.
    • extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD.
    • extensive LAP in the neck due to lymphoma.
    • chronic cystitis?
  • 2023-08-07 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-08-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 32) / 146 = 78.08%
      • LVEF (%) = 78
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Dilated LV; normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Aortic valve sclerosis with mild AS (AVA (Doppler) = 1.79 cm² ,Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR.
      • Marked sinus bradycardia during exam.
  • 2023-08-04 PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
  • 2023-08-02 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:3(T_value) N:3(N_value) M:____(M_value) STAGE:____(Stage_value)
  • 2023-07-25 Aspiration Cytology - thyroid
    • Left neck mass — Positive for malignant tumor, in favor of lymphoma
      • NOTE: Correlation with biopsy result and clinical findings is recommended.
    • Smears show non-cohesive high-grade tumor cells with large hyperchromatic nuclei, irregular nuclear contour, mitotic activity, variable-sized nucloeli and scanty cytoplasm.
  • 2023-07-25 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • Section shows several pieces of respiratory epithelium lined tissue with infiltration of large lymphoid cells.
    • The immunohistochemical stains show CD3(-), CD20(+), CD56(-), CK(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), C-MYC(+), and MUM1(+). The Ki-67 is > 90%.
  • 2023-07-25 SONO - head and neck soft tissue
    • Clinical Impression/Intent: left neck level II mass
    • Sonographic Impression: left neck level II confluent LAP, R/O malignancy
    • Diagnosis: left neck level II confluent LAP, R/O malignancy, s/p FNA

[MedRec]

  • 2023-08-01 ~ 2023-08-16 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Nasopharynx diffuse large B-cell lymphoma, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Hyperlipidemia, unspecified
      • Insomnia, unspecified
      • Constipation, unspecified
    • CC
      • Left tinnitus with left neck mass noted for 2 months+ odynophagia and blood tinged sputum in the morning noted for 2 weeks.
    • Present illness
      • This 75-year-old man has history of diabetes mellitus and hypertension for years under regular medication control.
      • According to the patient’s statement, left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
      • After the biopsy, left odynophagia and left headache were complained.
      • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
      • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up.
    • Course of inpatient treatment
      • After admission, arrange a series of study and examination. The neck MRI revealed oropharynx, nasopharynx and Pterygoid structures tumor, with unilateral lymph nodes extension below the caudal border of cricoid. The whole body PET scan revealed compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm and involving multiple bone or bone marrow as mentioned above (stage IV).
      • Due to left headache persist, pain control with Volna-K 1# po q6h, Acetal 1#po prnq6h for pain control.
      • Under the impression of large B-cell lymphoma, we consult hema-oncologist for further evaluation, hepatitis and AIDS, Syphilis titer were done.
      • The hema-oncologist has explained to the family about further work up examination and the follow up treatment include bone marrow aspiration, port-A implantation and chemotherapy etc. The patient’s family agreed with the treatment plan.
      • Bone marrow was done on 2023/08/07, pathology Section shows piece(s) of bone marrow with 30% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present. Confirmed as the IV stage after discussion at the team meeting. The port-A implantation are scheduled on 2023/08/08.
      • 2D echo was done before chemotherapy on 2023/08/07 showed LVEF: 78%, 1. Dilated LV; normal LV systolic function with normal wall motion, 2. Concentric LVH, dilated LA; LV diastolic dysfunction Gr II, 3. Normal RV systolic function, 4. Aortic valve sclerosis with mild AS (AVA(Doppler) = 1.79 cm², Mean aortic pressure gradient = 9 mmHg); moderate MR; mild TR; mild PR, 5. Marked sinus bradycardia during exam.
      • Discussion with family members about disease condition and treatment plan on 2023/08/09, they understand and consent to treatment. Follow up whole CT image on 2023/08/11 showed no neoplastic LAP in chest and abdomen, extensive emphysema and interstitial fibrosis in RLL, favor smoking related lung disease. extensive 3V-CAD, extensive LAP in the neck due to lymphoma, chronic cystitis?
      • He received chemotherapy with R-miniCHOP (Rituximab 375mg/m2, Cyclophosphamide 400mg/m2, Adriamycin 25mg/m2, Vincristine 1mg, Prednisolone 40mg) on 2023/08/11~2023/08/15(C1).
        • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
        • Tramacet 37.5 & 325mg/tab 1# PO Q6H, Limadol 100mg/2mL/amp 50mg IVD PRNQ8H for pain control.
        • Euricon 50mg/tab 1# PO QD before chemotherapy. IVF for avoid tumor lysis syndrome.
        • Type 2 diabetes mellitus with Diet control an check finger sugar. Uformin 500mg/tab 1# PO TIDCC and Trajenta 5mg/tab 1# PO QD was give for blood sugar control.
        • Hypertension with Sevikar F.C. 5 & 20mg/tab 1# PO QD.
        • Hyperlipidemia with CRESTOR 10mg/tab 1# PO QW1357.
        • Insomnia with Anxiedin 0.5mg/tab 1# PO HS.
        • Constipation with Through 12mg/tab 1# PO HS.
      • Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, he was discharged on 2023/08/16 and OPD followed up later.       
    • Discharge diagnosis
      • Euricon (benzbromarone 50mg) 1# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg)
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Through (sennoside 12mg) 1# HS
  • 2023-04-16 SOAP Metabolism and Endocrinology
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy without macular [E08.319]
      • Mixed hyperlipidemia [E78.2]
      • Essential hypertention, unspecified [I10]
      • Chronic kidney disease, stage 3 (moderate) [N18.3]
      • Nontoxic multinodular goiter [E04.2]
      • Hepatitis [K75.81]
    • Prescription
      • Crestor (rosuvastatin 10mg) 1# QW1357
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2017-03-14 SOAP Cardiology
    • Diagnosis:
      • HCVD, unspecified, without CHF [I11.9]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Dyslipidemia ; other and unspecified hyperlipidemia [E78.4]
    • Prescription
      • Eurodin (estazolam 2mg) 1# HS
      • Eazide (trichlormethiazide 2mg) 1# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
  • 2017-03-14 SOAP Metabolism and Endocrinology
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Essential hypertention, unspecified [I10]
      • Nontoxic multinodular goiter [E04.2]
      • Arterial embolism and thrombosis of lower extremity [I74.4]
    • Prescription
      • Trajenta (linagliptin 5mg) 1# QD
      • Glucobay (acarbose 100mg) 0.5# TIDAC
      • Robestar (rosuvastatin 10mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2017-03-14 SOAP Nephrology
    • Diagnosis: Renal failure, unspecified, uremia NOS [N19]

[consultation]

  • 2023-10-12 Radiation Oncology
    • Q
      • This 75-year-old man patient is a case of Nasopharynx diffuse large B-cell lymphoma with multiple lymph node and bone invasion, non-GCB type, BCL6(-), C-MYC(+) and BCL2(+), stage IV s/p chemotherapy with R-miniCHOP from 2023/08/11~2023/09/26 for 3 cycles.
      • This time, for left neck lymph node pain with progression (8x6cm -> 9x8cm). Now, for evaluate radiotherapy to left neck lymph node. Thank you.
    • A
      • Due to left neck lymph node pain with progression (8x6cm -> 9x8cm), palliative RT is indicated.
      • CT-simulation will be arranged on 10/19.
      • Plan to deliver at least 32.5 Gy/ 13 fx to the NP tumor and Lt neck LAPs.
      • RT will start around 10/23.
      • Possible tumor lysis symdrome should be monitored during the treatment.
  • 2023-08-02 Hemato-Oncology
    • Q
      • This 75-year-old man has history of DM and H/T for years under regular medication control.
      • The left neck palpable mass noted for 2 years. The left neck mass about 1cm in size initially. Due to left neck mass enlarge with left side tinnitus, left nasal blood tinged discharge noted in recent 2 months, he came to our ENT OPD for help. Physical examination revealed left nasopharyngeal tumor, left neck palpable mass 6 cm in size. Nasopharyngeal and left neck mass biopsy was done.
      • The pathology revealed diffuse large B-cell lymphoma, non-GCB type.
      • Under the diagnosis of large B-cell lymphoma, he was admitted for cancer work up. We request your consultation for further management.
    • A
      • Arrange PET scan for staging.
      • We will arrange bone marrow tomorrow.
      • Consult GS for port A insertion.
      • Please arrange our OPD after discharge.

[radiotherapy]

[immunochemotherapy]

  • 2023-10-16 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP, DC Adriamycin 25mg/m2 for prepare radiotherapy to left neck lymph node)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-26 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-01 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-11 - rituximab 375mg/m2 600mg NS 500mL 10hr + cyclophosphamide 400mg/m2 500mg NS 250mL 30min + vincristine 1mg/m2 1mg NS 50mL 10min + doxorubicin 25mg/m2 30mg NS 50mL 24hr + prednisolone 40mg/m2 60mg QD PO D1-5 (R-miniCHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-26

[withhold doxirubicin until heart problems are ruled out]

Based on the PharmaCloud database, no medication discrepancies were found.

Given that the ECG from 2023-10-24 indicated atrial fibrillation with rapid ventricular response, incomplete right bundle branch block, and nonspecific ST abnormality, it may be prudent to temporarily suspend the use of doxorubicin in the planned R-miniCHOP until cardiac symptoms improve.

2023-10-11

On 2023-09-06, our endocrinologist provided a repeat prescription for Crestor (rosuvastatin), Kentamin (Vit B1, B6, B12), Sevikar (amlodipine, olmesartan), Trajenta (linagliptin), and Uformin (metformin) to manage the patient’s existing conditions, these drugs are currently in use. Since this hospital stay, blood glucose levels have consistently ranged from 120 to 200 mg/dL. There are no inconsistencies in medication.

Recent lab results indicate that the WBC count remains above 3K/uL and there is no evidence of tumor lysis syndrome. While the LDH level remains in the normal range, the B2 microglobulin level reached 3646 ng/mL in mid-Sep. There’s no need to adjust the dose of the current medications, as the patient’s kidney and liver function tests are within normal limits.

2023-08-09

No recent lab results for LDH or beta-2-microglobulin were found in HIS5. If needed, initiate testing to establish a baseline prior to treatment.

700013816

231025

[lab data]

2023-10-25 HBV DNA-PCR (quantitative) 143000 IU/mL
2023-10-24 Anti-HBs 0.66 mIU/mL

2023-10-24 HBsAg Reactive
2023-10-24 HBsAg (Value) 222.81 S/CO

2023-10-24 Anti-HCV Nonreactive
2023-10-24 Anti-HCV Value 0.08 S/CO

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

2023-06-30 HLA A-high 11:01
2023-06-30 HLA A-high 33:03
2023-06-30 HLA B-high 46:01
2023-06-30 HLA B-high 58:01
2023-06-30 HLA C-high 01:02
2023-06-30 HLA C-high 03:02

2023-06-30 HLA DQ-high 02:01
2023-06-30 HLA DQ-high 03:03

2023-06-30 HLA DR-high 03:01
2023-06-30 HLA DR-high 09:01

2023-06-08 HBsAg (NM) Negative
2023-06-08 HBsAg Value (NM) 0.652
2023-06-08 Anti-HCV (NM) Negative
2023-06-08 Anti-HCV Value (NM) 0.076

2023-06-07 Aspergillus Ag Negative
2023-06-07 Aspergillus Ag Value 0.07 Ratio

[exam findings]

  • 2023-10-23 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Nonspecific ST abnormality
    • Prolonged QT
  • 2023-10-23 CT - abdomen
    • Abdominal CT without IV enhancement revealed:
      • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
      • Cardiomegaly is noted.
      • Bilateral mild pleural effusion is found.
      • Calcified coronary arteries is found.
      • Increased pulmonary vasculature is found.
    • Imp:
      • Minimal infiltration at perirenal fat over bilateral sides is found. r/o pancreatitis.
      • Mild bilateral pleural effusion
  • 2023-10-23 KUB
    • Compression fracture of L2.
    • Non-specific small bowel and colon gas pattern.
    • A calcified spot at RLQ.
  • 2023-10-23 ECG
    • Sinus rhythm with Premature atrial complexes
    • Prolonged QT
  • 2023-10-20, -10-09 CXR
    • S/P PICC catheter insertion via right forearm.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-10-09 SONO - artery
    • Patent bilateral lower limbs arteries.
    • Tissue edema at bilateral lower limbs.
  • 2023-10-06 SONO - vein
    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral posterior vein engorgement, with perforator veins draining off lower limb soft tissue edema
  • 2023-09-14 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Negative for malignancy (1~2 % of blasts)
    • Microscopically, it shows normal ellularity of bone marrow (approximately 30%) and presence of trilineage hematopoietic cells. Myeloid and eythroid tatio is 3:1. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in normal in numbers (2 of HPF)and demonstate no significant morphologic abnormalities. Blast-like cells (CD117+, 1~2%) are present. Monocytic lineage cells are highlighted by CD68 & CD163 and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+), CD71 (+), TdT (-), CD61 (+).
  • 2023-09-13 Cardiac Catheterization
    • We try to puncture left basilic vein by peripheral echo guiding successful, but wire could not enter vessel
    • Then we try to pucnture right basilic vein successful. Then micro-sheath advanced. Because of prior wire demage. Another terumo wire and micro-puncture site was used.
    • Final, after successful pucnture. PICC catheter was advanced to SVC and RA junction smoothly.
  • 2023-07-24 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Acute monocytic / monoblastic leukemia
    • Microscopically, it shows hypercellularity of bone marrow (approximately > 90%) and markedly proliferation of monocytic lineage of immature mononuclear leukemic cells (highlighted by CD68 & CD163). Erythroid lineage is decreased in numbers and demonstrate maturation. Megakaryocytes are present in normal in numbers (3 per HPF) and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34 (<1%), CD20 (<1%), CD138 (focal+, 1~2%), MPO (+, >95%), CD71 (focal+, 2%), CD68 (+, >95%), TdT(<1%)., CD163 (+, 60%), CD117 (+, 5~10%).
  • 2023-06-12, -06-09 CXR
    • s/p PICC inserted via Lt arm, tip in SVC
    • extensive heterogeneous consolidation in both lungs in progression
    • moderate enlarged cardiac silhoutte
  • 2023-06-07 Cardiac Catheterization
    • We perform PICC under the cath room and fluroscopy guiding
      • Left basilic vein was puncture by peripheral echo guiding. Terumo wire in basilic to axillary vein.
      • The sheath advanced to puncture site and
      • A peripherally inserted central catheter (PICC) was implanted to SVC under the fluroscopy guiding.
    • Conclsuion
      • PICC was implanted via left brachial vein successful.
  • 2023-06-07 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Compatible with acute monoblast/monocytic leukemia
    • The sections show hypercellular marrow (85%). The marrow space is replaced by a population of medium to large-sized immature cells with round to oval, ocasional distorted nucleus, and abundant cytoplasm. Numerous mitotic figures can be found.
    • IHC: CD34 (<3% +), CD117(10% +), MPO(30%+), and CD68(70% +). The finding is compatible with acute monoblastic/monocytic leukemia. Suggest bone marrow smear, flow cytometry and clinic correlation.
  • 2023-06-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (178 - 93) / 178 = 47.75%
      • 2D (M-simpson) = 48
    • Conclusion:
      • Dilated LV with hypokinesia of posterior wall, lateral wall; impaired LV systolic function.
      • Preserved RV systolic function.
      • Gr II LV diastolic dysfunction and impaired RV relaxation; moderately dilated LA.
      • Degenerative changes of mitral valve with severe MR; moderate TR; mild PR; dilated aortic root with mild AR.
      • Possible moderate to severe pulmonary hypertension (the estimated systolic PA pressure > 62 mmHg).
      • Mild aortic root calcification.
  • 2023-06-06 CXR
    • S/P nasogastric tube insertion
    • S/P endotracheal intubation with the tip beyond the carina
    • extensive, multifocal consolidation, in both lungs
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2023-06-05 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-06-01 CXR
    • Ground glass opacity in LLL.
    • Atherosclerosis of the aorta.
  • 2023-06-01 ECG
    • Sinus rhythm with Premature atrial complexes
    • Otherwise normal ECG

[MedRec]

  • 2023-07-22 ~ 2023-08-23 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Acute monoblastic/monocytic leukemia, Karyotype:46~47,XY,+11[cp4]
      • Chronic renal failure, stage 4
      • Hypokalemia
      • hypoalbuminemia
      • Hypocalcemia
    • CC
      • for regular chemotherapy
    • Present illness
      • This 70 y/o male with type 2 DM without treatment.
      • According to his statement, he suffered from fever for one month and shortness of breath on exertional for 2 weeks. He went to our OPD for help then referred to ER for WBC 72170/uL, Plat 48K, Hgb 6.9g/dL. Leukocytosis with white count 100280/uL, Hb:7.0 g/dl, PLT:47K, hypocalcemia (Ca:1.97 mmol/L) and elevated LDH (865U/L). Urine examination revealed no pyuria. Chest film revealed no pneumonia. Feburic self-paid and blood transfusion 1U/day by hematology suggested. Under the impression of acute leukemia, he was admitted to evaluation and management on 2023/06/02, but dyspnea devloped happened, so be transffered to ICU on 2023/06/06.
      • Bone marrow was done on 2023/6/6 and report showed compatible with acute monoblast/monocytic leukemia s/p first chemotherapy as 7-3 on 2023/06/20.
      • This time, he denied fullness in this week and he was admitted for refular chemotherapy on 2023/07/22.
    • Course of inpatient treatment
      • After admission, he received bone marrow and pending report. DC Hydrea during hospitalization. Potassium and Calcium are correct during hospitalization. Comfirm VS for newly chemotherapy as FLAI. Blood transfusion frequency for anemia and thrombocytopenia. Antibiotics as Cefepime and Targocid for neutropenic fever control. No evidence of bacterermia. Proctologist was consulted for anal pain, who diagnosis of acute anal fissure over 1 o’clock, no pus now. Transamine for few bleeding sign. After treatment, his WBC with neutrophil recovery and no fever. PICC was removed on 2023/08/23. Under the stable condition, he can be discharged on 2023/08/23. OPD follow up is arranged.
    • Discharge diagnosis
      • Tresiba Flex Touch (insulin degludec) 6 unit HS SC
      • Concor (bisoprolol 1.25mg) 1# BID
      • MgO 250mg 1# TID
      • Trajenta (linagliptin 5mg) 1# QD
      • Const-K ER (potassium chloride 750mg 10mEq) 1# QD
      • Ulstop (famotidine 20mg) 1# QD
  • 2023-06-12 POMR Chest Medicine Progress Note
    • Problem List
      • R/I acute myeloid leukemia, Pending bone marrow biopsy
        • Assessment: serious
          • 20230608 HBsAg(-), Anti-HCV(-)
          • Hydroxyurea 1# QD (20230607 ~ 9)
          • 20230606 Bone marrow
        • Plan
          • BT with LPR 1U and LPRBC 2u on 20230612 for thrombocytopenia and anemia
          • Consider chemotherapy if Oncology suggest
          • Blood transfusion with LPRBC 2u and LRP 1PH on 20230612, s/p Lasix 0.5amp iv injection
      • Bilateral pneumonia, suspect leukemic lung with hypoxic respiratory failure post intubation on 2023-06-06
        • Extubation on 20230609
        • Assessment: serious
        • Plan
          • Nasal cannula supply
          • Antibiotics with Targocid plus Mepem (since 20230606) were prescribed
          • Anti-fungus agent with Mycamine (since 20230606)
          • Sevatrim oral form(IV form 20230606 ~ 10, since 20230610) for cover PJP
          • Kalimate 2pk qid was given for correct hyperkalemia (Baktar side effect)
          • Collect K qd
          • 20230605 Pending CMV and PJP result
      • EFrEF with vere MR
        • Assessment: serious
          • 20230607 Heart echo EF 48%, severe MR
        • Plan
          • Concor 1# BID
          • Diuretic with Lasix 0.5# PO QD
      • Type 2 Diabetes mellitus
        • Assessment
          • HbA1c 6.5% on 20230605
        • Plan
          • RI 14u SC TIDAC as sliding scale and Toujeo 10u SC HS
          • Tragenta 1# QD
      • Acute kidney injury and imbalance electrolyte
        • Assessment: impairment renal function
        • Plan:
          • Closely monitor renal function and electrolyte
          • Correct hypocalcemia with Calcium gluconate 1amp IVD QD
          • Add MgSO4 1amp iv infusion loading for correct hypo-Mg
    • Attending Physician’s Rounds Record and Comment
      • keep O2 support, closely monitor his respiratory pattern and O2 saturaiton
      • keep Targocid, Meropenem, Micafungin and oral Baktar for infection control, trace culture result
      • give PRBC and PLT transfusion to correct anemia and thrombocytopenia, regular hemogram f/u, if prograssive leukopenia (ANC < 500), may add G-CSF
      • keep Kalimate to correct hyperkalemia
      • because of CXR still showed pulmonary congestion, keep Diuretic used to keep I/O negative balance for CHF and severe MR
      • wait Bone marrow biopsy result
      • explained his condition to himself and his family
      • consult Hema doctor f/u, if possible, may let him transfer to Hema general ward
  • 2023-06-01 SOAP Hemato-Oncology
    • S
      • Referred from clinic for WBC 72K, PLT 48K, HGB 6.9 (20230601)
      • fever in recent days for 1 month
      • Exertional shortness of breath (dyspnea on exertion) for 2 wks
    • A
      • Suspected acute leukemia with hyperviscosity
      • Suspected coexisting infection
    • P
      • Marked leukocytosis –> refer to ER for emergent treatment and admission

[consultation]

  • 2023-06-08 Cardiology
    • Q
      • for severe MR
      • This is a 70 y/o male with type 2 DM without treatment. The impression of acute leukemia, he was admitted to Hema ward on 20230602. Due to acute hypoxic respiratopry failure, he received intubation then transffered to MICU on 20230606. At MICU, antibiotic with Targocid, Mepem, Sevatrim, Mycamine (since 20230606) for infection control. F/u Bone marrow on 20230606 (pending result), Oral chemotherapy with hydroxyurea was precribed. Arrange 2-D echo on 20230607 for heart function evaluation and which revealed EF 48%, severe MR. We really need your help for treatment suggestion, thank you!!
    • A
      • This is a 70 years old man with suspected acute leukemia, acute hypoxic respiratory failure. We were consulted for severe MR management.
      • Labs
        • Worsening renal function
      • Impression
        • Heart failure with mildly reduced EF, dilated LV with hypokinesia of posterior and lateral wall, with severe primary mitral regurgitation, with moderate to severe pulmonary HTN.
        • Acute respiratory failure with bilateral pneumonia r/o pulmonary congestion
        • Acute on chronic renal impairment, r/o prerenal type.
        • r/o acute leukemia;
      • Suggestion
        • Surgical intervention for MR is not suitable at present due to poor general condition (underlying hematolic malignancy + sepsis).
        • Keep lasix + concor use; may consider adding low dose candesarten if Cr < 2.0.
  • 2023-06-06 Infectious Disease
    • A
      • 70-year-old DM male patient is a fresh case of AML, that bone marrow study not done yet.
        • Persistent fever is noted before and during hospitalization, that leukemic fever likely.
        • Serial CxR films showed rapid onset bilateal perihilar infiltrations, especially right lung, that leukemic lung is the first consideration.
        • Possibility of PJP infection also exist, that sputum PJP-PCR study necessary.
        • IV steroid is necessary, as well as intubation for severe hypoxemia.
      • Suggestion:
        • Continue the present Mepem, Targocid and Mycamine.
        • Decrease Sevatrim dosage to 2 vials iv q12h due to AKI.
        • Send sputum for bacterial culture, PJP-PCR.
        • Check cryptococcal/Aspergillus antigen, and CMV viral load too.

[note]

Prevention of Hepatitis B Reactivation During Immunosuppressive Therapy - 2023-10-25 - https://www.hepatitis.va.gov/hbv/reactivation-prevention.asp

  • Table 1. Immunosuppressant Medications by Class
Medication Class Agents
TACE: Trans arterial chemoembolization, HCC: Hepatocellular carcinoma Doxorubicin Epirubicin (USED in TACE for HCC)
B-cell depleting agents Obinutuzumab, Ocrelizumab, Ofatumumab, Rituximab
Anthracycine derivatives Doxorubicin, Epirubicin (USED in TACE for HCC)
TNF inhibitors Adalimumab, Certolizumab, Etanercept, Infliximab
Other cytokine inhibitors and integrin inhibitors Abatacept, Mogamulizumab, Natalizumab, Ustekinumab, Vedolizumab
Tyrosine kinase inhibitors Imatinib, Nilotinib
Proteasome inhibitors Bortezomib, Carfilzomib, Ixazomib
Traditional immunosuppressive agents Azathioprine, 6-Mercaptopurine, Methotrexate
Corticosteroids Prednisone, Prednisolone, Methylprednisone, Dexamethasone
  • Table 2. HBV Reactivation Risk Determination
Medication Class HBsAg+, HBcAb+ HBsAg-, HBcAb+
B cell depleting agents High risk; Use prophylaxis High risk; Use prophylaxis
Anthracycine derivatives High risk; Use prophylaxis Moderate risk; Use prophylaxis
Corticosteroids ≥ 10 mg/day for ≥ 4 weeks High risk; Use prophylaxis Moderate risk; Use prophylaxis
Corticosteroids < 10 mg/day for ≥ 4 weeks Moderate risk; Use prophylaxis Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
HCC treatments: TACE, Surgical resection or Immunotherapy High risk; Use prophylaxis Lack of data; Use Prophylaxis
HCC: Local Ablation, Systemic therapies Moderate risk; Use prophylaxis Lack of data; Use Prophylaxis
TNF inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Other cytokine inhibitors and integrin Moderate risk; Use prophylaxis Moderate risk: Use prophylaxis
Tyrosine kinase inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Proteasome inhibitors Moderate risk; Use prophylaxis Moderate risk; Use prophylaxis
Traditional immunosuppressive agents Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Intra-articular steroids Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
Corticosteroids: any dose for ≤ 1 week Low risk; No prophylaxis; Monitor HBV DNA, ALT every 3 months Low risk; No prophylaxis; Monitor HBsAg, HBV DNA, ALT every 3 months
  • Table 3. Recommended Nucleos(t)ide analogues for HBV
Nucleos(t)ide Analogue QD Dose Potential Side Effects Use in HIV Lowest CrCl Without Dose Adjustment Renal Dose Reductions (CrCl, mL/min)

[chemotherapy]

  • 2023-09-23 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1 (FLAI)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
  • 2023-09-19 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
  • 2023-07-31 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-2 + idarubicin 10mg/m2 16mg NS 100mL 10min D2 (FLAI)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2
  • 2023-07-28 - fludarabine 30mg/m2 50mg NS 500mL 30min D1 + cytarabine 1000mg/m2 1600mg NS 500mL 4hr D1-3 + idarubicin 10mg/m2 16mg NS 100mL 10min D1,3 (FLAI)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1-3 + NS 250mL D1-3
  • 2023-06-20 - daunorubicin 45mg/m2 75mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 160mg NS 500mL 24hr D1-7
    • dexamethasone 4mg D1-7 + diphenhydramine 30mg D1-7 + palonosetron 250ug D1-7 + NS 250mL D1-7

FLAI (Fludarabine 25 mg/sqm/day days 1–5, Ara-C 2 gr/sqm/day days 1–5, Idarubicine 10 mg/sqm/day days 1, 3, 5) https://ashpublications.org/blood/article/106/11/1857/137804/Fludarabine-Based-Regimen-FLAI-Is-an-Effective https://doi.org/10.1182/blood.V106.11.1857.1857

The FLAI regimen is given as follows: (2023-10-25 GBard)

  • Fludarabine: 25 mg/m² intravenously (IV) over 30 minutes on days 1-5
  • Cytarabine: 200 mg/m² IV over 24 hours on days 1-5
  • Idarubicin: 12 mg/m² IV over 30 minutes on days 1-3

The FLAI regimen is used as an induction treatment for newly diagnosed patients with Acute Myeloid Leukemia (AML), except acute promyelocytic leukemia (APL). The regimen includes the following drugs: (2023-10-25 BingChat https://ashpublications.org/blood/article/104/11/878/75705/Efficacy-and-Toxicity-of-FLAI-vs-ICE-for-Induction https://doi.org/10.1182/blood.V104.11.878.878)

  • Fludarabine (FLUDA): 25 mg/sqm/day for 5 days
  • Cytarabine (also known as ARA-C or HDAC): 2g/sqm/day for 5 days
  • Idarubicin (IDA): 10mg/sqm/day for 5 days

FLAI Regimen Dosing and Schedule: (2023-10-25 ChatGPT)

  • Fludarabine (Fludara):
    • Dose: Typically around 30 mg/m^2/day.
    • Schedule: Administered intravenously over 30 minutes daily for 5 days, usually from day 1 to day 5.
  • Cytarabine (Ara-C):
    • Dose: Typically around 2 g/m^2/day.
    • Schedule: Administered intravenously over 4 hours daily, immediately after the Fludarabine infusion, usually from day 1 to day 5.
  • Idarubicin:
    • Dose: Typically around 8-10 mg/m^2/day.
    • Schedule: Administered intravenously over 30 minutes daily, usually from day 1 to day 3.

Fludarabine, Cytarabine, and Attenuated-Dose Idarubicin (m-FLAI) 2023-10-25 https://doi.org/10.1182/blood.V118.21.3626.3626

  • The m-FLAI regimen was comprised of
    • fludarabine (25mg/m2, days 1–4),
    • cytarabine (1000mg/m2, days 1–4), and
    • attenuated-dose idarubicin (5mg/m2, days 1–3)

==========

2023-10-25

[HBV reactivation]

Hepatitis B virus (HBV) that has been reactivated is treated with the medication Baraclude (entecavir) today.

[HRP > Patient Safety Incident Notification > Medication Incident - HBV reactivation]

Patient medical record No. 700013816.

The lab results from 2023-07-29 indicated a reactive Anti-HBc, but there were no previous Anti-HBc test results for reference. Multiple chemotherapy sessions were administered on 2023-06-20 (standard 7+3), 2023-07-28, 2023-07-31, 2023-09-19, and 2023-09-23 (FLAI), both before and after this test result.

Due to the lack of timely preventive measures to counteract the potential reactivation of HBV infection, which can be triggered by the immunosuppressive effects of the treatment, reactivated hepatitis developed. As a response to this event, Baraclude (entecavir) was added to the patient’s active medication list on 2023-10-25.

2023-10-25 HBV DNA-PCR (quantative) 143000 IU/mL

2023-10-24 ALT 1986 U/L
2023-10-23 ALT 2487 U/L
2023-10-23 ALT 2645 U/L
2023-10-20 ALT 44 U/L
2023-10-17 ALT 37 U/L
2023-10-06 ALT 52 U/L

2023-10-24 AST 1635 U/L
2023-10-23 AST 3211 U/L
2023-10-23 AST 3758 U/L
2023-10-20 AST 36 U/L
2023-10-17 AST 27 U/L
2023-10-06 AST 28 U/L

2023-07-29 Anti-HBc Reactive
2023-07-29 Anti-HBc-Value 6.96 S/CO

There are multiple clinical practice guidelines that offer a approach to screening and managing hepatitis B virus (HBV). For example, the American Society of Clinical Oncology (ASCO) guideline recommends that all patients who are about to start systemic anticancer therapy be tested for HBV. Patients with chronic HBV who are receiving systemic anticancer therapy should receive antiviral prophylaxis throughout the course of treatment and for at least 12 months afterwards.

Ref: Hepatitis B Virus Screening and Management for Patients With Cancer Prior to Therapy: ASCO Provisional Clinical Opinion Update. J Clin Oncol. 2020 Nov 1;38(31):3698-3715. doi: 10.1200/JCO.20.01757. Epub 2020 Jul 27. PMID: 32716741.

2023-06-28

  • Patient body weight 64.7kg => CrCl 27mL/min. Considering the patient’s CrCl falls within the range of 20 to 50 mL/min, the levofloxacin dosage should be adjusted. Instead of the initially intended daily dose of 750mg, it is recommended to administer 750mg of levofloxacin every other day.
    • 2023-06-28 BUN 81 mg/dL
    • 2023-06-28 Creatinine 2.20 mg/dL
    • 2023-06-28 eGFR 31.52
  • Fluconazole in patients with CrCl ≤50 mL/minute: Reduce dose by 50%. 2# switch to 1# QD is recommended.

2023-06-12

  • The patient’s renal function is showing signs of improvement, but still remains inadequate. The administration of furosemide should continue to ensure a net outflow in the fluid balance, thus helping to alleviate pulmonary congestion, congestive heart failure (CHF), and mitral regurgitation (MR). Please note that the oral bioavailability of furosemide varies greatly, but on average it’s around 50% of the intravenous (IV) dose.
    • 2023-06-12 Creatinine 2.17 mg/dL
    • 2023-06-10 Creatinine 2.51 mg/dL
    • 2023-06-09 Creatinine 2.90 mg/dL
    • 2023-06-07 Creatinine 3.14 mg/dL

2023-06-06

[tube feeding - Concor]

  • The manufacturer’s instructions for Concor (bisoprolol 5mg/tab) advise that it should be swallowed with a drink of water and not be chewed. If the patient is receiving tube feeding, the Simple Suspension Method (SSM) may be used. In the simple suspension method, the packaged tablets can be dissolved in 55-degree Celsius water and left for 5-10 minutes, then can be flowed through a feeding tube. This method involves disintegrating tablets and capsules in warm water before suspending them for administration. This method could be applicable for administering Concor tablets through a feeding tube.

[assessment]

Since the start of Hydrea (hydroxyurea) treatment on 2023-06-02, there has been a noticeable reduction in the patient’s WBC count from a peak of 105K/uL. However, along with this, It is also seen a concurrent suppression of the patient’s HGB and PLT levels, despite the administration of blood transfusions on 2023-06-01 and 2023-06-05.

  • 2023-06-06 WBC 66.82 x10^3/uL

  • 2023-06-05 WBC 99.17 x10^3/uL

  • 2023-06-04 WBC 105.86 x10^3/uL

  • 2023-06-03 WBC 105.55 x10^3/uL

  • 2023-06-02 WBC 100.28 x10^3/uL

  • 2023-06-01 WBC 75.10 x10^3/uL

  • 2023-06-06 HGB 7.8 g/dL

  • 2023-06-05 HGB 7.9 g/dL

  • 2023-06-04 HGB 6.9 g/dL

  • 2023-06-03 HGB 7.4 g/dL

  • 2023-06-02 HGB 7.0 g/dL

  • 2023-06-01 HGB 6.3 g/dL

  • 2023-06-06 PLT 44 x10^3/uL

  • 2023-06-05 PLT 62 x10^3/uL

  • 2023-06-04 PLT 37 x10^3/uL

  • 2023-06-03 PLT 43 x10^3/uL

  • 2023-06-02 PLT 47 x10^3/uL

  • 2023-06-01 PLT 63 x10^3/uL

2023-06-06 lab Cre 2.63mg/dL, eGFR 25.72, CrCl 27. Tarcocid (teicoplanin) for CrCl <30 mL/minute:

  • If the usual indication-specific dose is 6 mg/kg once daily:6 mg/kg every 72 hours or 2 mg/kg once daily
  • If the usual indication-specific dose is 10 mg/kg once daily:10 mg/kg every 72 hours or 3.3 mg/kg once daily
  • If the usual indication-specific dose is 12 mg/kg once daily:12 mg/kg every 72 hours or 4 mg/kg once daily

The maintenance dose, which stands at 700mg Q3D, is equivalent to 9.5 mg/kg. This is within the reasonable therapeutic range.

700034834

231025

[lab data]

2023-10-11 Anti-HBc Nonreactive
2023-10-11 Anti-HBc-Value 0.38 S/CO
2023-10-11 Anti-HBs 53.10 mIU/mL
2023-10-11 HBsAg Nonreactive
2023-10-11 HBsAg (Value) 0.35 S/CO
2023-10-11 Anti-HCV Nonreactive
2023-10-11 Anti-HCV Value 0.28 S/CO

[exam findings]

  • 2023-10-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-10-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (108 - 27) / 108 = 75.00%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA
      • Mild MR, TR
      • Moderate AR
  • 2023-10-11 PET scan
    • Increased FDG uptake in stomach (Deauville score: 5), compatible with the diffuse large B-cell lymphoma.
    • Increased FDG uptake in lymph nodes in bilateral neck regions, left SCF, right axilla (Deauville score: 5), left upper back (Deauville score: 4), abdomen including the spleen, pelvis, and bilateral inguinal regions (Deauville score: 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Diffuse large B-cell lymphoma, stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-09-27 CT - abdomen
    • CC: epigastric pain, discomfort for 1 month, BW from 85 Kgs to 75 Kgs.
    • 20230919 gastroscopy: One large fungated mass with ulcerative surface was noted at 2nd portion duodenum, AW site.
    • Biopsy and pathology: diffuse large B cell lymphoma
    • Findings:
      • There are multiple enlarged nodes in the hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, bilateral internal iliac chain, and bilateral inguinal area that are c/w malignant lymphoma.
      • There is wall thickening at the duodenum 2nd portion that is c/w malignant lymphoma.
      • There is mild to moderate left side hydroureteronephrosis and delayed contrast excretion of left kidney that is c/w obstructive uropathy. The etiology is lymphoma in left external iliac chain with passive compression the left M/3 ureter.
        • In addition, a renal cyst 1.3 cm in left upper pole is noted.
      • There is a poor enhancing lesion 1.4 cm in the spleen that may be lymphoma with spleen involvement.
      • There is a gallstone 0.7 cm.
    • Impression:
      • Malignant lymphoma is noted. Please correlate with PET scan.
  • 2023-09-20 Patho - stomach biopsy
    • Duodenum, 2nd portion, biopsy — Diffuse large B-cell lymphoma, non-germinal-center B-cell typel
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Duodenal 2nd portion
      • Procedure: Biopsy
      • Tumor site: Duodenal 2nd portion
      • Histologic type: Diffuse large B-cell lymphoma, non-germinal-center B-cell type
    • Immunophenotyping: CK(-), CD3(-), CD56(-), CD20(+), BCL2(+), BCL6(+), CD10(-), MYC(-) and MUM1(-)
  • 2023-09-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Superficial gastritis
      • Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy
    • Suggestion:
      • pursue pathology and arrange CT for duodenal cancer survey

[MedRec]

  • 2023-09-26 SOAP Hemato-Oncology He JingLiang
    • S: DLBCL of stomach
    • P: arrange admission for staging and R-COP
    • Prescription
      • Through (sennoside 12mg) 1# HS
  • 2023-09-25 SOAP Gastroenterology Chen JiangHua
    • S: for patho result -> diffuse large B cell lymphoma -> referred to oncologist
  • 2023-09-15 SOAP Gastroenterology Xu RongYuan
    • S
      • epigastric pain, discomfort for one months
      • BW from 85 Kgs to 75 Kgs
    • Prescription
      • Ulstop (famotidine 20mg) 1# BID
      • Emetrol (domperidone 10mg) 1# TIDAC
  • 2020-09-22 ~ 2020-11-06 POMR Infectious Disease Yang QingHui
    • Discharge diagnosis
      • Gram-negative sepsis, unspecified
      • Bacteremia
      • Chronic osteomyelitis, right ankle and foot s/p operation
      • Atherosclerosis of native arteries of extremities with intermittent claudication, right leg
      • Essential (primary) hypertension
      • Gout, unspecified
      • Chronic ulcer with osetomyelitis with wound culture: Bacteroides fragilis and Fusobacterium spp., Staph. auerus, Serrentia marsensus, Escherichia coli, Pseudomonas auerginso
      • Pseudomonas auerginosa and Escherchia coli positive sepsis due to chronic ulcer with chronic osteomyelitis.
      • Chronic ulcer with osteomyelitis s/p debridment on 2020/10/05.
      • pending for HBO
      • Anemia of chornic inflammation (Chronic oseteomyelitis with wound ulcer)
    • CC
      • Fever and chills off and on for four days
    • Present illness
      • A 73-year-old male has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis.
      • He was a chief officer before. He denied travel, occupation, contact or cluster history recently, nor allergy history.
      • This time, he had intermittent fever with chills since 2020-09-18, runny nose was also noted. There was a chronic ulcerative wound over his right sole, with discharge under chronic osteomyelitis status for long times (for years). He denied dizziness or headache, no cough or sputum or dyspnea, no cheat pain or abdomen pain, no nausea or vomit, no urinary pain or hematuria, no limbs edema. Then he came to our hospital for help.
      • In the emergency department, the temperature was 40.0’C, the pulse 105 beats per minute, the blood pressure 116/58 mmHg, the respiratory rate 23 breaths per minute, and the oxygen saturation 96%. The physical examination revealed a chronic ulcerative wound over his right sole, with yellow discharge.
      • A laboratory testing revealed a peripheral-blood leukocyte count of 10.490 cells per cubic millimeter, with 88.3% polymorphonuclear cells. A biochemistry testing revealed glucose level of 141 mg/dL, C-reactive protein level of 14.43 mg/dL, creatinine level of 1.4mg/dL, and lavtic acid was 4.3mg/dL. A x ray of right foot revealed deformity of 3-5th metatarsal bones, especially 5th metatarsal bone with bone destruction and sclerotic change, compatible with chronic osteomyelitis, and osteopenia of visible bones. The patient is administrated with Brosym injection. He is hospitalized on 2020/09/22.
    • Course of inpatient treatment
      • After admission, patient received antibotic with Oxacillin and Brosym iv for sepsis control. Collect blood culture and yield E-coli noted. Fever is subside after medication. PS was consulted for right foot wound evalutaion, the wound debridement was perfomted on 9/28, he will arrange operation again at necxt week for close wound.
      • Wound culture yield Pseudomonas and OSSA, K.P, Serretia injecton, kept on current antibiotic treatment and wound care. Abdomen echo was perfomted for fever and R/O IAI, fatty liver and GB stone is noted, without IAI. During hospitalization, osteomyelitis scan was performed for HBO therapy, kept pending answer. More elevat of blood pressure is noted, we give add anti-hypertension used and noted his blood pressure became stable.
      • On 10/05, he received Deep debridement + fasciocutaneous flap coverage for chronic ulcer with osteomyelitis is found about 4 x 12 cm in size over the right lateral sole. Wound is improving and less bleeding, later we added pletaal. Post operation fever was noted and infection markers are increasing, so we added iv invanz along with ciprofloxacin. Blood culture was followed and showed GNB (Micro-organism report is still pending) and Wound culture revealed Enterococcus fecalis. Patient is relatively stable.    
      • This week, we continue antibiotic therapy : invanz and ciprofloxacin. Hyperbarric oxygen treatment was started. We noted his blood pressure is relatively stable and we taperred antihypertensive medication. Daily wound dressing and nature of the wound is improving.
      • Another week showing improving of his foot wound condition and no more newer culture results under invanz and ciproxin. Patient was afebrile however, wound was dehiscent partially and we called Dr.Zhang and suggest NS : BI2 wound dressing. Patient antibiotic were shift to per oral form (cefixime and cipro) this week. He is currently under HBO management. Due to stable condition and under antibiotic used under time, so he can be arranged for discharge today, take oral antibiotic back home, INF, PS, CV OPD follow up is arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H if fever > 38’C or pain
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Euricon (benzbromarone 50mg) 1# QD
      • fusidic acid 2% BID EXT for buttock wound
      • Ceficin (cefixime 100mg) 2# Q12H
      • Diovan (valsartan 160mg) 1# QD hold if SBP < 120mmHg
      • Nebilet (nebivolol 5mg) 0.5# QD
  • 2017-12-06, -09-13, -06-21, -03-29, -01-04 SOAP Cardiology Huang XuanLi
    • Diagnosis
      • Arterial embolism and thrombosis of lower extremity [I74.4]
      • Essential hypertention, unspecified [I10]
      • Neuralgia,neuritis,and radiculitis,unspecified [M54.10]
      • Gout, unspecified [M10.9]
      • Edema [R60.9]
      • Allergic rhinitis cause unspecified [J30.9]
    • Prescription x3
      • Isoptin (verapamil 240mg) 0.5# QD
      • Euricon (benzbromarone 50mg) 1# QD
      • Pletaal (cilostazol 100mg) 0.5# BIDAC
      • Blopress (candesartan 8mg) 1# QN

[consultation]

  • 2023-10-25 Infectious Disease
    • Q
      • for Neutropenia fever evaluation
      • This 73-year-old male patient has past history of 1). Hypertension, 2). Gout, 3). Peripheral arterial occlusion disease, 4). Varicose veins of bilateral limbs, and 5). Chronic osteomyelitis of right foot post sequestrectomy for osteomyelitis 6) diffuse large B cell lymphoma. He denied travel, occupation, contact or cluster history recently, nor allergy history. Due to epigastric pain. Upper G-I panendoscopy was performed on 2023/09/19 and revealed Superficial gastritis; Duodenal ulcerative tumor, suspicious lymphoma or adenocarcinoma, s/p biopsy.
      • Duodenum biopsy pathology showed Diffuse large B-cell lymphoma, non-germinal-center B-cell typel.
      • He received C1 R-COP on 2023/10/13, then he suffered from fever (BT: 39.2C), 2023/10/23 wbc: 640/uL, Band: 3.2%, Neurophoil: 65.6%, ANC: 440, Lenograstim 250mcg, followed-up cultures, and the antibiotic with Cefim was given. We need your help for infection control, thanks a lot!!
    • A
      • Thi is a case of diffuse large B-cell lymphoma, non-germinal-center B-cell type.
      • Please use cefim 2g iv q8h for q8h for neutropenic fever.
      • G-CSF use
      • Protesctive isolation and keep oral and anal region hygiene.
      • Re-evaluation clinical conidtion closely and consider add anti-MRSA agents if the patient’s condition get worse.
      • Please f/u the B/C results closely.

[immunochemotherapy]

  • 2023-10-13 - rituximab 375mg/m2 700mg NS 500mL 8hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-COP, Endoxan 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + aprepitant 125mg PO + NS 250mL

==========

2023-10-25

[tube feeding]

Const-K 750mg is an extended-release tablet that contains 10 mEq of potassium. One Const-K tablet provides less potassium than a single banana (which contains about 2.2 mEq/inch or 0.9 mEq/cm).

The tablet can be crushed into fine particles and swallowed with water if injectable potassium supplementation is not preferred.

[elevated PCT and CRP]

On 2023-10-24, lab results showed a moderate amount of gram-positive cocci bacteria, gram-negative bacteria, and gram-positive rods in the (sputum) sample, as well as a high number of neutrophils and a low number of epithelial cells. PCT and CRT levels were also elevated and continued to rise over these 2 days (2023-10-24 and 2023-10-25). After consultation with an infectious disease specialist, cefepime was started on 2023-10-24 and is currently being administered.

  • 2023-10-25 Procalcitonin(PCT) 3.67 ng/mL

  • 2023-10-24 Procalcitonin(PCT) 0.12 ng/mL

  • 2023-10-25 CRP 10.5 mg/dL

  • 2023-10-24 CRP 6.7 mg/dL

  • G(+) Cocci 2+, GNB 2+, GPB 4+, Neutrophil/LPF > 25, Epithilial cell/LPF < 10

The patient’s white blood cell count has passed its nadir on 2023-10-23 and returned to normal. The recovery of the patient’s immune system should help them fight off bacterial infections.

  • 2023-10-25 WBC 4.43 x10^3/uL
  • 2023-10-24 WBC 2.26 x10^3/uL *
  • 2023-10-23 WBC 0.64 x10^3/uL ***
  • 2023-10-20 WBC 1.25 x10^3/uL **
  • 2023-10-18 WBC 5.10 x10^3/uL
  • 2023-10-16 WBC 7.96 x10^3/uL
  • 2023-10-13 WBC 4.68 x10^3/uL
  • 2023-10-12 WBC 4.53 x10^3/uL

700768893

231025

[exam findings]

  • 2023-10-03 CT - brain
    • No evidence of intracranial hemorrhage.
  • 2023-08-24, -08-02, -08-01 CXR
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-07-29 KUB
    • Calcifications in the pelvic cavity, could be due to phleboliths.
  • 2023-07-29 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Nonspecific ST abnormality
  • 2023-07-13 EGD
    • Gastric cancer, borrmann type IV
    • Reflux esophagitis LA Classification grade A
  • 2023-06-05 CT - abdomen
    • Indication: Gastric cancer s/p C/T
    • Abdominal CT with and without enhancement revealed:
      • Diffuse gastric wall thickening at antrum is found. In comparison with CT dated on 2023-01-11, the lesion is stationary.
      • The GB is well distended without soft tissue lesion
      • There is no evidence of destructive bone lesion.
      • Dilated IHDs and CBD is found.
      • s/p enterostomy with its orifice at RLQ.
      • The urinary bladder is partially distended without evidence of abnormal soft tissue lesion.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • The spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Diffuse gastric wall thickening, stable.
      • Dilated IHDs and CBD. Suggest close observation.
  • 2023-02-10 Lower GI Series (colon filling study)
    • Filling LGI series show
      • No evidence of abnormal filling defect along the course from rectum into descending colon.
      • Increased intestinal gas is found.
      • There is no evidence of destructive bone lesion.
  • 2023-02-06 CXR
    • Blunted left costophrenic angle.
  • 2023-02-06 ECG
    • Normal sinus rhythm
    • Low voltage QRS
  • 2023-02-06 Flow volume loop
    • moderate restrictive impairment
  • 2023-02-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 16) / 54 = 70.37%
      • M-mode (Teichholz) = 69
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2023-01-13 Patho - doudenum biopsy
    • Labeled as “duodenum, SDA”, biopsy (B)— benign duodenal tissue with marked chronic inflammation and mild to moderate dilatation of lymphatics.
  • 2023-01-13 Patho - stomach biopsy
    • Stomach, GC, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic signet ring-like cells.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0). CD68 (-).
  • 2023-01-11 CT - abdomen
    • History:
      • 20220927 CT:Pneumoperitoneum. Swelling and wall thickening of the terminal ileum and ascending colon.
      • Emergent S/P right hemicolectomy and terminal ileostomy: A-colon perforation, Compatible with diverticulitis with perforation and suppurative peritonitis
    • Indication: weight loss
    • Impression:
      • There is dilatation of IHDs, CHD, CBD, and pacreatic duct.
        • Please correlate with serum alk-p and bilirubin level.
      • There is edematous wall thickening of the distal esophagus, stomach, and duodenum. Please correlate with gastroscopy.
      • Adhesion bands induce mechanical high grade small bowel obstruction is highly suspected.
        • please correlate with clinical condition.
      • There is edematous wall thickening of the transverse-and descending colon. Please correlate with colonoscopy to R/O ulcerative colitis or Crohn disease.
  • 2023-01-10 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-01-10 SONO - abdomen
    • Gallbladder sludge
    • CBD dilatation and IHD dilatation
  • 2022-12-26 Patho - stomach biopsy
    • Stomach, unspecified site, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
  • 2022-12-23 Esophagogastroduodenoscopy, EGD
    • Giant folds of stomach with poor distention upon air inflation, r/o inflitrated type malignancy, s/p CLO test and biopsy
    • Reflux esophagitis LA Classification grade A
  • 2022-10-14 CXR
    • Focal sclerotic change of left humerus.
    • Blunted bilateral costophrenic angles.
  • 2022-10-12 CXR
    • Bilateral pleural effusion.
    • Ground glass opacity in bilateral lower lungs.
    • Some calcifications at left humerus.
  • 2022-10-10 CXR
    • Ground glass opacity in RLL.
    • Patch density at LLL.
    • Focal sclerotic change at left humeral head.
  • 2022-10-04 CTA - chest
    • Indication: pulmonary embolism
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Status post endotracheal tube placement.
        • Consolidation over both lower lungs with bilateral pleural effusion is found.
        • Increased pulmonary vasculature is found.
        • No evidence of pulmonary embolism nor aortic dissection is found.
        • There is no evidence of mediastinal LAP
        • Patent airway is found.
      • Visible abdomen:
        • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • Minimal infiltration at mesentery is found.
        • Suggest clinical correlation
    • Imp:
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Increased pulmonary vasculature is found.
      • BIlateral pleural effusion and consolidation over bilateral lower lungs.
      • Moderate ascites at abdominal cavity is found mostly around pancreas is found. Please exclude the possibility of pancreatitis.
  • 2022-09-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 38) / 92 = 58.70%
      • M-mode (Teichholz) = 58.5
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Mild MR and TR , trivial AR
    • No regional wall motion abnormalities
  • 2022-09-29 SONO - chest
    • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
  • 2022-09-27 Patho - colon resection (non tumor)
    • PATHOLOGIC DIAGNOSIS
      • Ascending colon, right hemicolectomy — Compatible with diverticulitis with perforation and suppurative peritonitis
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Right hemicolectomy
      • Specimen site: Right colon
      • Specimen size: 25 cm (ascending colon), 8 cm (ileum), and 7 cm (appendix) in length, respectively
      • Grossly, the surface of intestine is coated by fibrinous exudate. There is a subtle diverticulum with a perforated hole in ascending colon is present. The appendix is congested. The ileum is unremarkable.
      • Representative parts are taken for section and labeled: A1= ascending colon with perforation, A2-A4= colon + pericolic soft tissue, A5-A6= appendix
    • MICROSCOPIC EXAMINATION
      • The sections of ascending colon show a picture compatible with diverticulitis with perforation, composed of diverticulum with transmural necrosis, moderate neutrophil infiltration, subserosal fibrosis, granulation tissue, and acute serositis. Suppurative peritonitios with bacterial colonies and abscess formation are present.
      • The sections of appendix show mucosal hyperplasia and periappendicitis.
      • The sectiobns of ileum show acute serositis.
  • 2022-09-27 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-09-27 CTA - chest
    • Clinical history: 60y/o female patient with sudden low abdominal pain since 2 hours ago, epigastric pain for half month.
    • With and without contrast enhancement CT: CTA, Chest
      • Presence of ascites and pneumoperitoneum.
      • Swelling/thickening at terminal ileum.
      • Enlarged mesentery lymph nodes in right lower abdomen.
      • No abnormal fluid accumulation in the mediastinum and pleural space.
    • Impression:
      • Pneumoperitoneum with ascites, suspected hallow organ perforation.
      • Swelling/thickening at terminal ileum.
  • 2022-09-27 ECG
    • Sinus rhythm with ventricular premate complexes
    • Nonspecific ST abnormality
    • Prolonged QT

[MedRec]

  • 2023-07-25 SOAP Hemato-Oncology
    • Taking “Astragalus Root” (huang2qi2) since the beginning of chemotherapy
  • 2023-07-18 SOAP Hemato-Oncology
    • P: Changing regimen from FLOT to FOLFOX

[consultation]

  • 2023-02-23 Hemato-Oncology
    • Q
      • Gastric cancer for neoadjuvant chemotherapy
      • This 60 y/o female with past history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
      • However, poor intake, poor appetite with body weight loss was still persisted after operation.
      • Further UGI scope was performed which revealed enlarged Gastric folds prob Scirrhous s/p biopsy. Pathology showed adenocarcinoma. IHC stains: CK highlights neoplastic cells. Her2/neu: negative. (score=0). CD68 (-).
      • She was admitted to our ward for nutrition support first then further oepration was performed on 2023/02/20. Operation finding showded severe intraperitoneal adhesion (frozen peritoneal), huge gastric ca with possibly peritoneal spread. We discussion with her family then further chemotherapy will be consider first. We need your help for further managememt for chemotherapy. Port-A insertion will be arrange on 2023/02/22 PM. Thanks for your time!!
    • A
      • This 60 year old woman is a case of previously untreated, unresectable, non-HER2-positive gastric cancer with possibly peritoneal spread (pending pathology result). She had history of ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. We are consulted for further treatment.
      • Please check PD-L1, HbsAg, AntiHbc, Anti HCV. Please arrange port A insertion. And arrange chest CT+/-contrast for complete staging.
      • Chemotherapy +/- immunotherapy is indicated in this patient. Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-02-06 Anesthesiology
    • Q
      • CVC insertion for nutrition with TPN
      • This 60 y/o female was a case of 1) Ascending colon diverticulitis with perforation status post Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27. 2) Gastric cancer.
      • This time, she sufferred from poor appetite with vomit then BW weight loss was noted in recent months. We need your help for CVC insertion with nutrition support. Thanks for your time!!
    • A
      • Procedure
        • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 m.l..
        • The right IJV was difficult to cannulated.
        • We performed 7 fr CVC insertion to left internal jugular vein with ultrasound-guided under Seldinger technique
        • The pt tolerant the procedure well.
        • There was no sign of hematoma, pneumothorax, infection after the procedure.
      • The recommandation is as followed:
        • Please check chest roentgenography for localization.
        • Change IV set QD if TPN used or Q4D if general fliud.
        • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
        • We do not recommand routinely change the CVC unless there are some infectious signs.
  • 2022-10-19 Cardiac surgery
    • Q
      • For further evaluation of D-dimer elevation, deep vein thrombosis ???
      • This 60 y/o female suffered from sudden low abdominal pain for hours, and epigastric pain for half month.
        • CT: Pneumoperitoneum with ascites.
        • Ascending colon diverticulitis with perforation was diagnosed. Operation of Hartmann’s operation (resection of ascending colon with end ileostomy) on 2022/09/27.
        • During hospitalization. D-dimer elevation was noted and Clexane 30mg SC QD was give since 2022/10/14. Bilateral legs no distention, and freely movable.
        • D-dimer
          • 2022-09-30 05:58 2100.45 ng/mL(FEU)
          • 2022-10-04 12:28 > 10000.00 ng/mL(FEU)
          • 2022-10-09 07:50 7286.88 ng/mL(FEU)
          • 2022-10-10 05:17 6349.13 ng/mL(FEU)
          • 2022-10-12 05:09 8695.92 ng/mL(FEU)
          • 2022-10-14 07:28 9250.27 ng/mL(FEU)
          • 2022-10-19 07:42 8570.57 ng/mL(FEU)
      • So we consult you for further evaluation and management of blood D-dimer elevation the problem. (is it possible to swift oral medication?).
    • A
      • This 60 y/o female, history reviewed as above and herself examined, consulted for elevated D-dimer under clexane therapy
        • Chest CTA 2022/10/04 no pulmonary embolism
        • PE both limb soft, without tender swelling, already off-bed ambulation, dyspnea (-)
      • Recommendation
        • no clinical evidence of significant DVT
        • may arrange duplex PRG (lower limbs sonography for peripheral vessel) to exclude DVT possibility, then DC clexance accordingly
  • 2022-10-07 Thoracic Medicine
    • Q
      • for Left pleural effusion.
      • This 60 y/o female had history of gastric ulcer. Under the impression of sigmoid colon with perforation, fecal peritonitis + necrosis of omentum and septic shock s/p emergent Hartman procedure on 2022/09/27. CXR showed Left pleural effusion on 2022/10/07. We need your help for treatment assessment (chest echo?? tapping??). Thank you so much!!!
    • A
      • Series image showed progressive bilateral pleural effuison, Left side > right side.
      • severe hypoalbuminemia : <1.9 —> 2.3 —> 2.3
      • 20221004 CT showed: peritonitis with ascites, reactive bilateral pleural effusion
      • Suggestion:
        • Please take the permit. We will arrange chest echo for chest tapping +/- 14Fr. pig-tail catheter insertion for her.
        • Change antibiotics to Unasym or consult infection to adjust antobiotics use
        • Albumin replacement to keep Albumin level = 3.5 at least
        • Lasix for remove third space edema
        • thanks and f/u prn.
  • 2022-09-27 Thoracic Medicine
    • Q
      • This 60 y/o female had history of gastric ulcer. According to her family’s history, she had got lower abdominal pain since last night. Epigastric pain had been noted for half month. At ER, dyspnea with chest pain and cold sweating were also noted. Vital signs showed BP 115/67mmHg, HR 93bpm, BT 36.9’C, RR 18. Lab data revealed: WBC 13K, CRP 1.0, Troponin within normal range, no elevated Bilirubin or Lipase. CT showed: Pneumoperitoneum with ascites, r/o hallow organ perforation and swelling terminal ileum. Brosym was prescribed and operation was arranged. Resection of A colon with ileostomy was perforemed. Under the impression of Pneumoperitoneum with ascites due to A colon perforation, she was admitted to our ICU for further care.
      • Consult purpose: decrease saturation with Bilateral pleural effusion, r/o lung compartment syndrome. consider Bronchoscopy?
    • A
      • S: short of breath
      • O:
        • 20220929 bed-side chest sono: bilateral small amount pleural effusion
        • 20220929 CRP=37, WBC=27.5K
        • 20220927 albumin < 1.5
        • 20220927 BW=63.1 Kg –> 20220929 BW=66.5Kg
        • 20220928 CXR: bilateral lung consolidation
        • 20220929 breath sound: clear
      • A:
        • ARDS, moderate to severe degree; favor secondary to intra-abdmonial infection
        • pneumoperitoneum s/p operation
      • P:
        • Bronchoscopy was relatively contra-indicated due to high oxygen demand [FiO2=100% on 20220929 PM3:00]. Bronchoscopy probably causes desaturation during and after the procedure.
        • arrange cardiac echo and check serum D-dimer and NT-proBNP for suspected pulmonary embolism and congestive heart failure
        • follow up ABG/CXR QD
        • prone position was relatively contra-indicated due to septic shock status and large surgical wound over anterior abdominal wall
        • check serum Aspergillus Ag, serum cryptococcus Ag, serum Mycoplasma IgM, serum Chlamydia IgM, and urine legionella Ag, urine streptococcus Ag for pathogen survey
        • check sputum TBPCR, TB culture, acid-fast stain and aerobic culture for pathogen survey
  • 2022-09-27 General and DigestiveSurgery
    • A
      • P,E showed regid abdomen, with muscle guarding
      • diffuse local tenderness and knocking pain, right
      • Lab and CT showed neumoperitoneum , in favor of PPU
      • Emergency op is indicated

[chemotherapy]

  • 2023-09-11 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-08-09 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-06-27 - (FLOT)
  • 2023-06-13 - (FLOT)
  • 2023-05-30 - (FLOT)
  • 2023-05-16 - (FLOT)
  • 2023-04-25 - (FLOT)
  • 2023-04-11 - (FLOT)
  • 2023-03-23 - (FLOT)
  • 2023-02-24 - docetaxel 35mg/m2 50mg D5W 160mL 1hr + oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 200mg/m2 270mg NS 250mL 2hr + fluorouracil 2600mg/m2 3500mg NS 500mL 24hr (FLOT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-20

[elevated bilirubin level with high DBI to TBI ratio]

Lab bilirubin level:

  • 2023-10-20 Bilirubin total 1.14 mg/dL

  • 2023-10-20 Bilirubin direct 0.48 mg/dL

  • 2023-10-20 DBI/TBI 42.11 %

  • 2023-10-13 Bilirubin total 1.30 mg/dL

  • 2023-10-13 Bilirubin direct 0.54 mg/dL

  • 2023-10-13 DBI/TBI 41.54 %

The direct and total bilirubin levels on 2023-10-20 appear to be slightly lower than those on 2023-10-13. Despite this decrease, the ratio of direct bilirubin (DBI) to total bilirubin (TBI) continues to be elevated, which could typically signify issues with the liver’s capacity to secrete bilirubin into the bile or an obstruction within the bile ducts, leading to a buildup of conjugated bilirubin in the bloodstream. It’s noteworthy that oxaliplatin, a component of the FOLFOX regimen, is linked to a 13% incidence of increased serum bilirubin. However, it’s been over a month since the last FOLFOX cycle was administered during the previous hospitalization.

2023-10-16

[hypocalcemia]

corrected calcium level for hypoalbuminemia

injectable calcium supplements with Bfluid

  • Two injectable calcium supplements are available from stock: Vitacal (calcium chloride, equivalent to 5.44 mEq/amp) and Calglon (calcium gluconate, equivalent to 4.65 mEq/amp).

  • Bfluid 1000 mL contains 5 mEq of calcium per liter and can be supplemented with a maximum of an additional 5 mEq of calcium per liter.

2023-09-11

[leukopenia, anemia]

FOLFOX regimen was administered on 2023-08-09 and 2023-09-11, there was no observed leukopenia (WBC < 3K/uL) since 2023-08-25, however, there was still anemia (HGB < 8mg/dL) observed on 2023-09-11.

2023-09-11 WBC 3.72 x10^3/uL
2023-09-07 WBC 5.61 x10^3/uL
2023-09-04 WBC 6.04 x10^3/uL
2023-08-31 WBC 8.23 x10^3/uL
2023-08-28 WBC 22.74 x10^3/uL
2023-08-25 WBC 8.85 x10^3/uL
2023-08-23 WBC 1.87 x10^3/uL 2023-08-21 WBC 1.08 x10^3/uL 2023-08-17 WBC 2.59 x10^3/uL * 2023-08-14 WBC 1.60 x10^3/uL ** 2023-08-09 WBC 3.03 x10^3/uL
2023-08-07 WBC 3.90 x10^3/uL
2023-08-01 WBC 7.93 x10^3/uL

2023-09-11 HGB 7.9 g/dL 2023-09-07 HGB 9.3 g/dL 2023-09-04 HGB 10.3 g/dL 2023-08-31 HGB 8.6 g/dL 2023-08-28 HGB 9.7 g/dL 2023-08-25 HGB 9.3 g/dL 2023-08-23 HGB 10.2 g/dL 2023-08-21 HGB 8.1 g/dL 2023-08-17 HGB 7.9 g/dL 2023-08-14 HGB 8.0 g/dL * 2023-08-09 HGB 9.1 g/dL 2023-08-07 HGB 9.6 g/dL 2023-08-01 HGB 12.4 g/dL

A blood transfusion was performed on 2023-09-11 without a problem.

2023-08-11

[Astragalus Root]

The patient has been consistently using Astragalus Root since starting chemotherapy (2023-07-25 Onc Opd). To assess whether Astragalus Root might impact the effectiveness of chemotherapy, a literature search was conducted, and a relevant article was found: “Meta-Analysis of Astragalus-Containing Traditional Chinese Medicine Combined With Chemotherapy for Colorectal Cancer: Efficacy and Safety to Tumor Response. Front Oncol. 2019;9:749. Published 2019 Aug 13. doi:10.3389/fonc.2019.00749

Here is a summary of the key points from the research article:

  • The article is a meta-analysis evaluating the efficacy and safety of combining Astragalus-containing traditional Chinese medicine (TCM) with chemotherapy for treating colorectal cancer, compared to chemotherapy alone.
  • 22 randomized controlled trials with a total of 1409 patients were included. Trials used various oral, injected or external TCM preparations containing Astragalus.
  • The meta-analysis found combining Astragalus-based TCM with chemotherapy significantly improved tumor response rate and quality of life compared to chemotherapy alone.
  • Combination therapy also reduced chemotherapy side effects including myelosuppression, nausea/vomiting, diarrhea and neurotoxicity.
  • No significant differences were found between groups for liver or kidney dysfunction side effects.
  • Limitations include generally low quality of included trials and all Chinese studies, reducing applicability. More rigorous research is needed.
  • Overall, the meta-analysis suggests Astragalus-containing TCM combined with chemotherapy may have benefits for colorectal cancer, but further high-quality studies are warranted.

Based on the findings of this study, there is currently no evidence to suggest that the patient should discontinue the use of Astragalus Root.

2023-03-20

  • Leukopenia was observed on 2023-03-08, approximately 2 weeks after the patient received her first cycle of FLOT regimen chemotherapy, which started on 2023-02-24. The patient then received Granocyte (lenograstim 250ug) for three consecutive days (since 2023-03-08) and has not experienced any further episodes of leukopenia.

    • 2023-03-15 WBC 9.76 x10^3/uL
    • 2023-03-08 WBC 1.76 x10^3/uL
    • 2023-02-23 WBC 5.75 x10^3/uL
    • 2023-02-21 WBC 6.51 x10^3/uL
  • According to a study, preoperative FLOT chemotherapy appears to be safe and feasible for the treatment of resectable locally advanced gastric cancer. The FLOT regimen used in the study consisted of docetaxel (60 mg/m2), oxaliplatin (85 mg/m2), leucovorin (200 mg/m2), and 5-fluorouracil (2,600 mg/m2 as a 24 hr infusion). The study suggests that FLOT may be more effective in reducing morbidity and improving overall survival compared to initial surgery followed by chemotherapy. The patient received a reduced version of the FLOT regimen, which includes docetaxel 35mg/m2, oxaliplatin 75mg/m2, leucovorin 200mg/m2, and fluorouracil 2600mg/m2. (ref: Docetaxel, oxaliplatin, leucovorin, and 5-fluorouracil (FLOT) as preoperative and postoperative chemotherapy compared with surgery followed by chemotherapy for patients with locally advanced gastric cancer: a propensity score-based analysis. Cancer Manag Res. 2019;11:3009-3020. Published 2019 Apr 10. doi:10.2147/CMAR.S200883).

  • The dose used in this patient was lower than what is recommended in our in-hospital “Prescription Collection of Chemotherapy for Gastric Cancer” protocol (dated 2022-06-21). The protocol recommends a dose of docetaxel 50 mg/m2 IV D1, oxaliplatin 85 mg/m2 IV D1, and 5-FU 1200 mg/m2 IV continuous infusion (over 24 hours daily) on D1 and D2.

  • There is no need to adjust the dosage at this time. It is recommended to continue monitoring the patient’s blood cell counts to evaluate the response after the second cycle of treatment.

700552963

231024

[exam findings]

  • 2023-09-19 SONO - abdomen
    • Liver cyst, S4
  • 2023-03-15 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, partial mastectomy — Free
      • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11)
      • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 3.8 x 2.5 x 2.0 cm
      • Skin: Not included
      • Nipple: Not included
      • Tumor Size: 2.5 x 2.0 x 1.5 cm
      • Resection Margin: Free, 0.2 cm from the deep margin
      • Lymph node: Sentinel and axilla, left
      • Representative parts are taken for section and labeled: F2023-00100 FSA1= 12’, 3’, 6’ margins, FSA2= 9’ and deep margins, FSB= left axilla sentinel LNs, A1-A5= tumor. S2023-04655= left axilla LNs
    • MICROSCOPIC EXAMINATION
      • Disease Type
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 2.5 x 2.0 x 1.5 cm
        • Histologic grade (Nottingham histologic score): Grade 2 (score=6)
        • Skin involvement: Not applicable
        • Muscle involvement: Present
        • Ductal carcinoma in situ: Absent
      • Margins: Negative, Closest margin ( 2 mm from deep margin)
      • Nodal status: Positive (sentinel 1/3; axillary 1/8)
        • numbers
          • number of lymph node examined: 3 (sentinel), 8 (axilla)
          • number with macrometastases (> 2mm): 1 (sentinel), 1 (axilla)
          • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
          • number with isolated tumor cells (<= 0.2mm and <=200 cells): 0
        • Extranodal extension: Present
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Absent
    • IMMUNOHISTOCHEMICAL STUDY (Data from VGH)
      • ER (Ab): Positive (95%)
      • PR (Ab): Positive (90%)
      • HER-2/Neu (Ab): Negative (score= 1+)
      • Ki-67: 28%
  • 2023-03-14 Frozen Section
    • 3’, 6’, 9’, 12’, upper and deep margins, breast, left, frozen section — Free of carcinoma
    • Sentinel lymph nodes, axilla, left, frozen section — Metastatic carcinoma (1/3)
  • 2023-03-14 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
    • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
  • 2023-03-13 SONO - abdomen
    • fatty liver: minimal
  • 2023-03-09 Tc-99m MDP bone scan
    • Increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
  • 2023-03-09 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Left breast cancer
    • Treatment
      • explain the finding
    • Suggestion and Plan
      • further treatment
    • BI-RADS:
      • score 6. known biopsy-proven malignancy

[consultation]

  • 2023-08-28 Radiation Oncology
    • Q
      • This 57-year-old female patient denied any past history including hypertension, DM, HBV or heart disease. She denied cancer history. She had COVID infection on 2022/11.
      • She noted a palpable mass at left breast by health examination in VGH. Core needle biopsy revealed invasive carcinoma, ER(95%+) PR(90%+) HER2/neu(1+) Ki 67 28%. CA-153 11.912 U/ml, CEA 2.452 ng/ml. Due to personal reason, she came to our OPD for help.
      • Breast sono showed a lesion, left 6’/0.43 cm , size: 1.19x1.67cm. Tc-99m MDP whole body bone scan and abdomen echo showed no obvious lesion for metastasis. Under surgery of left partial mastectomy + ALND on 2023/03/14.
      • Pathology invasive carcinoma with axillary LN metastasis, pT2N1aM0; Anatomic stage IIB; Prognostic stage IB.
      • Adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles was plan.
      • AI and radiotherapy for axillary LN after chemotherapy.
      • Under the impression of left breast invasive carcinoma with axillary LN metastasis, she was admitted for 8th adjuvant chemotherapy Taxotere 75mg/m2. We need your help for radiotherapy. Thank you so much!!
    • A
      • Subjective:
        • Previous RT: denied.
        • Other disease: HTN, thyroid CA s/p thyroidectomy, HCVD, hyperlipidemia and insomnia.
        • Family history: denied.
        • Habit: Alcohol: denied; Smoking: denied; betel nut: denied.
        • Married. Caregiver: her husband. Job: accountant (rest now). Mild or no economic stress at least.
        • Language: Mandarin. Taiwanese.
        • Religion: Buddism
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2023/8/28: No palpable SCF LAPs.
        • Pathology, 2023/03/14
          • Breast, left, partial mastectomy — Invasive carcinoma of no special type, 2.5 cm, free margin (2 mm from closest deep margin); LVSI(+). ER(95%+); PR(90%+); HER2/neu(1+); Ki 67 28%.
          • Lymph nodes, sentinel and axillary, left, lymphadenecomy — Metastatic carcinoma (2/11), ECS(+).
          • AJCC 8 th edition, Pathology stage: pT2N1a(cM0); Anatomic stage IIB; Prognostic stage IB.
        • Images:
          • Breast sonogram, 2023/03: a lesion, left 6’/0.43 cm, size: 1.19x1.67cm.
          • CXR, liver echo, bone scan, 2023/03: negative for metastasis.
      • Diagnosis: Left breast cancer, invasive carcinoma, s/p partial mastectomy + ALND on 2023/03/14, pT2N1a cM0; Anatomic stage IIB; Prognostic stage IB s/p adjuvant chemotherapy Lipo dox 35mg/m2 + Endoxan 600mg/m2 for 4 cycles then Taxotere 75mg/m2 for 4 cycles (last on 2023/8/28); ECOG =1.
      • Plan: Adjuvant RT to left breast and SCF lymphatics for 5000cGy/25 fractions then boost scar to 6000cGy/30 fx is suggested for locoregional control. CT simulation is arranged on 9/06, 10:30. Possible RT toxicity is told. Diet education is given.

[surgical operation]

  • 2023-03-14
    • Surgery: Partial mastectomy (round-block) + axillary lymphnode dissection        
    • Finding
      • a 2.5x2x1.5 cm slight firm mass in lt breast
      • SLN 1(+)/3   

[chemotherapy]

  • 2023-08-28 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + famotidine 20mg
  • 2023-08-07 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-07-17 - docetaxel 75mg/m2 115mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-21 - docetaxel 75mg/m2 114mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-31 - cyclophosphamide 600mg/m2 900mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 52mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-08 - cyclophosphamide 600mg/m2 924mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-17 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1
  • 2023-03-25 - cyclophosphamide 600mg/m2 920mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 54mg D5W 250mL 2hr (AC(Lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL + Granisetron 1mg + aprepitant 125mg PO D1

==========

2023-10-24

[grade 3 diarrhea]

The patient experienced grade 3 diarrhea (characterized by an increase of seven or more stools per day over baseline, the patient had a total of 8 bowel movements on 2023-10-23). However, the last administration of docetaxel, known to cause diarrhea in 23% to 43% of cases (with severe cases being <=6%), occurred almost two months ago, on 2023-08-28. This timeline makes it improbable that the recent severe diarrhea was solely a result of the previous docetaxel treatment.

Currently, the patient is on both loperamide and buscopan to manage the symptoms.

Additionally, it’s important to note that the patient’s current medication, abemaciclib, can also induce diarrhea. It’s advisable to temporarily discontinue abemaciclib until the diarrhea subsides to <= grade 1, after which the medication can be cautiously reintroduced.

700526640

231023

[exam findings]

  • 2023-10-21, -10-11, -09-25 KUB
    • Ascites is noted. Please correlate with sonography.
    • Spondylosis of the L-spine is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5 and L5-S1.
  • 2023-09-17 CT - abdomen
    • Findings
      • Cystic tumors in the pelvic cavity, up to 7.4cm. R/O recurrent tumors.
      • Presence of ascites with peritoneal nodularity, r/o carcinomatosis.
      • There are liver tumors, up to 3.4cm in right lobe, could be due to liver metastasis. Progression.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • S/P hysterectomy.
      • R/O calcified granuloma in left lower lung.
      • Right lower lung nodule, r/o lung metastasis.
    • Impression:
      • Peritoneal carcinomatosis.
      • Liver metastasis with progression.
      • R/O calcified granuloma in left lower lung.
      • Right lower lung nodule, r/o lung metastasis.
  • 2023-09-17 KUB
    • Small bowel ileus.
    • Lumbar spondylosis.
    • Disc space narrowing at L4/5 level.
  • 2023-09-15 Vein Sonography
    • No evidence of DVT, bilateral lower legs
    • Right CFV trivial reflux
    • Right LSV trivial reflux, involved right sphenofemoral junction (SFJ); proximal GSV size 0.41 cm,
    • Left LSV mild reflux, involved left sphenofemoral junction (SFJ); proximal GSV size 0.42 cm,
    • Left CFV mild reflux
    • Both SSV without reflux.
  • 2023-09-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78 - 16) / 78 = 79.49%
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Aortic valve calcification with moderate AS
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Trivial MR, moderate TR
      • Preserved RV systolic function
  • 2023-08-13 Gynecologic ultrasonography
    • s/p staging operation(ATH + BSO + BPLND)
    • A 76.7x70.0mm pelvic mass was noted, suspected hematoma?
  • 2023-08-10 Gynecologic ultrasonography
    • ATH + BSO
    • R/O RT mass: 91mm X 82mm, no blood flow
  • 2023-06-21 Vein Sonography
    • No evidence of DVT, bilateral lower legs
    • Both LSV trivial reflux
  • 2023-06-15 Patho - ovary (non-tumor)
    • Soft tissue, pelvic, exploratoy laparotomy — Metastatic serous carcinoma
    • The sections show a picture of metastatic serous carcinoma, composed of papillary fronds lined by pleomorphic polygonal neoplastic cells, with high mitotic activity. Solid sheets of neoplastic cells admixed with reactive mesothelial cells can be found also.
  • 2023-05-30 MRI - pelvis
    • S/P hysterectomy with recurrence in the pelvic cavity, progression.
    • Stationary liver tumor, r/o liver metastasis.
    • Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis.
    • Lymphocele in the pelvic cavity with regression.
  • 2023-02-16 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 20 dB HL, normal to moderately severe SNHL
      • L’t : 19 dB HL, normal to moderate SNHL
    • Tymp
      • R’t : Type A
      • L’t : Type As
    • ART
      • R’t : absent
      • L’t : absent except Ipsi 500-1k Hz.
  • 2023-01-16 MRI - pelvis
    • S/P hysterectomy, r/o recurrent tumor in the pelvic cavity (near right vaginal stump and cul-de-sac), progression.
    • Liver tumor, 1.3cm in S8. progression, r/o liver metastasis.
    • Lymphocele in the pelvic cavity.
  • 2022-10-31 MRI - pelvis
    • S/P hysterectomy. R/O recurrent tumor in the cul-de-sac and right vaginal stump.
    • Stationary liver tumor (metastatic?), 1.1cm in S8.
    • Lymphocele in the pelvic cavity.
  • 2022-08-01 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Uterus, endometrium, ATH — Serous carcinoma
      • Ovary, left, BSO — Involved by serous carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic serous carcinoma (21/36)
      • Omentum, infracolic omentectomy — Invoved by serous carcinoma
      • CDS, right, excision — Involved by serous carcinoma
      • AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH+BSO+infracolic omentectomy+BPLND+para-aortic LN dissection
      • Specimen Size: 12 x 8 x 5 cm (uterus), 3.0 x 2.5 x 2.0 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3.0 x 2.5 x 2.0 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube), 28 x 15 x 2.0 (omentum), and right CDS
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium
      • Tumor Size: No definite mass can be identified grossly
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, and bilateral para-aortic
      • Representative parts are taken for section and labeled as: A1-A2= left iliac LNs, B= left obturator LNs, C1-C2= right iliac LNs, D= right obturator LNs, E= left para-aortic LNs, F= right para-aortic LNs G1-G2= left ovary and fallopian tube, G3-G4= right ovary and fallopian tube, G5-G6= cervix, G7-G10= uterine corpus, H1-H2= omentum, I= right CDS.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Serous carcinoma
      • Histologic Grade: High-grade
      • Adenomyosis: Not identified
      • Uterine Serosal Involvement: Present
      • Cervical Stromal Involvement: Present
      • Other Tissue/Organ Involvement: Left ovary involvement
      • Peritoneal/Ascitic Fluid: Pending
      • Margins: Involved by carcinoma
      • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: Metastatic serous carcinoma (21/36)
        • number of lymph node examined: 7 (left iliac), 5 (left obturator), 2 (right iliac), 8 (right obturator), 6 (left para-aortic), 8 (right para-aortic)
        • number with metastases: 5 (left iliac), 3 (left obturator), 1 (right iliac), 1 (right obturator), 5 (left para-aortic), 6 (right para-aortic)
      • Pathologic Stage
        • Primary Tumor: ypT3a (tumor involving the serosa and adnexa)
        • Regional Lymph Nodes: ypN2a (metastasis to para-aortic lymph nodes >2mm)
        • Distant Metastasis: Metastasis to omentum
      • FIGO Stage: Stage IVB
      • AdditionalPathologic Findings
        • Cervix: Involved by carcinoma
        • Myometrium: Involved by carcinoma and leiomyoma
        • Ovary, right: No remarkable change
        • Ovary, left: Involved by carcinoma
        • Fallopian tubes, blateral: No remarkable change
        • Omentum: Involved by carcinoma
        • CDS, right: Involved by carcinoma
  • 2022-07-19 Bronchodilator Test
    • Normal spirometry
    • without significant response to bronchodilator
  • 2022-07-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 21) / 75 = 72.00%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild AS, AR, TR
  • 2022-07-11 CXR + Lat. LT
    • Spondylosis of the T-spine
    • A nodular opacity projecting in the left lower medial lung, retrocardiac area, shows stationary. Old calcified granuloma is highly suspected. Follow up is indicated.
  • 2022-07-11 CT - abdomen
    • Findings
      • Low density lesion at S8 of liver about 1.69cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-05-03, the lesion is stationary.
      • Wall thickening at endometrium is found. Endometrial cancer is considered. In regression.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Endometrial cancer, in regression.
      • Liver meta. Stable.
  • 2022-05-10 Patho - endometrium curretage/biopsy
    • DIAGNOSIS:
      • A. Labeled as “endometrium”, Dilataion and curettage with frozen section (F2022-218FSA) — Serous adenocarcinoma, high grade.
        • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type), p16 (<70%).
      • B. Labeled as “left pelvic mass”, clinically left ovary obscured, SILS biopsy with frozen section (F2022-218FSB) — Serous adenocarcinoma, high grade.
        • IHC stains: PAX-8 (+), WT-1 (focal +), Napsin-A (-), p53 (aberrant type). ER: (-), PR (-).
    • Note: Ovarian origin is favored.
  • 2022-05-06 Ascites tapping
    • Course: 18G needle was inseted at RLQ under echo guided insertion.
    • Findings: 3000 ml yellowish color ascites were drained.
  • 2022-05-05 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Chronic active gastritis, H pylori present
  • 2022-05-05 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Suspected gastric ulcer scar
      • Gastric erosive lesion, suspected healing ulcer, s/p biopsy
      • Deformed prepyloric antrum
      • Duodenal ulcer scars
    • CLO test: Positive
    • Suggestion:
      • PPI therapy
      • Pursue pathology and CLO test result
  • 2022-05-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 18) / 66 = 72.73%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA,
      • Mitral inflow EA fusion due to tachycardia
      • Mild AR, AS, TR
      • 5.Presence of left pleural effusion
  • 2022-05-05 Colonoscopy
    • Colon polyps, probable adenoma (without polypectomy)
    • Colon diverticulosis
    • Failure of cecal intubation
  • 2022-05-04 Flow volume loop
    • mild restrictive impairment
  • 2022-05-03 CT - abdomen
    • Findings
      • Prominent ascites with multiple soft tissue tumors in the peritoneum, could be due to peritoneal carcinomatosis.
      • Prominent density in the uterine cavity.
      • Liver cyst, 1.9cm in left lobe.
      • Low density nodules in right lobe of the liver, up to 1.7cm in S7, r/o liver metastasis.
      • S/P right mastectomy.
      • Outpouching lesions in ascending and descending colon, suggesting diverticula.
      • R/O calcifie granuloma in left lower lung.
    • Impression:
      • Peritoneal carcinomatosis and liver metastsis.
      • Prominent density in the uterine cavity. Suggest GYN study.
      • Liver cyst.
      • S/P right mastectomy.
      • Colon diverticulosis.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVb(Stage_value)
  • 2022-05-03 Gynecologic ultrasonography
    • R/O Endometrial hyperplasia: 39.0mm (solid + fluid)
    • Ascites
    • R/O Rt mass: 50x44mm
  • 2022-04-30 Ascites tapping
    • paracentesis under direct sonography-guidance: an IC cath (18 gauge) was inserted into peritoneal cavity at RLQ: 2000cc yellowish ascites was drained out
  • 2022-04-30 SONO - abdomen
    • Diagnosis:
      • Peritoneal tumors, multiple, favor seeding
      • Ascites, massive
      • Hepatic tumor favor hemangioma
      • Hepatic cyst
      • Susp. parenchymal liver disease
    • Suggestion:
      • paracentesis

[MedRec]

  • 2023-07-06 SOAP Radiation Oncology Huang JingMin
    • A: Serous carcinoma of the uterine endometrium, AJCC 8 th edition, Pathology stage: ypT3aN2aM1; stage IVB; FIGO stage IVB, s/p neoadjuvant chemotherapy and Debulking surgery (ATH + BSO + BPLND + paraaortic LN dissection + infracolic omentectomy), and chemotherapy, with relapse, s/p excision.
    • P: Radiotherapy is indicated for this patient with the following indicators: tumor recurrence
      • Goal: palliation
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT and IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions of the vaginal cuff mucosa surface.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-07-13.
  • 2023-07-04 SOAP Hemato-Oncology Xia HeXiong
    • P: Arrange admission for Lipo-Dox with or without Carboplatin or CCRT with plaitnum first followed by C/T
  • 2023-07-04 SOAP Obstetrics and Gynecology Huang SiCheng
    • P: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-06-29.
      • Treatment plan: Systemic therapy and consult radiation oncology
  • 2023-06-12 ~ 2023-06-26 POMR Obstetrics and Gynecology Yan XuanShang
    • Discharge diagnosis
      • Endometrial cancer
      • Pelvic cystic mass tumor–>Excision of intraabdominal tumor, malignant on 2023-06-14
      • Female pelvic peritoneal adhesions (postinfective) -> Adhesionolysis on 2023-06-14
    • CC
      • Constipation and dysuria for about 2 weeks.
    • Present illness
      • This is a 79 y/o, G4P2SA2 woman with a medical history of:
        • Endometrial cancer, high grade serous adenocarcinoma, with peritoneal carcimatosis and liver metastases, s/p SILS biopsy + dlatation and curettage and port-A insertion, s/p palliative chemotherapy (III) with Taxol / Carboplatin (2022/05/17, 2022/06/13, 2022/07/04)
        • Debulking surgery + HIPEC on 2022/08/01. Pathology report show endometrial cancer, high grade serous adenocarcinoma with stage: ypT3aN2aM1; stage IVB; FIGO stage IVB s/p palliative chemotherapy.
        • Hypertension under medical control
        • Diabetes mellitus under medical control
        • Right breast cancer, status post oeration and chemotherapy.
      • The patient, who has a history of endometrial cancer and was previously followed up at our OPD, presented this time with complaints of constipation and dysuria for approximately 2 weeks. There is no associated abdominal pain or fever. She denies symptoms such as nausea, vomiting, and tarry or bloody stool.But have lower limbs mild weakness and numbness. Laboratory data revealed elevated levels of BUN (46 mg/dL), creatinine (2.58 mg/dL), and a decreased hemoglobin level (9.8 g/dL). Additionally, CA125 was measured at 1365.6 U/mL, and CA199 was measured at 337.15 U/mL. Urine examination showed the presence of occult blood (2+) and ediment-RBC = 3-5 /HPF, Sediment-WBC = >=100 /HPF.
      • An MRI of the pelvis conducted on 2023-05-30, revealed the following findings: 1. S/P hysterectomy with recurrence in the pelvic cavity, progression. 2. Stationary liver tumor, r/o liver metastasis. 3. Ascites with peritoneal enhancement, r/o peritoneal carcinomatosis. 4. Lymphocele in the pelvic cavity with regression.
      • After discussing patient’s symptom with the patient, she decided to undergo further surgery. She was admitted on 2023-06-12, for debulking surgery, exploratory laparotomy, and HIPEC, scheduled for 2023-06-14.
    • Course of inpatient treatment
      • The patient was admitted on 2023-06-12 and underwent Excision of intraabdominal tumor, malignant + Adhesionolysis the next day. Her postoperative course was uneventful. Eating and urination by self voiding was smooth. The vital sign was stable after surgery. She is discharged on 2023-06-26 and her followup appointment is scheduled on next week.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# TID
      • Cephalexin (cephalexin 500mg) 1# TID
      • Uretropic (furosemide 40mg) 0.5# QD
      • Wecoli (bethanechol 25mg) 1# QD
  • 2022-05-16 SOAP Gastroenterology Chen ZhiXiang
    • S
      • Refer for NUC (nucleotide analogue) prophylaxis for occult HBV
      • Scheduled neo C/T for endometrial ca tomorrow
  • 2022-05-02 ~ 2022-05-12 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Ovary cancer,suspected with cancer peritonitis
      • Right breast cancer s/p op and chemotherapy
      • Hypertension
      • Diabetes mellitus
      • Old CVA with left lower limbs mild weakness
      • Reflux esophagitis
      • colon polyps
    • CC
      • abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month
    • Present illness
      • This 78 year-old female has the histories of
        • Old CVA with left lower limbs mild weakness
        • Hypertension
        • Diabetes mellitus
        • right breast ca status post oeration and chemotherapy
      • She came to GI OPD due to progressive abdominal distenetion, poor appetite, acid regurgitation sensation, body weight loss, thinner in stool shape in recent 1 month.She denied nausea, vomiting, abdominal pain, tarry or bloody stool and no hematuria, no cough, no dyspnea, no cold sweating, no fever, no chills, no chest or back pain. She also denied TOCC history. Blood analysis showed leukocytosis (11.36x10^3/uL), and left shift (SEG: 78.8 %), no anemia (Hb: 12mg/dL), normal PT/aPTT level, normal renal function, no electrolyte imbalance, normal hepatobiliary enzyme (ALT: 6 U/L, AST: 13 U/L, TBI: 0.42 mg/dl, DBI: 0.15 mg/dl, ALP: 143 IU/L).
      • Under the impression of cancer peritonitis. She was admitted to GI ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission ward, abdominal CT was performed on 5/3 for cancer survey and revealed: 1) Peritoneal carcinomatosis and liver metastsis. 2) Prominent density in the uterine cavity. Suggest GYN study. 3) Liver cyst. 4) S/P right mastectomy. 5) Colon diverticulosis.
      • Due to the abdominal CT report, the GYN Doctor was consulted and the suggestion was given as follows: 1) suspect ovarian cancer 2) Check CA125, CA199, CEA, Albumin, FDPdimer 3) transfer to GYN ward after EGD and colonscope, operation will be arranged next week.
      • GYN sonography was done on 05/03 and showed 1) suspect ovarian cancer. 2) R/O Endometrial hyperplasia: 39.0mm (solid + fluid). 3) Ascites. 4) R/O Rt mass: 50x44mm. The Chest Medicine Department was also consulted for CXR report with solitary pulmonary nodule at left pulmonary hilar region and suggestion was given as follows: 1) The left lung nodule is stationary compared with previous CXR and may be related to previous old TB calcified lesion -> Keep F/U 2) However, 1 tiny nodule over RLL, cause unknown, should survey the etiology of the ascites.
      • EGD was performed on 05/05 and reveled 1) Reflux esophagitis LA Classification grade A. 2)Superficial gastritis, s/p CLO test. 3) Suspected gastric ulcer scar. 4) Gastric erosive lesion, suspected healing ulcer, s/p biopsy. 5) Deformed prepyloric antrum. 6) Duodenal ulcer scars.
      • The followed pathological report of stomach biopsy menifested chronic active gastritis, H pylori present.
      • Colonscopy was performed and reveled 1) Colon polyps, probable adenoma. 2) Colon diverticulosin.
      • Oral PPI was used with Nexium. After asccites tapping, her symptom relieved.
      • Cardiac sonography and pulmonary fuction test were also arranged for pre-operation prepare.
      • Aspirin was held for operation next week since 5/4.
      • The patient was transferred to GYN ward on 5/6 for further surgery. After transfer to GYN ward, we closely monitor her general condition and clinical presentation. No special complaint was noted and preoperative anesthesia evaluation was done 05/06.
      • She accepted SILS biopsy + Dilatation and curettage and Port-A insertion via left subclavian vein on 2022/05/09. Frozen section revealed endometrium adenocarcinoma and washing cytology revealed metastatic carcinoma. Her postoperative status was stable and tolerable wound pain was told. She was then discharged on 2022/05/12 under stable condition and follow-up at OPD.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • MgO 250mg 2# QID
      • cephalexin 500mg 1# QID

[surgical operation]

  • 2023-08-12
    • Surgery: Cul-do centesis
    • Finding: Vaginal bulging from 11-5 o’clock of direction; suspect pseudo cyst over CDS by TVS about 9cm; dark-brown fluid about 220ml was drained out
      • EBL 5ml Cx and BT: nil
  • 2023-06-14
    • Operation
      • Excision of intraabdominal tumor, malignant
      • Adhesionolysis
    • Finding
      • s/p midline incision with severe adhesion of small bowel and large bowel
      • A cystic tumor mass in the pelvic cavity with papillary tumor nest was encountered
      • Drain: 19Fr Blake drain x1, in the pelvic cavity

[radiotherapy]

  • 2023-07-21 ~ 2023-09-01 - 4500cGy/25 fractions of the pelvic, and 5400cGy/30 fractions of the vaginal cuff mucosa area.

[chemotherapy]

  • 2023-10-13 - docetaxel 35mg/m2 60mg NS 200mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-09-23 - docetaxel 35mg/m2 60mg NS 200mL 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-08-30 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-23 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-08 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - carboplatin AUC 2 100mg D5W 2hr (Y-sited with NS 1000mL) (carboplatin QW CCRT)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-21 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-07 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-22 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-08 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-20 - topotecan 0.75mg/m2 1.25mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-06 - topotecan 1.2mg/m2 2mg NS 40mL 0.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-25 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 250mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-10-04 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 240mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-09-13 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-08-01 - [liposome doxorubicin 35mg/m2 60mg D5W 250mL + carboplatin AUC 5 450mg NS 250mL] IP 90min (HIPEC)

  • 2022-07-04 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-13 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-05-17 - paclitaxel 160mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 250mL 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-10-23

Lab data

  • 2023-10-23 Neutrophil 80.6 %

  • 2023-10-23 WBC 5.01 x10^3/uL

  • 2023-10-23 HGB 7.8 g/dL

  • 2023-10-23 PLT 295 *10^3/uL

  • 2023-10-23 Albumin(BCG) 2.8 g/dL

  • 2023-10-23 Creatinine 1.14 mg/dL

  • 2023-10-23 eGFR 48.87 ml/min/1.73m^2

The patient has anemia, hypoalbuminemia, and altered renal function (calculated CrCl 44 mL/min).

If the patient is scheduled to receive the same dose of docetaxel as before, there is no need to adjust the dose for any degree of kidney dysfunction. However, anemia (and/or hypoalbuminemia with edema) may need to be treated before chemotherapy can begin.

2023-10-13

[leukopenia]

Lab data showed leucopenia on 2023-10-05 at 2.26K/uL.

  • 2023-10-12 WBC 13.14 x10^3/uL
  • 2023-10-11 WBC 15.84 x10^3/uL
  • 2023-10-09 WBC 34.63 x10^3/uL
  • 2023-10-05 WBC 2.26 x10^3/uL *
  • 2023-09-28 WBC 6.10 x10^3/uL
  • 2023-09-20 WBC 4.82 x10^3/uL
  • 2023-09-17 WBC 6.34 x10^3/uL

The most recent chemotherapy treatments prior to the leukopenia event were docetaxel (35mg/m2 60mg) on 2023-09-23 and carboplatin (AUC 2 100mg) on 2023-08-30, the latter as part of CCRT.

According to the updated lab data in WBC level, there is no more leukopenia occurs after the event.

The hype of WBC level after the leukopenia event might be due to Granocyte (lenograstim 250ug) x 4 days since 2023-10-05.

2023-09-19

MgO, metformin, linagliptin, aspirin, trichlormethiazide, bisoprolol, olmesartan, rosuvastatin, and quetiapine were prescribed at NTUH on 2023-07-28 as a repeat prescription. These drugs were refilled on 2023-08-18, and with the exception of MgO, which might no longer be necessary, all the other drugs have been added to the active medication list.

701090517

231023

[MedRec]

  • 2023-09-27 SOAP Cardiology Zhou XingHui
    • Prescription x3
      • Alpraline (alprazolam 0.5mg) 1# HS
      • Concor (bisoprolol 1.25mg) 1# QD
      • Diovan (valsartan 160mg) 0.5# QD
      • Plavix (clopidogrel 75mg) 1# QD
      • Crestor (rosuvastatin 10mg) 1# QD
      • Ezetrol (ezetimibe 10mg) 1# QD
  • 2023-09-27 SOAP Urology Xu JunKai
    • Prescription x3
      • Betmiga (mirabegron 50mg) 1# QD
      • Urief (silodosin 8mg) 1# QD

==========

2023-10-23

This patient is in the hospital to have his gastrointestinal problems examined further. He is currently taking the medications prescribed by our urologist and cardiologist on 2023-09-27, and there are no discrepancies with these drugs.

701366805

231020

{High grade serous carcinoma FIGO stage IIIC, right ovarian cancer with peritoneal seeding s/p operation} (not completed)

[lab data]

  • CA125
    • 2022-04-22 401.9 U/mL
    • 2022-03-30 1091.2 U/mL
  • 2022-04-14
    • Anti-HBs 2.99 mIU/mL
    • Anti-HBc Nonreactive
    • Anti-HBc-Value 0.14 S/CO
    • Anti-HCV Nonreactive
    • Anti-HCV Value 0.15 S/CO
    • HBsAg Nonreactive
    • HBsAg (Value) 0.44 S/CO
  • 2022-03-31
    • Anti-HCV Nonreactive
    • Anti-HCV Value 0.16 S/CO
    • Anti-HBc Nonreactive
    • Anti-HBc-Value 0.13 S/CO
    • HBsAg Nonreactive
    • HBsAg (Value) 0.42 S/CO

[exam findings] (not completed)

  • 2022-05-10 Aspiration Cytology - LN
    • Left parotid tumor: Favor benign, pleomorphic adenoma
    • Two wet cellular smears show epithelial cells arranged in cord, nest or trabecular patterns and mononuclear cells in background resemble myoepithelial cells as well as chondromyxoid material in focal area. It maybe compatible with pleomorphic adenoma. Confirmatory biopsy is advised, if clinically indicated.
  • 2022-05-10 SONO - head and neck soft tissue
    • clinical impression/intent: right parotid tumor, previous cytology: atypia
    • sonographic impression: right parotid tumor
  • 2022-04-07 Patho - ovary (non-tumor)
    • Diagnosis
      • Ovary, right, oophorectomy — High grade serous carcinoma seeding on serosa
      • Fallopian tube, right, salpingectomy — High grade serous carcinoma seeding on serosa
      • F2022-00146:
        • Omentum, omentectomy — High grade serous carcinoma, metastatic (please see microdescription)
        • Ovary, left?, excision — Consistent with high grade serous carcinoma
    • Microscopic description
      • Sections show ovary and fallopian tube with high grade serous carcinoma seeding on serosa.
      • F2022-00146:
        • Sections show omentum with metastatic solid sheets and papillary tumor and psammoma bodies.
        • The cystic tumor reveals ovarian stroma with psammoma bodies. The lining epithelium is mostly denuded, and only scant tumor lining epithelial is seen.
        • The immunohistochemical stains reveal PAX(+), p53(aberrant expression +), WT-1(+), GATA3(-), Napsin A(-), PR(-), and Calretinin(-). The results are consistent with high grade serous carcinoma arising from ovary. Please correlate with the clinical presentation and image study.
        • Lymphovascular invasion is found. No fallopian tube is seen.
  • 2022-04-06 Body fluid cytology - ascites
    • Pathologic diagnosis: positive for malignancy
    • The smears show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-04-06 Frozen Resection
    • Preliminary diagnosis:
      • Pelvic mass, excision — Carcinoma, wait IHC for tumor origin
  • 2022-03-30 Gynecologic ultrasonography
    • Suspected rt adnexal mass: 124mm x 93mm, malignancy cannot be ruled out
    • Ascites (+)
  • 2022-03-25 CT - abdomen, pelvis
    • Findings:
      • There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.
    • Impression:
      • Primary peritoneal serous carcinoma is highly suspected.
      • The differential diagnosis include ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB. Please correlate with CA125 and CT-guided biospy of the omentum lesion.

[consultation]

  • 2022-03-31 Hemato-Oncology
    • A
      • Impression:
        • Primary peritoneal serous carcinoma is highly suspected.
        • The differential diagnosis including stomach cancer, ovarian cancer with carcinomatosis, mesothelioma, lymphoma and TB.
      • Suggestion:
        • Arrange PES to check UGI tract lesions, GYN ultrasound and CT-guided biospy of the omentum lesion
        • may check LDH, anti Hbc, HbsAg, Anti HCV
        • Thanks for your consultation, we wound like to follow up this case. If there is any problem, please feel free to let us known.
  • 2022-03-31 Obstetrics and Gynecology
    • A
      • Objective
        • The abdomen CT on 03/25 reported: There are lobulated enhancing soft tissue lesions in the omentum (omentum cake) and mesentery of the pelvis, and ascites that may be primary peritoneal serous carcinoma.
        • Lab data: CA125 1091.2 (0~35)
        • Echo: Right ovarian cystic mass 13 cm with solid part was noted, with small amount ascite, suspected ovarian cancer
      • Plan
        • please check CA199, CEA, Albumin, D-Dimer
        • check Esophagogastroduodenoscopy (EGD) and low gastrointestinal endoscopy

[surgical operation]

  • 2022-04-06
    • Operation
      • Enterolysis
    • Finding
      • Multiple peritoneal seedings including tumor nodules in small bowel and mesentery
      • Adhesion of small bowel and large bowel
  • 2022-04-06
    • Surgery
      • Pelvic mass, peritoenal carcinomatosis?
      • Perineal cake
      • Operation:
        • RSO and omentectomy
    • Finding
      • Uterus: 4x3cm, grossly normal, with severe adhesion to pelvic wall
      • RAD: grossly normal,adhesion to pelvic wall and the mass
      • LAD: Severe adhesion to the mass
      • CDS: Severe adhesion/partial obliterated
      • During the procedure, omentum attached to the anterior wall of the pelvic cavity, adhesion lysis was performed before we entered the pelvic cavity. (due to perineal cake, severe adhesion was found during the procedure)
      • Residual tumor over colon and pelvic with size 1x1 cm.
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2 U
      • Complication: nil        

[chemoimmunotherapy] (not completed)

  • 2023-10-19

  • 2023-09-13

  • 2023-08-17

  • 2023-07-24

  • 2023-06-29

  • 2023-05-31

  • 2023-04-26

  • 2023-03-08

  • 2023-02-03

  • 2022-12-20

  • 2022-11-29

  • 2022-10-24

  • 2022-09-12

  • 2022-08-12

  • 2022-07-19 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-06-27 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-06-01 - bevacizumab 7.5mg/kg 1.5hr + paclitaxel 175mg/m2 3hr + carboplatin 600mg 2hr

  • 2022-05-04 - paclitaxel 160mg/m2 3hr + carboplatin 600mg 2hr

Ovarian Cancer Continue Including Fallopian Tube Cancer and Primary Peritoneal Cancer, NCCN Evidence Blocks, Version 1.2022 - January 18, 2022, p42,43

  • Principles of Systemic Therapy
    • Primary Systemic Therapy Regimens - Epithelial Ovarian/Fallopian Tube/Primary Peritoneal
      • Primary Therapy for Stage I Disease
        • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
          • Useful in Certain Circumstances
            • For carcinosarcoma:
              • Carboplatin/ifosfamide
              • Cisplatin/ifosfamide
              • Paclitaxel/ifosfamide (category 2B)
        • Mucinous carcinoma (stage IC)
          • Preferred Regimens
            • 5-FU/leucovorin/oxaliplatin
            • Capecitabine/oxaliplatin
            • Paclitaxel/carboplatin q3weeks
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
          • Useful in Certain Circumstances
            • None
        • Low-grade serous (stage IC)/Grade I endometrioid (stage IC)
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
            • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
          • Other Recommended Regimens
            • Carboplatin/liposomal doxorubicin
            • Docetaxel/carboplatin
            • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
          • Useful in Certain Circumstances
            • None
      • Primary Therapy for Stage II-IV Disease
        • High-grade serous, Endometrioid (grade 2/3), Clear cell carcinoma, Carcinosarcoma
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
          • Useful in Certain Circumstances
            • IP/IV paclitaxel/cisplatin (for optimally debulked stage II-III disease)
            • For carcinosarcoma:
              • Carboplatin/ifosfamide
              • Cisplatin/ifosfamide
              • Paclitaxel/ifosfamide (category 2B)
        • Mucinous carcinoma (stage IC)
          • Preferred Regimens
            • 5-FU/leucovorin/oxaliplatin +- bevacizumab
            • Capecitabine/oxaliplatin +- bevacizumab (category 2B for bevacizumab)
            • Paclitaxel/carboplatin q3weeks
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
          • Useful in Certain Circumstances
            • None
        • Low-grade serous/Grade I endometrioid
          • Preferred Regimens
            • Paclitaxel/carboplatin q3weeks +- maintenance letrozole (category 2B) or other hormonal therapy (category 2B)
            • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7 & GOG-218)
            • Hormone therapy (aromatase inhibitors: anastrozole, letrozole, exemestane) (category 2B)
          • Other Recommended Regimens
            • Paclitaxel weekly/carboplatin weekly
            • Docetaxel/carboplatin
            • Carboplatin/liposomal doxorubicin
            • Paclitaxel weekly/carboplatin q3weeks
            • Hormone therapy (leuprolide acetate, tamoxifen) (category 2B)
          • Useful in Certain Circumstances
            • None
      • Primary Systemic Therapy Recommended Dosing
        • IV/IP Paclitaxel/cisplatin
          • Paclitaxel 135 mg/m2 IV continuous infusion Day 1;
          • Cisplatin 75-100 mg/m2 IP Day 2 after IV paclitaxel;
          • Paclitaxel 60 mg/m2 IP Day 8
          • Repeat every 21 days x 6 cycles
        • Paclitaxel/carboplatin q3weeks
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV Day 1
          • Repeat every 21 days x 3-6 cycles
        • Paclitaxel weekly/carboplatin q3week
          • Dose-dense paclitaxel 80 mg/m2 IV Days 1, 8, and 15 followed by carboplatin AUC 5-6 IV Day 1
          • Repeat every 21 days x 6 cycles
        • Paclitaxel weekly/carboplatin weekly
          • Paclitaxel 60 mg/m2 IV followed by carboplatin AUC 2 IV
            • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)
        • Docetaxel/carboplatin
          • Docetaxel 60-75 mg/m2 IV followed by carboplatinm AUC 5-6 IV Day 1
          • Repeat every 21 days x 3-6 cycles
        • Carboplatin/liposomal doxorubicin
          • Carboplatin AUC 5 IV + pegylated liposomal doxorubicin 30 mg/m2 IV
          • Repeat every 28 days for 3-6 cycles
        • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (ICON-7)
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 5-6 IV, and bevacizumab 7.5 mg/kg IV Day 1
          • Repeat every 21 days x 5-6 cycles
          • Continue bevacizumab for up to 12 additional cycles
        • Paclitaxel/carboplatin/bevacizumab + maintenance bevacizumab (GOG-218)
          • Paclitaxel 175 mg/m2 IV followed by carboplatin AUC 6 IV Day 1. Repeat every 21 days x 6 cycles
          • Starting Day 1 of cycle 2, give bevacizumab 15 mg/kg IV every 21 days for up to 22 cycles
      • Primary Systemic Therapy Recommended Dosing for Elderly Patients (age >70 years) and/or Those with Comorbidities
        • Paclitaxel 135/carboplatin
          • Paclitaxel 135 mg/m2 IV + carboplatin AUC 5 IV given every 21 days x 3-6 cycles
        • Paclitaxel weekly/carboplatin weekly
          • Paclitaxel 60 mg/m2 IV over 1 hour followed by carboplatin AUC 2 IV over 30 minutes
          • Days 1, 8, and 15; repeat every 21 days x 6 cycles (18 weeks)

==========

2022-07-20

Lab results 2022-07-19 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB during this hospitalization is relatively stable.

2022-06-28

No BRCA1/2 lab results were found. Patients with BRCA1/2-mutated clear cell carcinoma or carcinosarcoma may benefit from maintenance therapy with PARPi (poly ADP ribose polymerase inhibitor) if CR or PR is achieved after primary treatment with surgery and platinum-based first-line therapy

700926088

231019

[exam findings] (not completed)

  • 2023-09-11 CT - chest
    • Comparison was made with CT dated on 2023/1/5
      • Lungs:
        • interval significant increase in size of LUL tumor (6.6cm in longest dimension) with pleural tails and surrounding with inferior ground-glass opacity, that involves the hilum and adjacent mediastinal fat.
        • an ill-defined peribronchovascular ground glass nodule at RUL.
      • Mediastinum and hila: mediastinal LAP in A-P window and Lt anterior perivascular space, and left hilum.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta..
        • Heart: normal in size of cardiac chambers.
      • Pleura: minimal Lt-sided effusion and left upper mediastial thickening.
      • Visible abdominal contents: left renal cyst (43x50 mm).
      • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
    • Impression:
      • LUL lung cancer T4N2 s/p TKI, significant in progression LUL and stationary of the RUL tumor as compared with CT on 2023/01/05
  • 2023-01-05 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at left upper lobe and right upper lobe measuring 3.3cm and 2.52cm respectively. In comparison with CT dated on 2022-09-20, the lesion is stationary.
        • One subcutaneous nodule medial to left breast is found measuring 2.0cm in largest dimension. In enlargement. Suggest further inspection.
        • No evidence of bilateral pleural effusion.
        • Minimal opacity over right lower lobe is found.
      • Visible abdomen:
        • Left renal cyst measuring 5.3cm in largest dimension is found.
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp:
      • Left upper lobe and right upper lobe lung cancer s/p TKI. stable
      • Subcutaneous nodule at left breast. 2.0cm, suggest further management.
  • 2022-09-20 CT - chest
    • Findings
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (21 mm in largest axial dimension)
        • a spiculated nodule with pleural tails and corona radiata at LUL (23mm in largest axial dimension).
        • mild subpleural reticulation at both lower lobes.
      • Mediastinum and hila: no enlarged LN.
        • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
      • Visible abdominal contents: left renal cyst (43x50 mm).
        • diffuse thickening wall of the urinary bladder with lateral wall diverticulum.
      • Visualized bones: compression fracture of T7 and L1 vertebral bodies.
    • Impression:
      • lung cancer s/p TKI, slightly decrease in size of LUL and RUL tumors as compared with CT on 2022/06/27
      • mild interstial fibrosis in lower lobes of lungs.
  • 2022-06-27 CT - lung
    • Findings
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
        • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
        • subpleural reticulation at voth lower lobes.
      • Mediastinum: no enlarged LN.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Visible abdominal contents: left renal cyst (43 x 50 mm).
        • S/P suprapubic cystectomy.
        • marked diffuse thickening wall of the urinary bladder.
        • with lateral wall diverticulum.
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • lung cancer s/p TKI, stationary in size of LUL and RUL tumors, compared with CT on 2021/12/15
      • mild interstial fibrosis in lower lobes of lungs.
  • 2022-03-02 Neurosonography
    • Mild to moderate atheromatous lesions in L middle CCA; mild atheromatous lesions in R subclavian artery and R ICA.
    • Elevated flow velocity in R PCA (PS/ED = 234/97 cm/s), suggesting R PCA stenosis.
    • Normal extracranial carotid, vertebral, and other intracranial basal cerebral arterial flows.
  • 2022-01-24 KUB + L-spine Lat
    • Bilateral clear psoas shadows. Dilated bowel gas pattern. L1 compression fracture. Degenerative change of the spine with marginal spur formation. Grade 1 degenerative spondylolisthesis at L4-5 level. Placement of urinary catheter.
  • 2022-01-11 CT - abdomen
    • Compression fracture of L1.
    • Partial atelectasis at LLL.
    • Left renal cyst (5.0cm).
    • Atherosclerosis of aorta, iliac arteries.
    • S/P foley catheter indwelling.
  • 2022-01-11 L-spine AP + Lat (including sacrum)
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L1.
    • Presence of spondylolisthesis at L4/5, grade I.
  • 2022-01-07 L-spine Lat. only. (including sacrum)
    • L1 compression fracture
    • Gr.I spondylolisthesis and disc space narrowing at L4/5
    • Facet degeneration of lumbar spine
  • 2021-12-15 CT - chest
    • Comparison made with previous CT dated on 2021/09/03
      • Lungs:
        • an ill-defined peribronchovascular ground glass nodule at RUL (23 mm in largest axial dimension)
        • a spiculated nodule with pleural tails at LUL (25 mm in largest axial dimension).
      • Mediastinum:
        • no enlarged LN.
        • minimal anterior pericardial effusion.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Visible abdominal contents: left renal cyst (43 x 50 mm).
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • lung cancer s/p TKI, decrease in size of LUL and RUL tumors, and no enlarged mediastinal LNs compared with CT on 2021/09/03
  • 2021-09-03 CT - chest
    • Indication: Lung cancer s/p TKI
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated, dense plate like lesion at left upper lobe up to 3.03cm in largest dimension is found. In comparison with CT dated on 2021-05-04, the lesion is stationary.
        • Band like opacity with spicualted change at right upper lobe is also noted. r/o synchronous lung cancer.
        • Small lymph nodes are found at bilateral paratracheal region.
        • Calcified coronary arteries is found.
        • MIld pericardial effusion is found.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • Left renal cyst up to 5.6cm in largest dimension is found.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy, cT2N3Mx, stable.
      • Synchronous lung cancer at right upper lobe
  • 2021-07-19 Patho - skin cyst/tag/debridement
    • Skin, eyelid, excision biopsy — Basal cell carcinoma, ulcerated with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
    • Section shows one piece of ulcerated skin with basal cells carcinoma infiltration, with keroid pattern and pigmented pattern, involving the deep margin and un-oriented, unspecified side margins.
    • IHC stain: Ber-EP4 (focal weak +), EMA (-), bcl-2 (diffuse +), CD10 (-).
  • 2021-06-02 Patho - pleural/pericardial biopsy
    • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma and proliferating along the alveolar wall.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(focal weak +), and CD56(-). The results are supportive for the diagnosis.
  • 2021-05-25 MRI - brain
    • No brain nodule or metastasis
    • Old left middle corpus callosum infarct or demyelination?
    • Brain atrophy. Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2021-05-20 Tc-99m MDP bone scan with SPECT
    • Increased activity in the lower C-spine, middle T- and lower L-spines. Degenerative change or compression fracture may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. However, please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral wrists, knees and both feet, compatible with benign joint lesions.
  • 2021-05-19 PET
    • Glucose-hypermetabolism in the left upper lung, compatible with the primary lung cancer.
    • Glucose-hypermetabolism in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably lung cancer with regional lymoh nodes involvement.
    • Glucose-hypermetabolism in the right level V cervical lymph nodes, probably lung cancer with distant metastases, suggesting biopsy for further investigation.
    • Left upper lung cancer, cTxN3M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2021-05-04 CT - lung
    • Smoking: quit for 30-40 years
    • 20210503 CxR: LLL bronchiectasis?
    • Findings
      • Lungs:
        • an ill-defined ground glass mass at RUL (32 mm in largest axial dimension)
        • a spiculated mass with pleural tails at LUL (35.4 mm in largest axial dimension).
        • a subpleural lobularlike GGO in RLL.
        • minimal fibrosis in LLL-posterobasal segment.
        • minimal fibrosis in paravertebral region of RLL, related to osteophytes of spine.
      • Mediastinum: small LNs in visceral and left anterior perivascular spaces. enlarged LN in subcarinal space.
        • minimal anterior pericardial effusion.
      • Hila: no enlarged LN.
      • Vessels: mild coronary arterial calcification
        • Aorta: normal caliber, extensive atherosclerotic change of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or thickening or nodule.
      • Chest wall: unremarkable.
      • Visible abdominal contents:
        • normal appearance of gallbladder.
        • no abnormal density in visible portion of the liver, spleen, adrenal glands, pancreas, and kidneys.
        • no enlarged lymph node.
      • Visualized bones: compression fracture of T17 vertebral body.
    • Impression:
      • LUL cancer and RUL cancer, synchronous lung cancers? without regional LN metastasis.
  • 2021-03-05 MRA - brain
    • IMP: Leukoaraiosis. General brain atrophy. Mild intracranial artherosclerosis.
  • 2021-02-10 EEG
    • This EEG study recorded background alpha rhythm (9-10 Hz) and plenty beta activity with intermittent bilateral frontal fast activity with right side more prominent.
    • No epileptiform discharge.
  • 2021-02-10 Clinical Dementia Rating, CDR
    • Score = 1, Mild
  • 2021-02-10 Mini-mental state examination, MMSE
    • Score = 24, Mild
  • 2021-01-12 NONO - nephrology
    • Bialteral chronic change of both kidneys.
    • Left renal cyst.
    • Foley in bladder.
  • 2021-01-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96 - 23) / 96 = 76.04%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR, trivial AR, mild to moderate TR
      • Mild pulmonary hypertension
      • Preserved RV systolic function

[MedRec]

  • 2023-10-13 SOAP Chest Medicine Yang MeiZhen
    • S: daughter: 0936 099 116, 0935 500 136
    • A
      • lung adenocarcinoma, cT4N3M1c, stage IVB
      • COPD
      • dementia, hearing impairment
  • 2023-07-03 SOAP Neurology Xiao ZhenLun
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Pletaal (cilostazol 100mg) 1# BID
      • Pentop (pentoxifylline 400mg) 1# BID
  • 2023-06-19 SOAP Ophthalmology Zhan LiWei
    • A: catatact
    • Prescription x3
      • Alphagan P (brimonidine 0.15%) Q12H OU
  • 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
    • A: Patient escape from 2023-01
  • 2022-03-29 SOAP Hemato-Oncology Xia HeXiong
    • P: patient has still vizimpro, indicating he does not take it everyday. Already request him to take it everyday.
  • 2021-09-16 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Vizimpro (dacomitinib monohydrate 30mg) 1# QD
  • 2021-09-07 SOAP Chest Medicine Yang MeiZhen
    • Prescription
      • Spiriva Respimat (tiotropium 2.5ug/puff, 60puff/bot) 2 puff QD INHL
      • Actein Effervescent (acetylcysteine 600mg) 1# BID
  • 2021-07-08 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Crestor (rosuvastatin 10mg) 1# QD
      • Pletaal (cilostazol 100mg) 1# BID
  • 2021-07-06 SOAP Chest Medicine Yang MeiZhen
    • Prescription
      • Compesolon (prednisolone 5mg) 2# QD
      • Xyzal (levocetirizine 5mg) 1# HS
      • Antica Syrup (orciprenaline, bromhexine, doxylamine) 8mL BID
  • 2021-07-06 SOAP Hemato-Oncology Xia HeXiong
    • O: AEs: 1. Gr 2 Skin rash; 2. Gr 1 diarrhea; 3. Gr 1 Oral mucositis
    • Prescription
      • Oralog Orabase (triamcinolone 5mg) 1# BID TOPI
      • Royalsense (clindamycin 10mg/g, 15g/tube) BID TOPI
  • 2021-06-29 SOAP Hemato-Oncology Xia HeXiong
    • O
      • 2021/06/25 EGFR
        • EGFR G719X = not detected;
        • EGFR Exon19 del = not detected;
        • EGFR S768I = not detected;
        • EGFR T790M = not detected;
        • EGFR Exon20 ins = not detected;
        • EGFR L858R = detected;
        • EGFR L861Q = not detected;
      • 2021/06/25 ALK IHC
        • ALK IHC = Negative;
        • ALK IHC Sample No. S2021-8066;
      • 2021/06/23 PD-L1 (22C3)
        • PD-L1(22C3) = TPS<1%;
        • PD-L1(22C3) Sample No. S2021-8066;
      • 2021/06/23 PD-L1 (28-8)
        • PD-L1(28-8) = TC>=5% and <10%;
      • 2021/06/23 PD-L1 IHC XiaoYe;
    • P: Now on dacomitinib C1D1 on 2021-06-29
    • Prescription
      • Vizimpro (dacomitinib monohydrate 15mg) 3# QD
  • 2021-06-22 SOAP Hemato-Oncology Xia HeXiong
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD 7D
  • 2021-06-15 SOAP Hemato-Oncology Xia HeXiong
    • S
      • COPD, Gout.
      • BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung meta; ECOG=0, use Spiriva
      • PFT: mild OBS impairment, no BD response
      • smoking: quit for 30-40 years, NKA
    • O
      • 2021/06/02 PATHO-pleural /pericardial biopsy
        • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • A/P
      • Well educate and explain
      • May try TKI first
        • lung adenocarcinoma, cT4N3M1C, stage 4B
        • COPD
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD 7D
  • 2021-06-01 ~ 2021-06-02 POMR Chest Medicine Huang JunYao
    • Discharge diagnosis
      • Malignant neoplasm of unspecified part of left lung s/p CT guided biopsy
      • Malignant neoplasm of unspecified part of right lung
      • Chronic obstructive pulmonary disease, unspecified
    • CC
      • Incidental finding of bilateral lung tumors on a CT 2 weeks ago.
    • Present illness
      • This is a 79 year old man who was admitted to our hospital for CT guided biopsy.
      • The patient had underlying COPD on control with medications. During one of the recent OPD follow ups with our Pulmonologist, CT on 2021/05/04 made an incidental finding of LUL cancer and RUL cancer, which are likely to be synchronous lung cancers.
      • Whole body PET scan on 5/19 showed left upper lung cancer, cTxN3M1c, stage IVB, while brain MRI on 5/25 ruled out brain metastases.
      • This time, he was admitted to our hospital for scheduled CT guided biopsy.
    • Course of inpatient treatment
      • The patient underwent CT guided biopsy on 6/2 with no obvious complications. Follow up CXR four hours later showed no apparent hemathorax or pneumothorax.
      • Since the patient patient was eager to leave the hospital due to personal reasons, he was allowed to be discharged from our hospital on 6/2, and OPD follow up was arranged.        
    • Discharge prescription
      • Transamin (tranexamic acid 250mg) 1# BID
      • Sodicon (dextromethorphan 15mg) 1# TID
  • 2021-03-18 SOAP Urology You ZhiQin
    • S
      • nocturia 3-4/night, freqency, small stream, straining, urgency, UUI(+) for months
      • improved medication, nocturia 1-2/night
    • Prescription
      • Harmalidge OCAS (tamsulosin 0.4mg) 1# QDAC
      • Vesicare (solifenacin 5mg) 1# HS
  • 2021-03-05 SOAP Ophthalmology Peng YiJie
    • S
      • BV ou -> IOP poor control
      • One left upper eyelid mass for 1-2 years
      • HTN + for 30+ years
      • Asthma +
    • A/P
      • Start antiglaucomatic medication
      • f/u 1 month
    • Prescription
      • Lumigan (bimatoprost 0.1mg/mL) HS OU
      • Simbrinza (brinzolamide 10mg/mL, brimonidine 2mg/mL) BID OU

[consultation]

  • 2023-10-18 Radiation Oncology
    • Q
      • This 82-year-old man patient is a case of BUL cancer, adenocarcinoma, cT4N3M1c,stage IVB, lung to lung metastases s/p TKI therapy.
    • A
      • Radiothearpy is indicated for tumor control. CT-simulation will be arranged on 10/23. Plan to deliver 30~45 Gy/ 10~15 fx to the LUL tumor, depending on the side effect. RT will start around 10/25 or 26. Thank you very much.

[chemotherapy]

  • 2021-06-29 ~ undergoing - Vizimpro (dacomitinib)
  • 2021-06-15 ~ 2021-06-28 - Iressa (gefitinib)

==========

2023-10-19

[reconciliation]

According to the PharmaCloud database, there’s no discrepancy between the previously prescribed medications.

The patient was diagnosed with BUL cancer, specifically adenocarcinoma, with metastases to both lung hila and bilateral mediastinal lymph nodes. Treatment was started on 2021-06-15 with Iressa (gefitinib) for two weeks before switching to Vizimpro (dacomitinib) from 2021-06-29.

The chest CT of 2023-09-11 showed significant disease progression in the LUL, while the RUL tumor remained stable compared to the previous CT of 2023-01-05. This may indicate disease heterogeneity and potential development of resistance in certain aspects of the disease after more than 2 years of use of Vizimpro.

700016937

231018

{pancreatic head cancer}

[exam findings]

  • 2023-07-31 SONO - nephrology
    • Right hydronephrosis
  • 2023-07-31 Bladder sonography
    • PVR: 72 ml
  • 2023-07-14 MRI - L-spine
    • MRI of thoracic and lumbar spine without/with Gadolinium-based contrast enhancement shows:
      • fine alignment of thoracolumbar spine.
      • degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • patchy signal intensity change and faint bone marrow enhancement at left anterior corner of L1, L2, L3 vertebral bodies. This is already seen in the abdomen MRI done on 20221004, but not seen in the lumbar spine MRI on 20140506. There are other similar bone lesions in thoracic vertebrae. This could be degenerative change but bone metastases cannot be completely excluded. Suggest correlation with other image modality and close follow up.
      • prominent disc-osteophyte complexes at multiple levels, as well as bilateral facet arthroses and hypertrophic ligamenta flava, causing severe L3-4, L4-5 central canal stenosis.
      • no evidence of abnormal signal lesion nor pathological enhancement in visible spinal cord.
    • Impression:
      • Patchy bone marrow lesions in multiple thoracic and lumbar vertebral bodies, could be degenerative change but bone metastases cannot be excluded. Suggest correlation with other image modality and close follow up.
      • Degenerative spinal and disc disease.
      • Severe L3-4, L4-5 central canal stenosis.
  • 2023-07-13 CT - abdomen
    • Findings
      • S/P operation. Focal fat stranding at mesenteric root without interval change r/o post-operative change.
      • Tiny liver cysts.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • S/P operation. No evidence of tumor recurrence.
  • 2023-06-05 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in several T- and L-spine, and increased activity in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet, in whole body survey.
    • IMPRESSION:
      • Hot spots in several T- and L-spine, the nature is to be determined (severe DJD or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
      • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, S-I joints, hips, knees, and feet.
  • 2023-03-13 CT - abdomen
    • Indication: Pancreatic head cnacer (or Ampulla of Vater cancer) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s surgery
    • Abdominal CT with and without enhancement revealed:
      • s/p colon cancer op. and Whipple op.
      • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
      • Increased intestinal gas is found.
    • Imp:
      • s/p colon cancer op. and Whipple op.
      • Minimal soft tissue at mesenterric root is found. Post op. change? Suggest follow up.
  • 2023-03-10, -02-01, 2022-12-21 CXR
    • Spondylosis of the T-spine
  • 2023-02-14 MRI - brain
    • Indication: Malignant neoplasm of ampulla of Vater
    • Imp:
      • No acute infarct. No brain nodule or metastasis
      • Brain atrophy with bilateral periventricular ischemic/aging white matter change.
  • 2022-10-27 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-10-25 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2022-10-21 Patho - pancreas total/subtotal resection
    • Diagnosis:
      • Small intestine, ampulla of Vater, Whipple operation — Adenocarcinoma, moderately differentiated; AJCC 8th edition: pStage IIIA, pT3bN1(if cM0)
        • Pancreas, head, Whipple operation — Adenocarcinoma, by direct invasion
        • Common bile duct, distal, Whipple operation — Adenocarcinoma, by direct invasion
        • Stomach, partial gastrectomy — Negative for malignancy
        • Lymph node, peri-pancreas, dissection — Adenocarcinoma, metastatic (3/10)
        • Lmph node, peri-gastric, dissection — Negative for malignancy (0/13)
      • Pancreas head, excision — Negative for malignancy
      • Lymph node, site ?, excision — Negative for malignancy (0/1)
      • Lymph node, retroperitoneal cavity, excision — Negative for malignancy (0/4)
    • Gross Description:
      • Procedure: Pancreaticoduodenectomy (Whipple resection), partial pancreatectomy: Pancreas: 4.7 x 3.7 x 3.0 cm; Duodenum: 16.0 cm in length; Lessser curvature: 6.0 cm in length; Greater curvature: 9.0 cm in length; Common bile duct: 4.5 cm in length;
      • Tumor Site: ampulla of Vater and invasion to pancreatic head, duodenum, distal common bile duct, peri-pancreatic soft tissue
      • Tumor Size: 2.4 x 2.0 x 1.5 cm.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma; The immunohistochemical stains reveal CK7(+) and CK20(-).
      • Histologic Grade (applies to ductal carcinoma only) :G2: Moderately differentiated
      • Tumor Extension: Tumor invades ampulla of Vater, duodenal wall, pancreas head, peripancreatic soft tissues, distal common bile duct
      • Margins
        • All margins are uninvolved by invasive carcinoma and high-grade intraepithelial neoplasia
        • Distance of invasive carcinoma from closest margin: 2 mm.
        • Specify: posterior peripancreatic soft tissue resection margin
        • Gastric resection margin: 10 cm; Distal small intestine margin: 10.5 cm; Pancreatic margin: 3.5 cm; Common bile duct resection margin: 3.5 cm; Anterior peripancreatic soft tissue margin: 0.8 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Regional Lymph Nodes: Number involved/examined: peri-pancreatic: 3/10; peri-gastric: 0/13; lymph node, site ?: 0/1; LN retroperitoneal: 0/4
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable): not applicable
          • Primary Tumor (pT): pT3b: Tumor extends into peripancreatic soft tissue
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to three regional lymph nodes
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings: None identified
  • 2022-10-07 Patho - duodenum biopsy
    • Diagnosis:
      • Major papilla, biopsy — adenocarcinoma, modertaely differentiated
    • Microscopically, it shows modertaely differentiated adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei,pleomorphism, and high N/C ratio.
    • Immunohistochemcial stain reveals CK(+), p53(focal+, 40%), Ki-67 index: 30%.
  • 2022-10-07 Endoscopic Ultrasound, EUS
    • Prominent major papilla, favor ampulla vater tumor, s/p biopsy
    • CBD dilatation
    • Reflux esopgagitis Gr.A
    • Duodenal shallow ulcers, bulb and SDA
  • 2022-10-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 7) / 53 = 86.79%
      • M-mode (Teichholz) = 87
    • Adequate LV,RV systolic function with normal wall motion
    • Impaired LV relaxation
  • 2022-10-04 MRI - pancreas
    • History and indication: An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD
    • Findings
      • A soft tissue tumor (1.5x2.2cm) at pancreatic head.
      • S/P PTCD. Liver and renal cysts (3-5mm).
    • IMP: A soft tissue tumor (1.5x2.2cm) at pancreatic head suspected malignancy.
  • 2022-10-01 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • 2022-09-30 CT - abdomen
    • History: T-COLON CA S/P R HEMICOLECTOMY 2005-07-21, cT3N1M0
      • 2022-09-24 Urine looked like black tea, Total bilirubin: 16.88 mg/dL (normal: < 1)
    • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
        • The pancreatic duct appears normal in size.
        • Cholangiocarcinoma at the distal CBD is highly suspected.
        • In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes.
        • There are few enlarged nodes in left para-aortic space that may be non-regional metastatic nodes? Please correlate with PET scan.
      • S/P cholecystectomy, S/P right hemicolectomy, and S/P near total right hepatectomy? please correlate with clinical history.
      • Others
        • There is no focal abnormality in the spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • CHOLANGIOCARCINOMA at the distal CBD is highly suspected.
      • Please correlate with ERCP (Endoscopic Retrograde CholangioPancreatography) and EUS.
  • 2022-09-24 SONO - kidney
    • bilateral renal stones
    • right hydronephrosis
  • 2022-08-27 Transrectal Ultrasound of Prostate, TRUS-P
    • benign prostatic hyperplasia

[MedRec]

  • 2023-08-28 SOAP Urology Xu JunKai
    • Prescription x3
      • Betmiga (mirabegron 50mg) 1# QD
      • Harnalidge (tamsulosin 0.4mg) 1# HS
      • Oxbu ER (oxybutynin 5mg) 1# QD
  • 2023-08-28 SOAP Metabolism and Endocrinology Yu LiJiao
    • Prescription x3
      • Trajenta (linagliptin 5mg) 1# QD
  • 2023-03-24 SOAP Hemato-Oncology
    • S: Owing to Leukopenia (WBC:2890, seg:33, ANC:971) was noted on 3/24 23 and hold C/T.
  • 2022-12-17 SOAP Hemato-Oncology
    • A: Pancreatic head CA (or Ampulla of Vater CA) , pT3bN1 (3/28) cM0, pStage IIIA, s/p Whipple’s Op on 2022-10-20

[consultation]

  • 2022-11-08 Urology
    • Q
      • for urinary pain and persisted U/A Bact 2+
      • This 73 years old male had the history of
        • T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
        • Ampulla of vater cancer s/p whipple with LN dissection on 2022/10/20
        • BPH with Cystitis by cystoscopy on 2022/10/01 and keep medication control
      • This time, he still sufferred urinary pain and oral medicaiton with Uropin support. But the symptom still persisted. On the other side, U/A with Bact 2+ and U/C still pending. Fever was also noted on 2022/11/05-06. Lab data with no leukocytosis but CRP showed 9.45. We need your help for evaluation for infection status. Thanks for your time!!
    • A
      • We will arrange non-invasive evaluation (UFM PVR)
      • sometimes the pain still painkiller
      • He has high bilirubin and good renal function
      • some painkiller with less burden on liver may be helpful
  • 2022-10-07 Ophthalmology
    • Q
      • for DM retinopathy
    • A
      • For DR survey
      • T-colon cancer, newly-diagnosed DM
      • O
        • od s/p phaco + IOL insertion
        • os old trauma with K scar
        • BCVA od 1.0 os 0.1(NCCLENS)
        • IOP 17/17
        • Pupil 3/3 +/+
        • conj icteric ou
        • K od clear os linear scar from paracentral to peripheral
        • AC D/cl ou
        • Lens od pciol os ns++
        • Fd c/d 0.3 , disc pinkish, no DR change ou
      • A
        • No DR change at present ou
      • P
        • Control sugar
        • inform the risk of DR change, if worsen vision, come back asap
        • regular f/u yearly
  • 2022-10-06 Metabolism and Endocrinology
    • Q
      • This 73 years old male had the history of T-colon cancer (T3N1M0, Duke’s C2) s/p right hemicolectomy + LN dissection on 2005-07-21, Cholecystectomy and Partial hepatectomy.
      • This time, he came to ER for dark urine, lethargy, poor appetite, poor activity and diarrhea for 2 months. Referred to ER from GI OPD due to high bilirubin. At MER, vital sign: BP:119/73; P:101; BT:36.4; RR:18; Con’s:E4V5M6, SPO2:97%, the CXR showed no active lung lesion. The KUB shows no ileus. Lab data revealed abnormal liver function. The abdomen CT reported 1. An ill-defined faint poor enhancing lesion measuring 1.8 cm in the distal CBD and pancreatic head area is suspected and it causing marked dilatation of the proximal CBD, CHD, and IHDs.
      • The pancreatic duct appears normal in size. Cholangiocarcinoma at the distal CBD is highly suspected. In addition, There are few enlarged nodes in the peripancreatic head area that may be metastatic nodes. Under the impression of obstructive jaundice, he was admitted to our ward for further evaluation and treatment.
      • Due to HbA1C:8.0, we need your help
    • A
      • We were consulted for blood sugar control.
      • O:
        • BH: 165 cm, BW: 75 kg
        • Diet: TPN and try low fat, soft diet
        • Medication in OPD: nil (newly diagnosed)
        • Medication during hospitalization: Oliclinomel + RI 16U, Januvia 1# QD
        • Na: 134, K: 3.7
        • ALT: 61, TBI: 28.95
        • BUN/Cr: 19/0.93 (eGFR: 84.65)
        • F/S:
          • Date 10/4 10/5 10/6
          • QDAC 153 179 170
          • QLAC 202 321 222
          • QNAC 265 272
          • HS - -
        • Blood glucose: 182 mg/dL
        • HbA1c: 8.0
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A: Type 2 DM, newly diagnosed
      • Suggestions:
        • DC Januvia. Avoid any other oral anti-diabetic agent
        • Adjust to 20U RI in each Oliclinomel
        • Use Apidra PRNTIDAC with sliding scales
          • F/S 201~250, Apidra 2U
          • F/S 251~300, Apidra 3U
          • F/S > 300, Apidra 4U
        • Check lipid profile, urine ACR
        • Consult OPH for DM retinopathy
        • At present no need nutritionist for DM diet education (self-paid TWD 600) (to consult right before discharge after appetite recovering)
        • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.

[surgical operation]

  • 2022-10-20
    • Surgery
      • Whipple operation with partial gastrectomy
      • retroperitoneal LN3,4sd,5,6,7,8,9,12,13,16 dissection
      • adhesivelyiss for 4 hrs due to previous rt hemicolectomy with LNdissection for T-colon ca and liver resection
    • Finding
      • severe small bowel adhesion
      • pancreatic head tumor 2 x 1.8 cm under papilla vater
      • CBD: 2.0 cm in diameter
      • P-duct 0.3cm with soft pancreas parenchyma
      • multiple LNat dodenal ligament and paraaorta area

[chemotherapy]

  • 2023-10-17 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-19 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-12 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Oxa 70%, Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (Irino 80% and LV, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-05-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-25 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr (Irino and 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-10 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2400mg/m2 4075mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-14 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-12-19 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

Modified FOLFIRINOX chemotherapy for pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F109546

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 150 mg/m2 IV
      • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-19 https://www.uptodate.com/contents/image?imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

==========

2023-10-18

[reconciliation]

The patient is currently taking the following medications, as prescribed by their urologist and endocrinologist on 2023-08-28:

  • Betmiga (mirabegron)
  • Harnalidge (tamsulosin)
  • Oxbu ER (oxybutynin)
  • Trajenta (linagliptin)

There are no discrepancies noted in the patient’s medication list.

[CA199 goes up]

Please note that CA19-9 levels have been monotonically increasing in recent months. This might suggest that the disease has a tendency to gradually gain resistance.

  • 2023-10-03 CA-199 (NM) 37.692 U/ml
  • 2023-09-28 CA-199 (NM) 36.410 U/ml
  • 2023-09-01 CA-199 (NM) 26.718 U/ml
  • 2023-08-11 CA-199 (NM) 23.676 U/ml
  • 2023-07-28 CA-199 (NM) 22.798 U/ml
  • 2023-07-04 CA-199 (NM) 20.102 U/ml

2023-09-19

The medications Betmiga (mirabegron) and Harnalidge (tamsulosin) and Oxbu ER (oxybutynin) prescribed by our urologist, along with Trajenta (linagliptin) prescribed by our endocrinologist on 2023-08-28, are currently being taken by the patient with no discrepancies noted.

2023-08-21

Our endocrinologist’s repeat prescription (issued on 2023-06-05) for Trajenta (linagliptin) is currently on the active medication list, and there are no discrepancies noted.

2023-07-13

The patient recently refilled his prescription for Trajenta (linagliptin) on 2023-07-10 for managing his T2DM. This drug is accurately included in the active medication list, with no reconciliation issues identified.

2023-06-20

  • According to the PharmaCloud database, all of this patient’s medical requirements have been addressed at our hospital over the past three months. As a result, no issues with medication reconciliation have been detected.

  • The patient’s DM is currently managed with Trajenta (linagliptin 5mg) 1# QD. He had an increased preprandial serum glucose level of 170mg/dL on 2023-06-20 at 06:24. The most recent HbA1c level was 5.7% on 2023-05-31. This sudden rise could be a temporary fluctuation and is worth continuous monitoring.

2023-05-19

  • The patient, with a body surface area (BSA) of 1.69 m2 calculated from a recorded height of 165 cm and weight of 62.2 kg (2023-05-18), is currently receiving a modified FOLFIRINOX regimen. This regimen includes oxaliplatin and irinotecan, but omits bolus fluorouracil.
  • The dose of oxaliplatin is 100mg, which is equivalent to 59mg/m2, approximately 69% of the standard dose of 85mg/m2. Likewise, the dose of irinotecan is 200mg, equivalent to 118mg/m2, approximately 65% of the standard dose of 180mg/m2. The frequency of the treatment is every three weeks, in contrast to the standard every two weeks.
  • The patient has a relatively advanced age of 73 years and a fair ECOG performance status of 1. He has had only one episode of leukopenia with WBC < 3K/uL (2.89K/uL on 2023-03-24). No other significant adverse events have been recorded. An abdominal CT scan performed on 2023-03-13 showed soft tissue at the root of the mesentery.
  • Given these factors, and in the absence of contraindications or other clinical concerns, it might be beneficial to consider a gradual dose escalation. This could be done with the aim to bring the dose closer to the standard levels, in order to optimize therapeutic effect.

2023-03-13

  • Since 2022-12-19, the patient has been receiving FOLFIRINOX with a reduced dosage of oxaliplatin (85 -> 60mg/m2) and irinotecan (180 -> 150mg/m2), skipping the 5-FU bolus to prevent adverse reactions. Bilirubin (direct and total) returned to normal range in 2022-12, but ALT readings have fluctuated between normal and not exceeding 110U/L after treatment. As of the 2023-03-10 lab data, BUN 29mg/dL, Creatinine 0.95mg/dL, and eGFR 82.60. No dosage adjustment is currently needed for the patient’s FOLFIRINOX regimen.

2023-02-02

  • It was noted that the blood sugar level did not exceed 180 mg/dL, which was an improvement over the prior hospital stay.

  • Renal sonography (2022-09-24) found bilateral renal stones, and calcium oxalate crystals in urine (2023-02-01). Primary hyperoxalurias are rare inborn errors of glyoxylate metabolism characterized by the overproduction of oxalate, which is poorly soluble and is deposited as calcium oxalate in various organs. The kidney stones in this patient should be less likely to be associated with primary hyperoxaluria.

    • Patients with kidney stones should consume enough fluids to consistently produce at least 2 liters of urine per day. At the present time, the patient is being hydrated with NS 500mL Q12H since this hospital admission.
    • It is recommended that all patients with calcium oxalate stones limit their intake of high oxalate foods, supplemental vitamin C, sucrose, and fructose. However, excessive restriction of oxalate is unlikely to be beneficial. Patients should continue to consume a variety of fruits and vegetables while avoiding those that are very high in oxalate. Intake of sugar and/or fructose increases urine calcium independently of calcium intake and has been associated with an increased risk of kidney stones.
    • Urine pH was 5.5 (2023-02-01) WNL, however, calcium oxalate stones are not pH dependent in the physiologic range. In recent lab results, there were no readings for calcium, oxalate, citrate, and uric acid in urine.
    • In the event that high urine calcium is detected, it is recommended that patients with recurrent calcium oxalate stones who have higher than desired urine calcium be treated with a thiazide diuretic in order to lower urinary calcium excretion.
      • All patients receiving a thiazide diuretic should maintain a low-sodium diet, which is essential for the diuretic to effectively lower urinary calcium.
      • Urinary calcium and sodium excretion should be monitored after the institution of thiazide therapy. A repeat 24-hour urine collection should be performed one to two months after initiating therapy.
      • If the urine calcium does not fall as desired or the thiazide is not well tolerated, an alternative therapy is administration of 40 to 60 mEq of alkali per day as potassium bicarbonate or potassium citrate (citrate is rapidly metabolized to bicarbonate).

701489999

231018

[lab data]

2023-07-31 Anti-HBc (NM) Positive
2023-07-31 Anti-HBc Value (NM) 0.636
2023-07-31 Anti-HBs (NM) Positive
2023-07-31 Anti-HBs value (NM) 677.000 mIU/mL
2023-07-31 Anti-HCV (NM) Negative
2023-07-31 Anti-HCV Value (NM) 0.043
2023-07-25 HBsAg (NM) Negative
2023-07-25 HBsAg Value (NM) 0.418

2023-07-25 CA-199 (NM) 354.780 U/ml
2023-07-25 CEA (NM) 31.940 ng/ml

[exam findings]

  • 2023-09-18 SONO - abdomen
    • Findings
      • Liver
        • Homogenous liver parenchyma.
        • One hyperechoic tumor with hypoechoic rim was noted at S4, 3.9cm.
        • One hyperechoic tumor with hypoechoic rim was noted at S7, 2.8cm.
        • One 0.4cm hyperechoic lesion with PAS was noted at S4.
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen
        • No splenomegaly
    • Diagnosis:
      • Liver tumors, S4 and S7
      • Liver calcification, S4
  • 2023-08-11 All-RAS + BRAF gene mutation analysis
    • ALL-RAS: Detected (NRAS codon 61 CAA>AGA, p.Q61R)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-08-09 MRI - pelvis
    • Findings:
      • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size, with direct adhesion the uterus that is c/w adenocarcinoma (T4b).
      • There are seven enlarged nodes in the adjacent mesocolon (N2b).
      • There are two poor enhancing masses 4.5 cm in S4 and 2.8 cm in S7 of the liver that are c/w liver metastases (M1a).
      • There are several masses in the uterus, showing hypointensity on T2WI that are c/w myomas. The largest one 6 cm in size.
    • IMP:
      • Rectal cancer is noted.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T4b N2b M1a, stage: IVA
  • 2023-07-21 CT - abdomen
    • CC: Dark red bloody stool passage off and on and noted again these days, Mucoid bloody stool passage
      • 20230720 colonoscopy: One mass in the sigmoid colon, 15 cm AAV, R/O malignancy
    • Findings:
      • There is segmental irregular wall thickening of the rectosigmoid junction, measuring 5 cm in size that is c/w adenocarcinoma (T3).
      • There are four enlarged nodes in the adjacent mesocolon (N2a).
      • There are two poor enhancing masses 3.7 cm in S4 and 2 cm in S7 of the liver that are c/w metastases (M1a).
      • There are several mild poor enhancing masses in the uterus that are c/w myomas. Please correlate with GYN. sonography.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-07-21 Patho - colorectal polyp
    • DIAGNOSIS: Intestine, large, rectosigmoid junction, 15 cm from anal verge, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-07-20 Colonoscopy
    • Diagnosis:
      • Siogmoid polyp s/p polypectomy
      • Rectosigmoid cancer s/p biopsy
      • Severe melanosis coli
      • Large mixed hemorrhoids

[MedRec]

  • 2023-08-07 SOAP Nutrition Consultation
    • S
      • Occupation: Homemaker
      • Dietary Habits:
        • Breakfast (6-7 AM): Meal replacement (Shou Mei Li) with or without a slice of thick toast (butter spread) / Boiled egg
        • Morning Snack: 1 can of Ensure (consistently consumed daily)
        • Lunch: Half a bowl of porridge + 2 and a half pieces of tilapia fish + 2/3 portion of greens
        • Afternoon Snack: 1 Kiwi
        • Dinner: Same as lunch
      • Exercise: Light jogging once a day, for 40 minutes including warm-up
      • Fluid Intake: 1500-2000 ml
    • A
      • Anthropometry:
        • BMI kg/m2: normal / over weight / obesity
        • Current energy intake: adequate / inadequate
        • Nutrition problem:
          • Ensure 1-2
    • P
      • Goal: BS control
      • Education topic: DM diet principle, 6 Food Groups and food groups contain CHO, eating-out principles, Food exchange list, protein restricted diet education,Balance diet
      • Meal planning: kcal
        • Cereal : ex/d
        • Meat/Bean-choose low fat protein (soy products, egg): ex/d
        • Green vegetable: ex/d
        • Fruits: ex/d
        • Low fat milk: ex/d
        • Oil: ex/d
        • Increase physical activity: 3 times/ week, 30 min/time
        • Decrease alcohol: ex/d →
        • SMBG with diet recoard
  • 2023-07-27 SOAP Hemato-Oncology
    • P
      • CCRT with FOLFOX and followed by FOLFOX with or wtihout bevacizumab and cetuximab (need further discussion with family).
      • Admission for CCRT with FOLFOX
  • 2023-07-27 SOAP Radiation Oncology
    • P
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectosigmoid tumor bed area.
      • The treatment planning of radiotherapy will be started at 1030, 2023-08-02.
  • 2023-07-27 SOAP Colorectal Surgery
    • A/P
      • Suggest pre-op chemotherapy + target therapy then colectomy + hepatectomy
      • Arrange MRI for differential uterine invasion; T4b ? or T3 ?
      • Refer to Radiotherapy for reducing size, better resectability

[chemotherapy]

  • 2023-10-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-25 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-09 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-18

[liver function]

The patient experienced a transient elevation in liver function test readings in mid-Sep, with peak values of 106 U/L for AST, 225 U/L for ALT, and 1.06 mg/dL for total bilirubin on 2023-09-18. However, the liver function test abnormalities have resolved, and there is no evidence of sustained liver injury at present.

  • 2023-10-17 AST 33 U/L

  • 2023-10-05 AST 21 U/L

  • 2023-09-25 AST 45 U/L

  • 2023-09-22 S-GOT/AST 51 U/L

  • 2023-09-18 S-GOT/AST 106 U/L

  • 2023-09-14 S-GOT/AST 96 U/L

  • 2023-09-07 S-GOT/AST 31 U/L

  • 2023-08-25 S-GOT/AST 21 U/L

  • 2023-08-09 S-GOT/AST 29 U/L

  • 2023-07-20 S-GOT/AST 15 U/L

  • 2023-10-17 ALT 41 U/L

  • 2023-10-05 ALT 25 U/L

  • 2023-09-25 ALT 86 U/L

  • 2023-09-22 S-GPT/ALT 110 U/L

  • 2023-09-18 S-GPT/ALT 225 U/L

  • 2023-09-14 S-GPT/ALT 136 U/L

  • 2023-09-07 S-GPT/ALT 40 U/L

  • 2023-08-25 S-GPT/ALT 17 U/L

  • 2023-08-22 S-GPT/ALT 17 U/L

  • 2023-08-09 S-GPT/ALT 13 U/L

  • 2023-07-20 S-GPT/ALT 11 U/L

  • 2023-10-17 Bilirubin total 0.61 mg/dL

  • 2023-10-05 Bilirubin total 0.44 mg/dL

  • 2023-09-25 Bilirubin total 0.50 mg/dL

  • 2023-09-22 Bilirubin total 0.68 mg/dL

  • 2023-09-18 Bilirubin total 1.06 mg/dL

  • 2023-09-14 Bilirubin total 0.74 mg/dL

  • 2023-09-07 Bilirubin total 0.68 mg/dL

  • 2023-08-25 Bilirubin total 0.50 mg/dL

  • 2023-08-22 Bilirubin total 0.40 mg/dL

  • 2023-08-09 Bilirubin total 0.87 mg/dL

  • 2023-07-20 Bilirubin total 1.25 mg/dL

The patient received 4 cycles of FOLFOX chemotherapy, administered on 2023-08-09, 2023-08-24, 2023-09-25, and 2023-10-17. Oxaliplatin, a drug used in FOLFOX, is associated with increased serum alanine aminotransferase (36%), increased serum alkaline phosphatase (42%), increased serum aspartate aminotransferase (54%), and increased serum bilirubin (13%). It is possible that oxaliplatin caused the elevated liver function test results in this patient.

In mid-Sep, the patient was prescribed BaoGan (silymarin), a herbal supplement that is thought to protect the liver, to mitigate the risk of liver damage.

In addition, FOLFIRI, an alternative chemotherapy regimen that contains irinotecan, is also associated with increased serum bilirubin (84%) and increased serum alkaline phosphatase (13%).

[RAS mutation detected]

Patients with colorectal cancer (CRC) who have an RAS mutation (2023-08-11 Lab result, NRAS mutation detected) are less likely to respond to targeted therapies that target EGFR. This is because NRAS mutations can activate the RAS-MAPK pathway downstream of EGFR, making the tumor resistant to anti-EGFR therapies.

The following targeted therapies are less likely to be effective in the setting of CRC with an NRAS mutation:

  • Cetuximab (Erbitux)
  • Panitumumab (Vectibix)

700186762

231017

  • 2023-10-13 SONO - breast
    • Diagnosis
      • Left fibroadenoma as described
      • s/p bil. breast operation
    • BI-RADS: 2. benign finding
  • 2023-08-11 Mammography
    • Impression:
      • Dense breast.
      • S/P right mastectomy.
      • Benign coarse calcifications in left breast.
      • Suggest clinical correlation and follow up.
    • BI-RADS:
      • Category 2: benign findings. - annual screening.
  • 2023-07-03 PET
    • In comparison with the previous study on 2023/01/16, the glucose hypermetabolic lesion at the T12 spine comes to more evident; other lesions including in some T- and L-spine, sacrum, bilateral pelvic bones and bilateral femurs disappear or become less evident, indicating breast cancer with disassociated response to current therapy.
    • However, glucose hypermetabolic lesions in the uterus are numerous and show more prominent, malignant neoplasm of uterus should be considered, suggesting biopsy for further evaluation.
    • Increased FDG accumulation in the colon and bilateral kidneys, physiological FDG uptake is more likely.
  • 2023-05-11 ECG
    • Sinus rhythm with Premature ventricular complexes
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-03-10 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, hysteroscopic endometrial curettage — squamous metaplasia
    • Microscopically, it shows pieces of bland squamous epithelial tissue fragments.
    • Immunohistochemical stain reevals p16(-) and Ki-67 (-).
  • 2023-02-17 Gynecologic ultrasonography
    • R/O Uterine myoma
    • R/O Nabothian cyst: 48mmx26mm
    • R/O Endometrial thickening, EM: 14.6mm
  • 2023-02-10 SONO - abdomen
    • Diagnosis:
      • Fatty liver, severe
      • Poor assessment of biliary tract and PV
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion:
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2023-01-16 PET
    • In comparison with the previous study on 2022/08/02, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly more evident. Multiple bone metastases in stable condition may show this picture. Please correlate with other clinical findings for further evaluation.
    • At least four focal areas of increased FDG uptake in the uterus, the nature is to be determined (benign or even malignant neoplasm of uterus or other nature ?), suggesting pelvis CT or MRI for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters, physiological FDG accumulaton is more likely.
  • 2022-08-02 PET
    • In comparison with the previous study on 2021/12/10, the glucose hypermetabolism in some T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs is slightly less evident. Multiple bone metastases with partial response to the current therapy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some focal areas of increased FDG uptake in the anterior pelvic region. The nature is to be determined (some kind lesions of the uterus? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.
  • 2022-04-29 MRA - brain
    • An old lacune in left basal ganglion.
  • 2022-04-26 Neurosonography
    • wall thickening on bil. common carotid arteries
    • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
    • poor left temporal windows
    • the transcranial doppler study of insonated right ACA, bil. MCA, PCA, VA and BA were normal
  • 2022-04-19 CT - brain
    • No definite intracranial lesion
  • 2022-02-22 Nerve Conduction
    • Finding
      • Motor nerve conduction study
        • Normal motor nerve conduction study in the left median nerve.
        • Conduction block noted over the left ulnar nerve across elbow level (more than 10m/s difference).
      • F-wave
        • Normal F-wave latencies in the left median and ulnar nerves.
      • Sensory nerve conduction study
        • Prolonged sensory peaked latency with decreased SNCV and normal SNAP amplitudes in the left median nerve (4D-wrist segment)
        • Prolonged sensory peaked latency with normal SNCV and normal SNAP amplitudes in the left median nerve (midpalm-wrist and 1D-wrist segments)
        • Normal sensory nerve conduction study in the left median nerve (forearm segment)
        • Normal sensory nerve conduction study in the left ulnar and superficial radial nerves.
    • Conclusion
      • Left median neuropathy at the wrist, demyelinated type.
      • Left ulnar motor neuropathy across the elbow, conduction block noted.
  • 2021-12-10 PET
    • A large focal area of mildly increased FDG uptake in the anterior pelvic region. The nature is to be determined (enlarged uterus? other nature?). Please correlate with other clinical findings for further evaluation.
    • Faint glucose hypermetabolism in multiple T- and L-spines, sacrum, bilateral pelvic bones and bilateral femurs. Either multiple bone metastases of faint FDG uptake or multiple bone metastases with response to the current therapy may show this picture. Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulaton is more likely.

[MedRec]

  • 2021-11-25 SOAP General Surgery Li ChaoShu
    • S: MBCa
    • O Koo Foundation Sun Yat-Sen Cancer Center OPD
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/11/18 21
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antihistamines for systemic use) Levocetirizine Dihydrochloride XYZAL FILM-COATED TABLETS 5MG 28 28 110/11/18 21
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/11/18 14
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Drugs for treatment of bone diseases) Denosumab XGEVA 1 1 110/11/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Corticosteroids,dermatological preparations) Betamethasone (Valerate) RINDERON-V CREAM 0.06% 7 1 110/11/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 28 28 110/10/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/10/18 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Endocrine therapy) Letrozole FEMARA FILM-COATED TABLETS 2.5MG 30 30 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
      • Sun Yat-Sen Cancer Center - OPD - 1101160026 Malignant neoplasm of lower-outer quadrant of right female breast - C50511 (Antineoplastic agents) Palbociclib IBRANCE CAPSULES 125 MG 21 21 110/09/13 0
  • 2020-09-04 SOAP Rehabilitation Qiu JiaYi
    • S
      • Right breast cancer s/p MRM + ALND (LNs 10/25) on 2019-06 s/p RT x 30 times with right shoulder limitation and lympehdema
      • Past Hx.: Left MCA infarction with nearly total recovery in 20170607
      • PH: HTN, hyperlipidemia
    • O
      • Body weight: 62.8 kg
      • Rt: 17.5 cm (wrist), 24.5cm (elbow), 31cm (axilla)
      • Lt: 17cm (wrist), 24cm, 30.5cm (axilla)
      • Skin: soft (pitting) edema, elevation reduces swelling, dry skin
      • ISL stage: II (early): limb elevation rarely reduces swelling
      • Other complications: Frozen shoulder +
    • Imp
      • right breast cancer s/p MRM with secondary right adhesive capsulitis and lymphedema
    • Plans
      • Consider PT: IFC, PROM, therapeutic, mobilization for Rt shoulde first, circulator for RUE; then add MLD.

[chemotherapy]

  • 2023-10-13 - fulvestrant 500mg IM 5min

==========

2023-10-17

[leukopenia]

Based on the HIS5 lab data, a leukopenia event was recorded on 2023-10-13 with a count of 1.83K/uL (marked with an asterisk in the following table). The most recent chemotherapy administered was 500mg of fulvestrant on the same day, very close in time to the WBC data collection, leaving open the possibility that the actual medication administration occurred after the blood sample was taken. Moreover, according to UpToDate, the occurrence of neutropenia (2%; grade 3: 1%; grade 4: <1%) is relatively low compared to other chemotherapy drugs. For these two reasons, it’s less likely that this drug was the main contributor to the neutropenia observed on 2023-10-13.

  • 2023-10-13 WBC 1.83 x10^3/uL *
  • 2023-06-26 WBC 3.41 x10^3/uL
  • 2023-05-11 WBC 3.23 x10^3/uL
  • 2023-03-02 WBC 3.24 x10^3/uL
  • 2023-01-16 WBC 4.02 x10^3/uL

701361625

231016

[exam findings]

  • 2023-08-19 CT - abdomen
    • Indication: Low rectal adenocarcinoma post operation with pelvic lymph node metastasis, status post Robotic low anterior resection and loop ileostomy on 2023/03/10, pT1N1b(3/19)cM0, pStage IIIA s/p chemotherapy with FOFLOX from 2023/04/18~
    • With and without contrast enhancement CT of abdomen shows:
      • s/p LAR and ileostomy. No local recurrent tumor.
      • Small para-aortic lymph nodes.
    • Impression
      • Low rectal adenocarcinoma, s/p LAR and ileostomy
      • Small para-aortic lymph nodes. Suggest clinical correlation and follow up evaluation.
  • 2023-07-19 All-RAS + BRAF gene mutation
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-10 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection — no residual primary tumor. Margins free.
      • Lymph node, pericolonic, dissection — metastatic adenocarcinoma (3/19), no extranodal extension. - IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • pTx pN1b (if cM0); pStage: IIIA, at least.
    • Gross Description:
      • Procedure - previously post Transanal minimally invasive surgery with local excision (2022-03-02), now rectal trsection
      • Tumor Site - Rectum 12.5 3.5 x 3.5 cm
      • Tumor Size: no rpimary tumor in this specimen.
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1-5: roevious excision site; A6-8 and X1-2: epri-rectal lymph nodes; B: separated proximal margin; C: separated distal margin.
    • Microscopic Description:
      • Histologic Type - Adenocarcinoma
      • Histologic Grade - G2: Moderately differentiated
      • Tumor Extension - No evidence of primary tumor
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
      • Distance of tumor from margin: > 5mm (radial margin)
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Tumor Budding - none.
      • Type of Polyp in Which Invasive Carcinoma Arose: no primary tumor in this specimen.
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: 3/19
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition): IIIA, at least.
        • TNM Descriptors (not applicable)
          • Primary Tumor (pT) - No residual of primary tumor
          • Regional Lymph Nodes (pN) - pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM) - if cM0
      • Additional Pathologic Findings - None in this specimen identified
      • Ancillary Studies : result of S2023-4391 A6 : IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2 (+), MLH1 (+).
  • 2023-02-21 PET
    • Increased FDG uptake in two focal areas in the right pararectal region. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the stomach. Inflammatory process may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-02-14 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Clinical rectal cancer s/p. There are enlarged lymph nodes, up to 1cm in perirectal region, progression as compare with CT study on 2022-09-01.
      • R/O liver cyst, 1.5cm in S4.
      • Low density tumor, 1.7cm in the uterus, r/o uterine myoma.
    • Impression
      • Clinical rectal cancer s/p. Progressive enlarged perirectal lymph node as compare with CT study on 2022-09-01, r/o metastatic lymph node.
      • R/O liver cyst.
      • R/O uterine myoma.
  • 2023-02-14 Colonoscopy
    • Rectal cancer s/p op
    • No evidence of recurrence
  • 2023-02-14 Esophagogastroduodenoscopy, EGD
    • Suspect duodenal SET, 2nd portion
    • Gastric polyps, body, GC
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis
  • 2022-09-01 CT - abdomen
    • History and indication: Rectal cancer at 5 cm from AV s/p polypectomy stage I
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer s/p operation. Small LNs (4mm, 5mm) at right pararectal region without interval change.
      • Renal cysts (up to 0.7cm).
      • Liver cysts (up to 1.8cm).
  • 2022-03-03 Patho - colon segmental resection for tumor
    • DIAGNOSIS:
      • Intestine, large, rectum, 5 cm from anal verge, transanal minimally invasive surgery (s/p polypectomy) — No residual malignant tumor — Margin free
      • Lymph node., regional, transanal minimally invasive surgery — Negative for malignancy (0/1)
    • Microscopically, it shows full-layer of colorectal tissue with a scar at the mucosa. The muscularis propria and perirectal soft tissue are not remarkable. One regional lymph node is not remarkable.
    • Immunohistochemical stain reveals CK(-).

[MedRec]

  • 2022-02-17 SOAP Colorectal Surgery
    • 20220113 Rectal cancer at 5 cm from AV s/p polypectomy stage I was diagnosed at ShuangHe Hospital, pT1, margin < 1mm

[surgical operation]

  • 2023-03-10
    • Surgery
      • Robotic LAR + Loop ileostomy    
    • Finding
      • Perirectal nodules R/O lymph nodes metastasis Redundant sigmoid colon adhesion to omentum
  • 2022-03-02
    • Surgery
      • Transanal minimally invasive surgery (TAMIS) for local excision    
    • Finding
      • Rectal cancer at right anterior wall 5 cm from AV s/p polypectomy, pT1 , margin not involve < 1mm.
      • Whole layer resection of the tumor base deep to vaginal wall anteriorly and perirectal fat

[chemotherapy]

  • 2023-10-13 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-22 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-07 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-08-21 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-28 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-10 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-05-30 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-05-02 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-04-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr (Y-sited 5-FU) + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 170mL 48hr (infusor)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-10-16

The current FOLFOX regimen was initiated on 2023-04-18, during which time multiple leukopenia events occurred (indicated in the table below with “**” for WBC < 2K/uL and “*” for WBC < 3K/uL). Since July, the regimen has eliminated the 5-FU bolus and reduced oxaliplatin from 85 mg/m2 to 75 mg/m2. Since these adjustments, there has only been one case of WBC < 2K/uL on 2023-10-05, primarily due to the intermittent administration of Granocyte (lenograstim) based on the patient’s condition. The most recent lab data (2023-10-12) showed a WBC of 4.15K/uL, indicating no current evidence of leukopenia.

  • 2023-10-12 WBC 4.15 x10^3/uL
  • 2023-10-05 WBC 1.86 x10^3/uL **
  • 2023-09-18 WBC 3.35 x10^3/uL
  • 2023-09-07 WBC 4.37 x10^3/uL
  • 2023-08-31 WBC 23.24 x10^3/uL
  • 2023-08-18 WBC 7.02 x10^3/uL
  • 2023-08-14 WBC 2.62 x10^3/uL *
  • 2023-08-07 WBC 2.04 x10^3/uL *
  • 2023-07-28 WBC 11.71 x10^3/uL
  • 2023-07-24 WBC 2.70 x10^3/uL *
  • 2023-07-10 WBC 2.52 x10^3/uL *
  • 2023-06-26 WBC 3.33 x10^3/uL
  • 2023-06-19 WBC 1.55 x10^3/uL **
  • 2023-06-12 WBC 2.10 x10^3/uL *
  • 2023-05-29 WBC 4.57 x10^3/uL
  • 2023-05-22 WBC 2.49 x10^3/uL *
  • 2023-05-16 WBC 1.50 x10^3/uL **
  • 2023-04-28 WBC 2.94 x10^3/uL *
  • 2023-03-09 WBC 6.31 x10^3/uL
  • 2022-02-18 WBC 4.91 x10^3/uL

700204091

231013

[exam findings]

  • 2023-09-12 CT - abdomen
    • History and indication: Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p OP and treatment
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
      • Grade 4 fatty liver.
      • Renal cysts (up to 4.1cm).
      • Some LNs (up to 1.3cm) at bil. inguinal regions.
    • IMP:
      • S/P hysterectomy. A cystic lesion (2.7cm) at right pelvic wall.
      • Grade 4 fatty liver.
  • 2023-08-29 Anoscopy
    • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion and fissure at posterior
  • 2023-07-04 SONO - nephrology
    • L’t Kidney - Cyst:(Max) Upper pole 3.9 x 3.0 cm 2.7 x 3.1 cm
    • Diagnosis: left renal cyst
  • 2023-06-15 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 15 dB HL, LE 21 dB HL
    • Bil WNL
  • 2023-05-18 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovarian tumor, right, frozen (F2023-00229) — Endometrioid carcinoma and endometrioma
        • Fallopain tube, right, ditto — Free of tumor invasion
      • Ovarian cyst, left, debulking surgery — Endometrioma and free of tumor invasion
        • Fallopain tube, left, ditto — Free of tumor invasion
      • Cervix, uterus, debulking surgery — Free of tumor invasion
        • Endometrium, uterus — Free of tumor invasion, proliferative phase
        • Myometrium, uterus — Free of tumor invasion, leiomyomas and adenomyosis
      • Uterosacral area mass, ditto — Endometrioid carcinoma
      • R’t peri-ureter tissue, ditto — Endometrioid carcinoma and endometriosis
      • R’t suspensory (IP), ditto — Free of tumor invasion
      • Omentum, omentectomy — Free of tumor invasion
      • Lymph nodes
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/5)
        • Lymph node, left obturator, dissection — Free of tumor metastasis (0/10)
        • Lymph node, right iliac, dissection — Free of tumor metastasis (0/11)
        • Lymph node, right obturator, dissection — Free of tumor metastasis (0/25)
        • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/12)
        • Llymph node, right paraaortic, dissection — Free of tumor metastasis (0/6)
      • Bilateral prametria — Free of tumor invasion
      • AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen sections and debulking surgery
      • Specimen type: uterus and left adnexa, pelvic and paraaortic LNs and omentum
      • Specimen size:
        • Right opened ovarian tumor (frozen): 5.2 x 4.8 cm with blood clot and one papillary tumor 1.2 x 0.7 cm
        • Right fallopian tube: 4.5 cm in length, 0.6 cm in diameter
        • Left ovarian cyst: 3.7 x 2.7 cm
        • Left fallopian tube: 3.7 cm in length, 0.7 cm in diameter
        • Uterus: 11 x 7 x 5 cm in size and 415 gm in weight, multiple myomas, up to 5.8 x 5.3 x 4.4 cm
        • Omentum: 31 x 9 x 0.5 cm
      • Uterosacral area mass: three pieces, up to 1.3 x 0.6 x 0.4 cm
      • R’t peri-ureter tissue: one piece, 3.7 x 2.6 x 2.1 cm
      • R’t suspensory (IP): one piece, 2.8 x 1.8 x 1.3 cm
      • Tumor site: R’t ovary, uterosacral area mass and R’t peri-ureter tissue
      • Tumor appearance: cystic tumor with papillary tumor at R’t ovary
      • Specimen integrity: opened ovarian tumor
      • Lymph node: pelvic and paraaortic LNs
      • Representative sections as A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D1-D3: right obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1-G3: uterine corpus, G4-G5: low segment of corpus + cervix, G6-G7: corpus, G8-G9: cervix, G10: endometrium, G11: myoma, G12-G14: adenomyosis, G15-G16: bilateral parametrium, H: right suspensory (IP), I: uterosacral area mass, J: omentum, K: right peri-ureter tissue [Reference: frozen section, F2023-00229 FSA1: R’t ovarian papillary nodule, FSA2: R’t ovarian cyst, A1-A2: R’t ovarian cyst and A3: R’t fallopian tube, B1: L’t fallopian tube, B2-B3: L’t ovarian cyst]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Endometrioid carcinoma, endometrioma and endometriosis
      • Histologic grade: Grade 1
      • Contralateral ovary involvement: Absent
      • Tumor side ovarian surface involvement: Absent
      • Contralateral ovary surface involvement: Absent
      • Right tube involvement: Absent
      • Left tube involvement: Absent
      • In situ adenocarcinoma in right &/or left fallopian tube: Absent
      • Right adnexa soft tissue involvement: Absent
      • Left adnexa soft tissue involvement: Absent
      • Pelvic soft tissue involvement: Present
      • Uterine serosa involvement: Absent
      • Omentum involvement: Absent
      • Uterine Cervix involvement: Absent, chronic cervicitis with Nabothian cysts
      • Endometrium involvement: Absent
      • Myometrium involvement: Absent, leiomyomas and adenomyosis
      • Appendix involvement: Not received
      • Lymph nodes metastasis: Free of tumor metastasis (0/69) in total number
      • Uterosacral area mass: endometrioid carcinoma
      • R’t peri-ureter tissue: endometrioid carcinoma and endometriosis
      • Immunohistochemistry (F2023-00229 FSA1): PAX-8 (+), vimentin (+), ER (+), WT-1 (-) and P53 (wild type)
      • Ascites cytology: Negative
  • 2023-05-17 Frozen Section
    • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
  • 2023-04-25 Patho - colon biopsy
    • Colorectum, splenic flexure, s/p biopsy removal — Hyperplastic polyp
  • 2023-04-25 Patho - stomach biopsy
    • Stomach, AW side of antrum, biopsy — Ulcer, H pylori present
    • Stomach, LC side of prepyloric antrum, biopsy — Ulcer, H pylori NOT present
  • 2023-04-24 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A-
    • Gastric ulcers, antrum, s/p biopsy at antrum (AW) and prepyloric antrum (LC)
  • 2023-04-24 Colonoscopy
    • Colon polyp, splenic flexure, s/p biopsy removal
    • Diverticulosis, descending colon
    • Internal hemorrhoid
  • 2023-04-19 CT - abdomen
    • Findings:
      • There is a homogeneous enhancing mass 6.4 cm in the uterus that is c/w myoma.
      • There is cystic lesion in bilateral adnexa with mild wall thickening but no mural nodule and septum.
        • Cystic adenocarcinoma of the ovary is highly suspected.
        • In addition, there are few small soft tissue nodules in right L3 peri-ureter area that may be tumor seeding (T2b)?
        • The right and left adnexal cystic lesion are measured 6.4 cm and 3.6 cm, respectively. Please correlate with GYN. sonography and CA125.
      • Two renal cyst 4 cm and 1.5 cm in left upper pole is noted.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T2b(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
  • 2023-04-14 Gynecologic ultrasonography
    • R/O Rt Ovarian mass: 68x49mm (papillary: 16x14mm, no blood flow)
    • Adenomyosis
    • Uterine myoma

[MedRec]

  • 2023-06-01 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Date: 20230525

        Treatment Plan:
        • Postoperative adjuvant chemotherapy (referral to Dr. Xia HeXiong)
        • Provide Ovarian Cancer Treatment Shared Decision-Making (SDM) form and explanation of the condition (including genetic testing and targeted therapy).
    • P
      • Arrange admission for 24hr CCr, audiomtery and C/T with TP
  • 2023-05-16 ~ 2023-05-25 POMR Obstetrics and Gynecology
    • Discharge diagnosis
      • Malignant neoplasm of right ovary
      • Leiomyoma of uterus, unspecified
      • Female pelvic peritoneal adhesions (postinfective)
      • Debulking surgery on 20230517
    • CC
      • Irregular menstrual cycles with short intervals.
    • Present illness
      • This is a 47 year old famle, G3P2AA1 (NSD x2, with no severe complications), LMP was 20230416. She had hypertension (under medicine control) and kindey cyst (suggested regular follow up), no surgery history, no known allergens.
      • ACCORDING TO THE PATIENT, SHE HAD IRREGULAR MENSTRUAL CYCLES WITH SHORT INTERVALS SINCE APRIL 2023 (03/27, 04/04 are previous cycles, mild menstrual pain). THEREFORE, SHE WENT TO OB/GYN CLINICS FOR HELP. She was informed elevated CA125 and CA199, then she was introduced to Dr. Huang. AT DR. HUANG OPD, TRANSVAGINAL SONOGRAPHY SHOWED Myoma 6051 / 3020 mm IN SIZE, ROV mass 68*49 mm (papillary:16x14mm,no blood flow).
      • CT was performed on 04/19, the findings are as followed: 1. Uterine myoma 6.4 cm. 2. Cystic lesions in bilateral adnexa.
      • UNDER THE IMPRESSION OF UTERINE MYOMA AND OVARAIN TUMOR, MALIGNANCY CANNOT BE RULE OUT, After the evaluation, the paitent was arranged with LSC myomectomy + BSO on 20230517, she was admitted to our ward day before for the pre-operation preparation.
    • Course of inpatient treatment
      • The patient was admitted on 20230516 due to ovarian tumor. The frozen section initial diagnosis:Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma. She underwent Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy on 20230517. The AJCC Pathologic staging — pT2bN0, if cM0, stage IIB / FIGO stage IIB. The GYN tumor board conference suggest the patient to receive chemotherapy on 20230525. Her postoperative course was uneventful. Self voiding was smooth. She was discharged on 20230525. Her follow up appointment is scheduled on 20230601. Keep intraperitoneal Port for chemotheraphy.      
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Actein (acetylcysteine 200mg) 1# TID
      • cephalexin 500mg 1# QID
      • MgO 250mg 1# TID

[consultation]

  • 2023-07-04 Urology
    • Q
      • for USK evaluation
      • This 47-year-old woman, a patient of Right ovarian endometrioid carcinoma, pT2bN0cM0, FIGO stage IIB s/p Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy), bilateral DBJ insertion and Tenckhoff tube insertion on 2023/05/17 . DBJ was removed on 20230605. We need expertise to evaluate her condition thanks!
    • A
      • we will arrnage USK to evaluate Tx effect after DBJ insertion
  • 2023-05-18 Urology
    • Q
      • For on D-J catheterization.
      • This 47-year-old female with ovarin cancer was admitted for Debulking surgery at 20230517.
      • We need your evaluation of her condition for on D-J catheterization.
    • A
      • intrapoerative finding showed tumor attached to right low ureter
      • Bilateral DBJ was inserted
      • tumor was dissected from right low ureter
      • For better healing and stablization after operation, DBJ may be kept for one month til 2023/06/05
      • I had explained to her on 2023/05/18 09:30

[surgical operation]

  • 2023-05-17
    • Surgery
      • Operation: Tenckhoff tube insertion
    • Finding
      • Tenckhoff tube over RLQ
    • Procedure
      • Under ETGA, GYN and GU performed operation at first. GS was consulted. Inserted a Tenckhoff tube with exit site over RLQ. Closed the wound with 1# Vicryl and skin staples.
  • 2023-05-17
    • Surgery
      • DBJ insertion, bilateral        
    • Finding
      • A 6 Fr 24 cm double-J catheter was inserted to left ureter.
      • A 6 Fr 24 cm double-J catheter was inserted to right ureter.
      • Bladder mucosa seems fair
      • no urin eleakage
      • Pelvic tumor is found medial to low ureter. After dissection, pelvic tumor is dissected from right low ureter as much as possible.
    • Procedure
      • With ETGA, the patient was in lithotomy position. Disinfection and draping the operation field were done as usual methods. Cystoscopy was performed to identify the ureteral orifices. After retrograde insertion of guidewire. A 6 Fr 24 cm double-J catheter was inserted to left ureter. A 6 Fr 24 cm double-J catheter was inserted to right ureter. A 14Fr Foley was inserted. Through open wound by gyn doctor, a firm pelvic tumor is found medial to right low ureter. After fine and blunt dissection, pelvic tumor is dissected from right low ureter as much as possible. The patient stood the procedures well. 
  • 2023-05-17
    • Surgery
      • Right ovarian cyst, frozen section — Malignancy, favor endometrioid carcinoma
    • Procedure
      • Debulking operation (ATH + BSO + BPLND + bilateral paraaortic LND + Cytoreduction surgery + infracolic omentectomy + )
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: AVFL, with multiple uterine myomas(intramural type, 6x5 / 3x2cm)
        • Some papillary tissue over right uteroscaral ligament, medial to ritght ureter, s/p excision
      • Adnexa:
        • Severe adhesion between bilateral adnexa and posterior uterien wall + cul-de-sac, s/p adhesiolysis
        • LOV cystic mass, 5x4 cm, intraoperative rupture with chocolate-like contents
        • ROV cystic mass, 7x5 cm, intraoperative rupture with papillary tissue and -chocolate-like contents
        • Some papillary lesions was noted over right suspensory ligament and right pelvic lateral wall, s/p excision
      • CDS: severe adhesion
      • Ascites: little, s/p washing cytology
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: diffuse chocolate spots was noted, suspect related to previous rupture of chocolate cyst; infracolic omentectomy was done.
      • Liver: grossly normal & smooth; Subdiaphragmatic surface: miliary tumor seeding(-)
      • Appendix: grossly normal
      • Previous rupture of chocolate was highly suspected, with diffused chocolate spots over the pelvic wall and and bowel adhesion were noted.
      • After the operation, optimal debulking surgery was achieved; Residual tumor: R0
      • Estimated blood loss: 400ml
      • Blood transfusion: LPRBC 2u
      • Complication: nil
      • 15Fr-Jvac x2 at bilateral Cul-de-sac
      • Antiadhesion agent: interceed x 1 piece

[immunochemotherapy]

  • 2023-10-13 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-12 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-15 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-24 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-03 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-14 - bevacizumab 15mg/m2 1100mg NS 100mL + paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 400mg NS 250mL 2hr (adjuvant Avastin 15mg/kg IVD Q3W x 6 + 12~15 for 15mo)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-08-15

The patient received a 28-day refill of rabeprazole on 2023-08-10. While the active medication list does not show any current use of PPIs, Stogamet (cimetidine) is being used. Therefore, there are no medication reconciliation concerns.

2023-07-25

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

2023-07-04

  • After reviewing the PharmaCloud database, there is no prior prescription that is still valid now from other healthcare providers or other departments in this hospital.
  • However, there is no records of Norvasc refilled in the past few weeks, and this drug should be a prescription medicine which can only be ordered by a doc, and this drug has been included as a patient-carried item in the active medication list, please check if the self-carried Norvasc does not pass its expired date.

700363763

231013

[lab data]

2023-07-17 CMV viral load assay 6060 IU/mL
2023-07-07 CMV viral load assay 331 IU/mL

2023-04-25 MTBC PCR DETECTED CFU/ml
2023-04-25 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

  • 2023-07-11 CT - abdomen
    • History and indication: Rectal cancer with obstruction post T-loop colostomy on 4/7 23.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
      • Nodules (up to 14mm) at bil. lungs.
      • Renal cysts (up to 1.2cm).
      • Wall thickening of urinary bladder.
      • Small amount pericardial effusion.
      • Atherosclerosis of aorta, iliac arteries.
      • Presence of scoliosis of the lumbar spine.
      • S/P NG tube indwelling.
    • IMP:
      • Much regression of rectal cancer. Some tiny LNs at pelvic cavity.
      • Nodules (up to 14mm) at bil. lungs.
      • Wall thickening of urinary bladder.
  • 2023-07-10 CXR (erect)
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-05-15, -05-08, -05-03, -04-27 CXR
    • Port-A catheter inserted via left subclavian vein, its tip overlies Rt paratracheal stripe
    • A poorly defined mass over LUL
    • areas of hyperlucency and decreased upper lung vascular markings due to emphysematous change of both lungs upper lung predominance
    • there is also areas of pulmonary fibrosis in the lungs
    • mild enlarged cardiac silhoutte
  • 2023-04-24 Patho - lung transbronchial biopsy
    • Lung, left, CT-guide biopsy — necrotizing granulomatous inflammation with marked interstitial fibrosis
    • Sections show alveolar lung tissue with marked interstitial fibrosis and necrotizing granulomatous inflammation. Several Langhan’s multinuclear giant cells are also seen.
    • The AFB special stain is positive. The PAS special stain is negative. No definite malignancy is found. The immunohistochemical stain of CK reveals no invasive tumor.
  • 2023-04-22, -04-20 CXR
    • Patch density at LUL.
    • Blunted left costophrenic angle.
    • Presence of scoliosis of the lumbar spine.
  • 2023-04-19 PET
    • Increased FDG uptake at the R-S junction of colon, compatible with rectal malignancy.
    • Increased FDG uptake in bilateral peri-rectal lymph nodes, highly suspected rectal cancer with regional lymph nodes metastases.
    • Increased FDG uptake in bilateral upper lungs, highly suspected the secondary (priority, colon cancer with lung mets) or another primary (left or right upper lung?) cancer, suggesting biopsy, if necessary, for investigation.
    • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, and in a left SCF lymph node, highly suspected rectal cancer with distant lymph nodes metastases (priority) or lung cancer with regional lymph nodes metastases.
    • Highly suspected rectal cancer with regional and distant lymph nodes, as well as bilateral upper lungs metastases, cTxN2M1b, stage IVB (AJCC 8th ed.), or double cancers of rectum and lung, by this F-18 FDG PET scan.
  • 2023-04-18 All RAS + BRAF
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-14 CT - chest
    • Indication: colon cancer with lung metastases
    • Findings
      • Spculated mass at left upper lobe with central lucency is found measuring 3.2cm in largest dimension. In comparison with CT dated on 2020-08-10, the lesion enlarged. Lung cancer is favored.
      • Severe centrilobular Emphysematous change over both lungs is found.
      • Minimal reticulation at bilateral lower lungs is found.
      • Tiny atelectatic change at left lower lobe with minimal left pleural effusion is found.
      • Small lymph nodes are found in the mediastinum. Stationary.
    • Imp: Left upper lobe spiculated mass. r/o lung cancer.
  • 2023-04-07 Patho - colon biopsy
    • Colon tumor, rectum, 10 cm above anal verge, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma characterized by glandular tumor cell infiltrate with stromal desmoplasia.
    • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2023-04-01 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of S-colon with adjacent fat stranding and colon dilatation. Some LNs at pelvic cavity.
      • Nodules (up to 7mm) at bil. basal lungs.
      • Renal cysts (up to 1.2cm).
      • Atherosclerosis of aorta, iliac arteries.
      • Presence of scoliosis of the lumbar spine.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2022-09-05 CXR
    • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
    • ill-defined nodular opacity at LUL and several nodular opacities at RUL, stationary as compared with previous image
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Mild dextroscoliosis of the T-spine
  • 2022-07-25 CT - brain
    • Findings
      • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp: Brain atrophy.
  • 2020-08-10 CT - chest
    • Indication: RUL nodule
    • Comparison: none prior CT dated on 2017 2018 2019
      • Lungs and large airways:
        • extensive centrilobular emphysema over bilateral lungs upper predominance.
        • ill-defined, dumbell-like nodular opacity in LUL (37-mm in longest dimension) and several solid nodular opacities up to 24-mm in longest dimension in RUL, and minimal fibrotic change at lung apex in the same lobe. several small calcified granulomas in posterior RUL too.
      • Mediastinum: no LAP or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion,
      • Hila: unremarkable.
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: dilated RV and RA?
      • Pleura: no effusion.
      • Chest wall and lower neck: unremarkable.
      • Visible abdomen: no abnormal density in visible portion of the liver, spleen, pancreas, kidneys, adrenal glands, and GB.
        • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: unremarkable.
    • Impression:
      • newly developed nodular lesions in both upper lobes compared
      • with CT on 2019/03/26, malignancy or MTB?
      • extensive emphysema.
  • 2020-03-02 CXR
    • Increased lung volume and areas of lucency and dirty marking due to emphysematous change of both lungs upper lung predominance
    • a small nodular opacity over RUL and a small nodular opacity (ill-defined) over LUL, may be malignant lesions, suggest do CT study Thoracic aortic arch calcified atheriosclerotic plaque
    • mild levoscoliosis of the L-spine
  • 2019-12-09 Bronchodilator test
    • mild obstructive ventilatory impairment
  • 2019-03-26 CT - chest
    • Comparison: none prior CT dated on 2017 2018 2019
      • Lungs and large airways:
        • extensive centrilobular emphysema over bilateral lungs upper predominance. minimal fibrotic change at RUL. a 6mm subpleural nodule or atelectatic lung tissue at RML.
      • Mediastinum: no LAP or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion,
      • Hila: unremarkable.
      • Vessels:
        • Aorta: normal in caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Pulmonary arteries: normal in caliber.
      • Heart: normal in size.
      • Pleura: small effusion with parietal pleural thickening, Rt.
      • Chest wall and lower neck: unremarkable.
      • Mild atherosclerotic change of the abdominal aorta.
      • Visualized bones: unremarkable.
    • Impression:
      • Rt pleural effusion, exudate.
      • a 6mm subpleural nodule or atelectatic lung tissue at RML.
      • extensive emphysema.

[MedRec]

  • 2023-09-01 SOAP Chest Medicine Huang GuoLiang
    • Prescription
      • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
      • Vit B6 (pyridoxine 50mg) 1# QD
      • Smecta (dioctahedral smectite 3mg) 1# BIDAC
  • 2023-08-04 SOAP Chest Medicine Chen XinYi
    • Prescription
      • AKruiT-4 (RIF 150mg, INH 75mg, PZA 400mg, EMB 275mg) 3# QDAC
      • Vit B6 (pyridoxine 50mg) 1# QD
      • Actein Effervescent (acetylcysteine 600mg) 1# BID

[consultation]

  • 2023-07-10 Gastroenterology
    • Q
      • for abnormal liver function and jaundice
      • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI 2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
    • A
      • This 79-year-old male was a case of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. We are consulted for bilirubin elevation.
        • Communicating with a pen at bedside.
        • No abdomen pain noted
      • A: Bilirubin elevation, suspect drug-induced cholestasis, r/o biliary obstruction
      • P:
        • Pending on Abdomen CT report
        • Check AST, ALT, ALP, rGT, TBI/DBI, ALB, PT, APTT to complete liver study
        • Regular monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Contact us, if any porblems
  • 2023-07-10 Chest Medicine
    • Q
      • for Tuberculosis of lung & anti-TB drugs evaluation
      • This 79-year-old man, a patient of rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stageIIIC S/P chemotherapy. Owing to high TBI :2.98mg/dl was noted during anti-TB drugs related. We need expertise to evaluate his condition thnaks!
    • A
      • Suggestion:
        • hold anti-TB medication
        • arrange liver echo or abdominal CT to define liver condition. May consult GI
        • for much sputum, do sputum culture, airway clearance, give amikin inhalation for anti-inflammatory effects.
  • 2023-06-26 Gastroenterology
    • Q
      • Due to the coffee ground noted via NG and tarry stool found via colostomy, we rechecked lab data for him which was revealed decreased level of Hb (12.3 -> 7.8). Thus, we need your expertise for evaluation of PES due to suspected Upper GI bleeding. Thanks!
    • A
      • 79 male with rectal cancer, s/p chemotherapy and colonostomy. However, due to tarry stool with coffee ground, we are consulted.
        • conscious: clear
        • chest: intubation
        • abdomen: soft and flat
      • impresson
        • UGI bleeding
      • suggestion
        • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
        • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
        • Proton pump inhibitor use
        • Avoid anticoagulants/antiplatelets use, and correct bleeding tendency if any;
        • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock;
        • Inform us to follow up if bleeding condition progression or any other GI problem progression
  • 2023-06-23 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
        • 79-year-old rectal cancer, COPD and pulmonary TB male patient has a new episode of severe pneumonia, BLL with respiratory failure and severe sepsis now.
        • He was just discharged from our Onco ward two days ago.
        • Use of Mepem acceptable before further culture report available.
      • Suggestion:
        • Continue Mepem for one week first
        • Check blood and sputum culture report.
  • 2023-05-24 Dermatology
    • Q
      • This is 78 y/o man who has underlying disease of 1) COPD, 2) Hypertension, 3) GERD, 4) Rectal cancer obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM0 stage IIIC, 5) Tuberculosis of lung under treatment.
      • This time, he complained of abdominal pain and distention for 3 days accompanied with constipation lasting a week. The patient denied chest tightness(-), headache(-), dizziness(-), radiated pain(-), shoetness of breating(-) nauseas(-) and vomitting(-), diarrhea(-). He also denied TOCC history.
      • For skin rash off and on was noted, we need your further evaluation and management. Thanks a lot!!! There are photos on the caregiver’s mobile phone.
    • A
      • The patient had sufferred from discrete reddish swelling papules on the abdomen without pruritus on and off for weeks.
      • xerotic dry skin with post-screthec lesions over four limbs.
      • Under the impression of acute urticaria and xerotic dermatits.
      • The following sugeetion:
        • for urticaria, consider keep allegra 1# bid po use -> consider shift to xzyal 1# HS po use if condition turn to stable.
        • for xerotic dermatitis, currently apply lotion extensively. Mycomb cream 2 tube topical bid use over itchy reddish papules and sinphraderm 1 tube topical QN use over dry scales.
  • 2023-04-28 Hemato-Oncology
    • Q
      • Consult our CRS and then operation of T-colostomy was performed for rectal cancer obstruction on 2023/04/07. General condition is stationary and then transfer to ward on 2023/04/13.
      • Follow chest CT: Left upper lobe spiculated mass, suspect lung cancer, cT2aN0M0 on 2023/04/14.
      • We needs your expert experience for further evaluation and neoadjuvant CCRT. Thaks a lot!!
    • A2 - 2023-04-28
      • This 78 year old man is a case of Rectal cancer with obstruction status post T-loop colostomy on 2023/04/07, cT4aN2aM1a stage IVa and suspect lung cancer, cT2aN0M0 on 2023/04/14. We are consulted for further evaluation and CCRT.
      • Please arrange PET CT scan, arrange port A insertion.
      • Please check All-RAS-BRAF, anti HCV, anti HBc, anti HBs, HBsAg.
      • We will discuss with patient about further systemic treatment. Thanks for your consultation.
    • A1 - 2023-04-20
      • Please consult chest surgeon for further OP evaluation. If not suitable operation, may arrange CT guide biopsy for tissue proof (left upper lung lesion).
      • In addition, may also check TB sputum culture. Pending the result. Thanks for your consultation.
  • 2023-04-26 Chest Medicine
    • Q
      • For further treatment of TB (Sputum Acid-fast Stain: Positive, MTBC PCR: detected) and take over
        • The uncle of Deputy Director Zheng Jingfeng
        • For deaf and mute individuals, please use written communication
    • A
      • Sputum Acid-fast Stain: Positive, MTBC PCR: detected. recommends isolation and treatment by Infection Control Team.
      • We takeover and give TB medication.
  • 2023-04-18 Radiation Oncology
    • A
      • A: Adenocarcinoma of the rectum, stage T4aN2aM1a (stage IVA).
      • P: Neoadjuvant CCRT is indicated for this patient with the following indicators: stage T4aN2aM1a (stage IVA)
        • Goal: palliation
        • Treatment target and volume: pelvic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-04-24.
  • 2023-04-07 Colorectal Surgery
    • Q
      • The sigmoidoscopy reveals Rectal cancer obstruction.
      • On 4/7 night, intubation for aspiration pneumonia with acute respiratory failure.
      • Due to Rectal cancer obstruction. consult for colostomy evaluaution. Thanks
    • A
      • RS colon cancer with obstruction for almost 1 week.
      • persist abdomen fullness and aspiration pneumonia
      • CRP: 8 yesterday
      • suggest T colostomy under risk, because bowel inflammation will worse for lont time obstruction.
  • 2023-04-07 Infectious Disease
    • A
      • Consultation for Mepem antibiotic
      • Rectal cancer with colon obstruction and severe sepsis case.
      • Serial CxR films showed newly developed pneumonia.
      • Please continue Mepem for 5 days first.
      • Check blood and sputum culture report.

[surgical operation]

  • 2023-04-07
    • Surgery
      • T colostomy
    • Finding
      • Severe dilation of T colon and mild ischemia
      • T colon ulcer

[radiotherapy]

[chemotherapy]

  • 2023-10-12 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-21 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-09-07 - oxaliplatin 65mg/m2 80mg D5W 250mL 2hr + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-08-08 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg D5W 500mL 46hr (FOLFOX without Ox)
    • dexamethasone 4mg + NS 250mL
  • 2023-06-13 - leucovorin 20mg/m2 25mg NS 250mL 10min D1-5 + fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
    • [dexamethasone 4mg + NS 250mL] D1-5
  • 2023-05-16 - fluorouracil 225mg/m2 300mg NS 100mL 10min D1-5 (CCRT)
    • [dexamethasone 4mg + NS 250mL] D1-5

==========

2023-10-13

After reviewing the PharmaCloud database and the hospital’s HIS5 records, no medication reconciliation issues were identified.

2023-09-05

[tube feeding]

As the adsorbent properties of this product may interfere with the rates and/or levels of absorption of other substances, it is recommended not to administer any other drugs at the same time as SMECTA. ref: https://www1.ndmctsgh.edu.tw/pharm/pic/medinsert/005SME01E.pdf

[hyperbilirubinemia follow-up]

2023-09-04 Bilirubin total 1.55 mg/dL
2023-08-11 Bilirubin total 1.61 mg/dL
2023-08-07 Bilirubin total 2.16 mg/dL
2023-07-17 Bilirubin total 1.43 mg/dL
2023-07-12 Bilirubin total 2.04 mg/dL
2023-07-10 Bilirubin total 2.98 mg/dL

2023-09-04 Bilirubin direct 0.74 mg/dL
2023-08-11 Bilirubin direct 0.64 mg/dL
2023-08-07 Bilirubin direct 1.03 mg/dL
2023-07-17 Bilirubin direct 0.59 mg/dL
2023-07-12 Bilirubin direct 1.06 mg/dL
2023-07-10 Bilirubin direct 1.61 mg/dL

At present, the patient’s bilirubin levels are lower than what was observed in mid-July, even after resuming AKruiT-4 on 2023-08-04.

It’s worth noting that AKruiT-4 is being administered alongside Smecta, which is not advisable. Smecta has the potential to alter the rate or level of AKruiT-4 absorption.

2023-07-13

[optional addition of Genurso for hyperbilirubinemia]

The addition of Genurso (ursodeoxycholic acid 100mg) #1 or #2 TID might be considered to help alleviate the patient’s hyperbilirubinemia. ref: Anti-Tuberculosis Drug Induced Liver Injury and Ursodeoxycholic Acid. Journal of Tuberculosis Research, Vol.8 No.2, 2020. https://doi.org/10.4236/jtr.2020.82007

2023-07-12

[approach to hepatotoxicity caused by antituberculous drugs]

AKuriT-4 was ceased on 2023-07-10, with bilirubin levels subsequently falling, though they still remain above twice the upper limit of normal (ULN).

  • 2023-07-12 Bilirubin total 2.04 mg/dL
  • 2023-07-10 Bilirubin total 2.98 mg/dL
  • 2023-06-26 Bilirubin total 2.15 mg/dL

As per the “Approach to hepatotoxicity caused by first-line antituberculous drugs in adults” from UpToDate (https://www.uptodate.com/contents/image?imageKey=ID%2F109447), when the bilirubin level is less than 2mg/dL and the enzyme levels are less than twice the upper limit of normal, either a regimen made up of liver-sparing drugs (like ethambutol, a fluoroquinolone or linezolid) may be considered or the gradual reintroduction of first-line agents may be done.

Another study released in the New England Journal of Medicine in 2021 titled “Four-Month Rifapentine Regimens with or without Moxifloxacin for Tuberculosis” deduced that the effectiveness of a four-month regimen based on rifapentine, with or without moxifloxacin, was not inferior to the standard six-month regimen in the treatment of tuberculosis. The manufacturer’s guidelines for rifapentine do not include suggestions for dose adjustments in patients with hepatic impairment. It is believed that the pharmacokinetics of rifapentine in patients with varying degrees of hepatic impairment are similar to those in healthy volunteers.

2023-06-07

[following up on bilirubin and albumin levels]

  • Laboratory data indicates that both total and direct bilirubin levels have started to decrease, though they have not yet returned to the normal range. This suggests that the current AKuriT-4 regimen is less likely to have a continuously damaging effect on the liver.
    • 2023-06-06 Bilirubin total 1.24 mg/dL
    • 2023-06-06 Bilirubin direct 0.53 mg/dL
    • 2023-05-29 Bilirubin total 1.54 mg/dL
    • 2023-05-29 Bilirubin direct 0.74 mg/dL
  • Moreover, the patient’s albumin level has dropped to a record low of 2.3g/dL. Given that the patient’s kidney function appears normal (Cre 0.98 mg/dL, eGFR 78, BUN 16 mg/dL), the possibility of protein loss due to nephrotic syndrome is less likely. With bowel movements recorded at less than or equal to 3 since June, protein-losing enteropathy also appears less likely. If we rule out malnutrition as a cause, reduced albumin synthesis such as that seen in liver disease could potentially be the reason, warranting further investigation. Please monitor for signs of edema.
    • 2023-06-06 Albumin 2.3 g/dL
    • 2023-05-29 Albumin 2.6 g/dL

2023-06-01

[AKuriT-4 follow-up]

  • Today, after discussing the patient’s condition with the attending physician and nurse practitioner, I learned that the changes in the patient’s liver function indicators have already been discussed with Dr. Su from the thoracic department. It is believed that there is no need to adjust the medication at this time.

2023-05-31

  • A blood transfusion was performed on 2023-05-15 due to the patient’s low hemoglobin (HGB) levels. However, recent lab results still show a decreasing trend in HGB and a stool occult blood test result of 2+, which could suggest the possibility of ongoing GI bleeding. Although the patient is currently on a PPI (esomeprazole), if an upper GI source is suspected, the addition of tranexamic acid may be beneficial to control bleeding.
    • 2023-05-29 HGB 11.0 g/dL
    • 2023-05-26 HGB 12.0 g/dL
    • 2023-05-15 HGB 9.1 g/dL
    • 2023-05-26 stool OB 2+
  • Furthermore, the patient’s serum albumin levels seem to be dropping. It’s recommended that the patient increase his protein intake, and nutritional support might be needed. If these measures are implemented and hypoalbuminemia persists, it might be necessary to consider adding an albumin supplement.
    • 2023-05-29 Albumin 2.6 g/dL
    • 2023-05-15 Albumin 2.6 g/dL
    • 2023-05-08 Albumin 2.9 g/dL
    • 2023-05-03 Albumin 2.9 g/dL
    • 2023-04-27 Albumin 3.1 g/dL
  • This patient is currently being treated for lung TB with AKuriT-4 (rifampin 150mg + isoniazid 75mg + pyrazinamide 400mg + ethambutol 275mg) since 2023-04-26. Rifampin is associated with hepatotoxicity, which can manifest in various patterns including asymptomatic abnormal liver function tests, isolated jaundice or hyperbilirubinemia, symptomatic self-limited hepatitis, or even fulminant hepatic failure and death. Despite the patient’s AST and ALT levels being within normal range as of 2023-05-29, there has been a continuous increase in the patient’s bilirubin levels in 2023-05. This continuous increase in the patient’s bilirubin levels might potentially suggest rifampin-induced hepatotoxicity, particularly once other causes of elevated bilirubin, such as hemolysis, have been ruled out.
    • 2023-05-29 Bilirubin total 1.54 mg/dL
    • 2023-05-26 Bilirubin total 1.07 mg/dL
    • 2023-05-15 Bilirubin total 0.79 mg/dL
    • 2023-05-08 Bilirubin total 0.80 mg/dL
    • 2023-05-03 Bilirubin total 0.62 mg/dL
    • 2023-05-29 Bilirubin direct 0.74 mg/dL
    • 2023-05-26 Bilirubin direct 0.44 mg/dL
    • 2023-05-15 Bilirubin direct 0.29 mg/dL
    • 2023-05-03 Bilirubin direct 0.14 mg/dL

700711453

231013

{not completed}

[exam findings]

  • 2023-10-06 SONO - abdomen

    • Diagnosis:
      • Suspected chronic liver parenchyma disease
      • Liver tumor, right. Propable metastases
      • Suspected liver cyst, right
      • Pancreatic tumor, body
      • S/p PTGBD
      • Mild IHD dilatation, bil
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window
    • Suggestion:
      • Please correlate with other image, liver function test and follow AFP, CA-199
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-10-05 Abdomen - standing (diaphragm)

    • Calcified pelvic mass, probably calcified uterine fibroid.
    • marginal spurs of multiple vertebral bodies of L-spine due to spondylosis.
    • S/P Percutaneous gallbladder drainage.
  • 2023-10-02 Percutaneous Gall Bladder Drainage, PTGBD

  • 2023-10-02 CT - abdomen

    • Abdominal CT with and without enhancement revealed:
      • Severely dilated IHDs and CBD and proximal pancreatic duct is found. The GB is severely distended with wall thickening. Mass like lesion at pancreatic body with extending to celiac trunk is found. In comparison with CT dated on 2023-06-24, the mass enlarged
      • There is one low density lesio at S5/6 measuring 3.5cm is found. Traction of right lobe liver surface is found.
      • Calcified dot at uterus is found. Myoma calcification is consiered.
    • Imp:
      • Pancreatic body tumor with celiac trunk lymphadenopathy and compression of pancreatic duct and biliary tree, causing severe cholecystitis. Suggest further treatment.
  • 2023-10-02 ECG

    • Sinus tachycardia with Premature atrial complexes
    • T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2023-06-24 CT - abdomen

    • History and indication: Malignant neoplasm of pancreas
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.
      • Some calcifications (up to 3.4cm) at pelvic cavity. R/O uterine myoma (2.5cm).
      • Colonic diverticula.
      • Atherosclerosis of aorta.
    • IMP:
      • Much regression of pancreatic cancer (1.1cm) and liver metastases (2.0cm). Fat stranding at upper mediastinum with vascular encasement.
  • 2023-03-30 Patho - pancreas biopsy

    • Pancreas, EUS FNB — Ductal adenocarcinoma, poorly differentiated
    • The sections show a picture of ductal adenocarcinoma, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasm arranged in solid and cribriform patterns, embedded in fibrous stroma. Subtle mucin secretion is present.
  • 2023-03-30 Patho - liver biopsy needle/wedge

    • Liver, EUS FNB — Adenocarcinoma, consistent with metastatic pancreatic ductal adenocarcinoma.
    • The sections show a picture of adenocarcinoma, composed of liver tissue with nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present. The finding is consistent with metastatic pancreatic ductal adenocarcinoma.
  • 2023-03-28 Patho - liver biopsy needle/wedge

    • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary-type, compatible with metastatic pancreatic ductal adenocarcinoma.
    • The sections show a picture of adenocarcinoma, pancreatobiliary-type, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells with abundant eosinophilic cytoplasma in fibrous stroma. Focal ductal differentiation and mucin secretion are present.
    • IHC shows: CK7(+), CA19-9(+), CK20(-), and Hepatocyte(-). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
  • 2023-03-17 CT - abdomen

    • CC: Severe epigastric hunger pain and loss 6 kgs (42 to 36 Kgs) for 2 months.
      • 2023/03/14 Ca 19-9 > 150
    • Past history: Hearing impairment. Uterine myoma.
    • Findings:
      • There is an ill-defined poor enhancing mass measuring 2.6 cm in the pancreatic body-tail junction, causing the upstream pancreatic duct dilatation that is c/w adenocarcinoma.
        • In addition, there is soft tissue lesions in the celiac trunk area with encasement that is c/w tumor invasion (T4).
      • There is an ill-defined poor enhancing mass measuring 3.3 cm in right lobe liver that is c/w metastasis (M1).
        • In addition, there is another poor enhancing lesion 0.8 cm in S4 of the liver. Metastasis is also highly suspected.
      • There are three calcified masses in the pelvis, the largest one 3.3 cm, that are c/w uterine fibroids.
      • The gallbladder shows small size. please correlate with clinical condition.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4 (T_value) N:N0 (N_value) M:M1 (M_value) STAGE:IV
  • 2022-11-09 ENT SONO - head and neck soft tissue

    • Clinical Impression/Intent:right thyroid tumor
    • Sonographic Impression:right thyroid isoechoic tumor, margin clear, with microcalcification
  • 2021-02-03 ENT SONO - head and neck soft tissue

    • Clinical Impression/Intent:thyroid nodule?
    • Sonographic Impression:bilateral thyroid nodule
  • 2021-01-27 ENT Hearing Test

    • Tymp bil type A
    • ART
      • RE absent
      • LE 1000-4000 Hz reduced thretholds
    • PTA:
      • Reliability FAIR
      • Average RE >120 dB HL, LE 53 dB HL
      • RE profound SNHL
      • LE mild to profound SNHL
  • 2018-03-19 Pure Tone Audiometry

    • Reliabilty Fair
    • R’t : >120 dB HL, profound HL
    • L’t : 49 dB HL, mild to severe SNHL

[MedRec]

[Consultation]

[chemotherapy]

  • 2023-09-05 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-29 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-15 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-08-08 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-25 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-11 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-07-04 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-06-20 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-06-13 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-30 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-23 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-09 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-05-02 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-18 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-10 - gemcitabine 1000mg/m2 1100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

[note]

gemcitabine 2023-04-11 https://www.uptodate.com/contents/gemcitabine-drug-information

  • Pancreatic cancer, locally advanced or metastatic:
    • IV: Initial:
      • 1,000 mg/m2 over 30 minutes once weekly for 7 weeks followed by 1 week rest; then administer on days 1, 8, and 15 every 28 days or
    • Off-label dosing/combinations: IV:
      • 1,000 mg/m2 days 1, 8, and 15 every 28 days (in combination with paclitaxel [protein bound]) or
      • 1,000 mg/m2 over 30 minutes days 1, 8, and 15 every 28 days (in combination with capecitabine) or
      • 1,000 mg/m2 over 30 minutes weekly for up to 7 weeks followed by 1 week rest; then weekly for 3 weeks out of every 4 weeks (in combination with erlotinib) or
      • 1,000 mg/m2 over 30 minutes days 1 and 15 every 28 days (in combination with cisplatin) or
      • 1,000 mg/m2 infused at 10 mg/m2/minute every 14 days (in combination with oxaliplatin).

==========

2023-10-13

The patient’s body weight was recorded as 33.7kg on 2023-10-09. It may be prudent to monitor for potential adverse reactions as administering standard doses to underweight individuals may increase the risk of side effects.

700736980

231013

{Neuroendocrine carcinoma}

[exam findings]

  • 2023-09-12 KUB
    • Lumbar spondylosis.
  • 2023-09-12 SONO - nephrology
    • Chronic renal parenchymal disease, moderate degree
    • Right renal cyst
    • Left hydronephrosis, mild to moderate degree
    • Left renal cysts
    • r/o mass lesion in the pelvic area
  • 2023-08-25 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
    • Findings
      • Lungs:
        • no interval change of a subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/04/25.
        • resolution of Rt apical lung solid nodule.
        • a new small nodule at LLL-S9.
        • dependent subpleural nodular consolidations at both lower lobes
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Mediastinum and hila: no enlarged LN or mass.
        • moderate calcified plaques of the LAD and right coronary arteries.
      • Visible abdominal-pelvic contents:
        • progressive increase in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with CT (2023/04/25).
        • many small hepatic and renal cysts (up to 2.0cm)
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • prostate with regional organs involvement and pelvic metastatic LAP and lung metastases,in progression compared with CT (2023/04/25).
      • suspect lower lobes infection or organzing pneumonia.
  • 2023-06-07 All-RAS + BRAF mutation
    • Tissue Block No: S2023-03264
    • RESULTS:
      • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
      • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-03 MRI - pelvis
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with progression .
      • No significant nodule in the liver.
      • Enlarged lymph nodes in left obturator, bilateral internal iliac regions, perirectal regions, could be due to metastatic lymph node.
      • No ascites.
      • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression.
      • R/O bilateral renal cysts.
  • 2023-04-25 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate with lung mets
    • Comparison was made with previous CT dated on 2023/02/02
      • Lungs:
        • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with CT on 2023/02/02.
        • a new solid nodule at Rt apical lung (7mm)
        • minimal subpleural fibrosis at both lower lobes and RML.
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD and right coronary arteries.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • progressive in size of infiltrative prostate tumor with adjacent organs invasion and Lt pelvic side metastatic LAP compared with previous abd. CT (2022/06/17) and MRI (2022/10/26).
        • many hepatic and renal cysts (up to 2.0cm)
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: prostate with regional organs involvement and pelvic metastatic LAP and lung metastases.
  • 2023-03-21 SONO - nephrology
    • Chronic renal parenchymal disease, mild to moderate degree
    • Bilateral renal cysts
  • 2023-03-07 ENT Hearing Test
    • Tymp: Bil type A.
    • PTA
      • Reliability FAIR
      • Average RE 29 dB HL; LE 31 dB HL.
      • RE normal to moderate SNHL.
      • LE normal to moderately severe SNHL.
  • 2023-02-02 MRI - pelvis
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. with partial response.
      • Non-enhancing nodules in bilateral kidneys (up to 2cm in left kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. With partial response.
      • R/O bilateral renal cysts.
  • 2023-02-02 CT - chest
    • Indication: Malignant poorly differentiated neuroendocrine tumors of prostate s/p C/T
    • Imp: No evidence of recurrent/residual tumor in the study.
  • 2022-10-26 CT - chest
    • Indication: Prostate NEC with rectal invasion s/p C/T
    • Comparison was made with previous CT dated on 2022/06/17
      • Lungs:
        • no interval change of a small subpleural solid nodule (7mm) at RLL-S9, a subpleural nodule (3mm) at LLL, and two subpleural solid nodules (up to 4mm) at RML as compared with previous CT on 2022/06/17.
        • minimal subpleural fibrosis at both lower lobes.
        • mild subpleural paraseptal emphysema at both apical lung regions.
      • Vessels:
        • mild calcified plaques of the LAD and right coronary arteries.
      • Visible abdominal-pelvic contents:
        • many hepatic and renal cysts (up to 2.0cm)
      • Visualized bones:
        • marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: four small lung nodules up to 7mm, stationary, some may be intrapulmonary LNs.
  • 2022-10-26 MRI - pelvis
    • Clinical history: 61 y/o male patient with Prostate NEC with rectal invasion s/p C/T.
    • With and without enhancement MRI: Pelvis
      • Prostate malignancy with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
      • Non-enhancing nodules in bilateral kidneys (up to 1.7cm in right kidney), r/o renal cysts.
    • Impression:
      • Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Stationary.
      • R/O bilateral renal cysts.
  • 2022-09-06 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Bilateral renal cysts
  • 2022-06-17 CT - abdomen, pelvis
    • Findings
      • Prior CT identifed a well-defined heterogeneous mass in between the rectum and prostage, measuring 9 cm in size, is noted again, marked decreasing in size that is c/w neuro-endocrine carcinoma S/P C/T with partial response.
      • Prior CT identified a soft tissue nodule at RLL of the lung measuring 7 x 4 mm at lung window setting is noted again, stationary. Follow up is indicated.
      • Liver and renal cysts (up to 2.0 cm).
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, and spleen.
    • Impression
      • Neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response.
  • 2022-04-08 MRI - brain
    • No evidence of intracranial lesion.
  • 2022-03-11 Pure Tone Audiometry, PTA
    • PTA
    • Reliability FAIR
    • Average RE 30 dB HL; LE 36 dB HL.
    • R’t normal to moderate SNHL.
    • L’t normal to moderately severe SNHL.
  • 2022-03-01 Patho - prostate needle biopsy
    • “pelvic tumor/peri-prostatic tumor, 9 cm with possible prostatic and recal invasion”, needle biopsy — neuroendocrine tumor.
    • IHC stains:
      • CD56 (+): neuroendocrine origin,
      • CK7 (- to equivocal), CK20 (-): dis-favor rectal adenocarcinoma,
      • vimentin (-): dis-favor sarcoma,
      • CD3 (-), CD20 (-): non-lymphoma,
      • PSA (-): non-prostatic origin.
      • Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
  • 2022-02-24 Transrectal Ultrasound of Prostate, TRUS-P
    • huge pelvic mass with suspected prostate invasion
  • 2022-02-24 Sigmoidoscopy
    • A hard, portuding lesion with intact mucosa was noted at rectum, anterior wall.
  • 2022-02-21 CT - abdomen, pelvis
    • A heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion suspected malignancy.
    • A nodule (4mm) at RLL.

[MedRec]

  • 2023-09-17 POMR Urology You Chicin
    • Course of Inpatient treatment
      • After admission, pre-operation survey was within normal range. Cystoscopic exam was smoothly done on 2023/09/18. After operation, There were no fever or infetious signs noted. We had suggested the patient to receive PCN to reserve his renal function on 09/19. However, the patient refused to receive PCN during this admission and he would like to discuss with Doctor Xia.
      • Urination was normal after removing Foley in 09/19 morning. We arranged his discharge on 2023/09/19 and his follow-up at Doctor You’s out-patient clinic on 2023/09/26.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Transamin (tranexamic acid 250mg) 1# BID
  • 2023-09-12 SOAP Nephrology Hong SiCun
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2023-08-24 ~ 2023-09-01 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~2023/07/27 (5th dose), disease progression, s/p chemotherapy with FOLFOX from 2023/08/29~
      • Chronic viral hepatitis B without delta-agent
      • Gout, unspecified
      • Essential (primary) hypertension
      • Anemia due to antineoplastic chemotherapy
      • Chronic kidney disease, stage 2 (mild)
      • Hordeolum externum right lower eyelid
      • Hypomagnesemia
      • Constipation, unspecified
    • CC
      • For further anti-cancer management
    • President illness
      • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
      • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
      • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6).
      • Brain MRI on 2022/04/08 showed no evidence of intracranial lesion.
      • The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
      • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5)(self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3), 2023/07/12(C4), 2023/07/27(C5). Taken altogether, his disease was in progression.
      • This time, he presented with right side lower eyelid redness and protrusion for 2-3days.
      • Now, he was admitted to ward for chest CT for re-staging and receive palliative chemotherapy with Topotecan(C6)(reduce Topotecan dose(total dose 1.8mg) for prevention thrombocytopenia after chemotherapy).
    • Course of inpatient treatment
      • After admission, Right side lower eyelid redness and protrusion for 2-3days was noted, consult oph for right side lower eyelid redness and protrusion evaluation, Hordeolum, od, s/p I&C with Cravit 1gtt QID od + Tetracycline oint 1qs BID od.
      • Chronic kidney disease, stage 2 (Cr.:1.52 mg/dL, BUN:26 mg/dL), given NS 500ml IVF Q8H hydration and Pentop 1# po QD, before chemotherapy.
      • Anemia due to antineoplastic chemotherapy, BT PRBC 2unit on 2023/08/24 for correction.
      • Arranged chest CT for cancer survey on 2023/08/25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases, in progression compared with CT (2023/04/25). suspect lower lobes infection or organzing pneumonia.
      • He received FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) due to disease progression, from 2023/08/29~2023/08/31(C1D1) smoothly.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H was given for nausea and vomiting.
      • Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC.
      • Gout with Feburic 80mg 0.5# po QD.
      • Hypertension with Concor 5mg/tab 1# PO QD.
      • Hypomagnesemia with Magnesium Sulfate 10%, 20mL/amp 1amp IVD BID was given for support.
      • Constipation with Through 12mg/tab 2# PO HS.
      • Post chemotherapy with Oxalip, given B-Red 1mg/mL/amp 1amp IM ST for avoid sensory peripheral neuropathies on 2023/08/31.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/09/01 and OPD followed up later.       
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Feburic (febuxostat 80mg) 0.5# QD
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Concor (bisoprolol 5mg) 1# QD
      • Through (sennoside 12mg) 2# HS
  • 2023-07-12 ~ 2023-07-16 POMR Hemato-Oncology
    • Discharge diagnosis
      • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14 to 2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan (1.5mg/m2) from 2023/05/12~    
      • Chronic viral hepatitis B without delta-agent
      • Gout, unspecified
      • Chronic kidney disease, stage 2 (mild)
      • Essential (primary) hypertension
    • CC
      • For further anti-cancer management
    • Present illness
      • This 62-year-old man patient suffered from anal protruding mass with pain and bleeding in 2022/02. The abdominal CT scan on 2022-02-21 showed a heterogeneous enhancing tumor (9cm) at pelvic cavity with rectum and prostate invasion, in addition with a suspicious metastatic nodule (4mm) at RLL. The sigmoidoscopy on 2022-02-24 showed the possibility of external compression, rectum and mixed hemorrhoid.
      • The TRUS biopsy for pelvic tumor was done on 2022-03-01 and the report of biopsy showed IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma, IHC stain: Ki-67 (90%): supporting a diagnosis of neuroendocrine carcinoma.
      • Port-A catheter insertion was done on 2022-03-11. Chemotherapy with EP (Etoposide 80mg x3 days, Carboplatin AUC:6) on 2022/03/14(C1). 2022/04/08(C2), 2022/05/16(C3), 2022/06/14(C4), 2022/07/06(C5), 2022/08/09(C6). Brain MRI on 2022/04/08 showed no evidence of intracranial lesion. The follow-up abdominal CT scan on 2022-06-17 showed neuroendocrine carcinoma with rectum and prostate invasion S/P C/T shows partial response. Then he was treated with oral etoposide.
      • The follow-up Chest CT on 2023-04-25 showed prostate with regional organs involvement and pelvic metastatic LAP and lung metastases. Pelvis MRI on 2023-05-03 showed 1. Prostate NEC with extracapsular and seminal vesicle invasion, left pelvic side wall invasion. Pelvic lymph nodes metastasis. With progression. 2. R/O bilateral renal cysts. He received chemotherapy with Topotecan (1.5mg/m2, D1~D5) (self pay) on 2023/05/12(C1), 2023/06/06(C2), 2023/06/28(C3). Taken altogether, his disease was in progression. Now, he was admitted to ward for palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12.
    • Course of inpatient treatment
      • After admitted, Palliative chemotherapy with Topotecan (C4) (reduce Topotecan dose (total dose 1.8mg) for prevention thrombocytopenia after chemotherapy) on 2023-07-12 ~ 2023-07-16.
      • Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. Chronic viral hepatitis B with Baraclude 0.5mg 1# po QDAC. Chronic kidney disease, stage 2 (mild) (Cr.:1.26mg/dL, BUN:27mg/dL) with NS 500ml IVF BID and Pentop 1# po QD. Gout with Feburic 80mg 0.5# po QD. Hypertension with Concor 5mg/tab 1# PO QD.
      • Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/16 and OPD followed up later.
    • Discharge prescription
      • Febric (febuxostat 80mg) 0.5# QD
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Acetal (acetaminophen 500mg) 1# PRNQ6H for fever, BT > 38’C or bone pain after G-CSF
      • Granocyte (lenograstim 250ug) QD SC on 2023/07/20, 2023/07/21, 2023/07/22
  • 2023-06-13 SOAP Nephrology
    • S: UPCR < 0.1 -> 1.71 -> 1.43
    • Prescription x3
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-11-01 SOAP Nephrology
    • S: UPCR < 0.1
      • ChatGPT:
        • In the medical context, UPCR stands for Urine Protein to Creatinine Ratio. This is a test often used to estimate the amount of protein being excreted in the urine, and to assess and monitor kidney function.
        • Proteinuria (protein in the urine) is a common finding in many renal diseases. Creatinine, on the other hand, is a waste product that’s typically excreted at a constant rate.
        • The ratio of protein to creatinine can provide a good estimate of protein excretion over 24 hours without needing a 24-hour urine collection. High levels of protein in the urine, indicated by a high UPCR, can be a sign of kidney disease.
    • Prescription x2
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-10-04 SOAP Nephrology
    • S: Cr 1.89, add Trental (pentoxifylline) and follow up one month
    • Prescription
      • Pentop (pentoxifylline 400mg) 1# QD
  • 2022-09-06 SOAP Nephrology
    • S
      • CKD for follow up
      • r/o carboplatin associated kidney injury, suggest follow up at regular interval
    • A/P
      • Admission for C/T EP on 2022-07-06. Using carboplatin due to impaired renal function
      • NEC, Stage IV
  • 2022-07-27 SOAP Hemato-Oncology Xia HeXiong
    • Admission for C/T EP (Carboplatin) on 2022-08-03. Using carboplatin due to impaired renal function
    • Considered hold platinum after 6 cycles of chemotehrapy, and might shift IV VP-16 to oral VP-16 after 6 cycles of EP on 2022-08-03
    • NEC, Stage IV
    • Avoid K+ food

[consultation]

  • 2023-08-24 Ophthalmology
    • Q
      • The patient is an 62-year-old male with a history of Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy with Etoposide/Carboplatin from 2022/03/14~2022/08/09 for 6 cycles with extracapsular, seminal vesicle and left pelvic side wall invasion and pelvic lymph nodes metastases s/p chemotherapy with Topotecan(1.5mg/m2) from 2023/05/12~, HTN, Chronic kidney disease, stage 2.
      • He presented with lower eyelid redness and protrusion for 2-3days, we need your further evaluation and management.
    • A
      • For right lower eyelid swelling
      • S
        • Past hx:
          • Neuroendocrine carcinoma with rectum and prostate invasion and lung metastasis, Stage IV s/p chemotherapy
          • HTN
          • Chronic kidney disease, stage 2
        • OPH hx: dneied
        • NKDA
      • O
        • nVA: 20/25 ou
        • PT: 13/14mmHg
        • pupil: 3mm, +/+, no RAPD
        • Hordeolum at right lower eyelid
        • K: cl ou
        • AC: D/C ou
        • lens: NS+ ou
      • A:
        • Hordeolum, od, s/p I&C
      • P:
        • pressure patch for 30mins, avoid water contact
        • Cravit 1gtt QID od + Tetracycline oint 1qs BID od
        • pus culture has been arranged
        • Inform the risk of progression, come back earlier if s/s worsen
        • OPD f/u
  • 2022-05-10 Oral and Maxillofacial Surgery
    • Q
      • The 61y/o male has neuroendocrine carcinoma under chemotherapy. He has toothache at the second to last molar on the lower right. He took amoxicillin for 2-3 days, but in vain, so we need your help for management. Thanks!
    • A
      • Dear doctor, this is a 61-year-old male iwth neuroendocrine carcinoma and was admitted for chemotherapy.
      • He complained of biting pain recently and we are therefore consulted
      • After examiantion (radiologic study), fractured root of right lower first molar was noted
      • Assessment:
        • Tooth fractureo of #46
      • Plan:
        • Explain the findings to the patient and his family members
        • Premedication (Continue using the current inpatient antibiotic, Augmentin.)
        • Arrange extraction of tooth 46 on Thursday (05/12) in the morning.

[surigcal operation]

  • 2023-09-18
    • Surgery: Cystoscopic exam
    • Finding
      • enlarged prostate
      • tumor invasion of bladder neck
      • bilateral UO could not be found due to tumor invasion

[chemotherapy]

  • 2023-10-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 400mg/m2 740mg NS 250mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-27 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-07-12 - topotecan 1.5mg/m2 1.8mg NS 60mL 30min D1-5 (even lower topotecan)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-06-28 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-2 + topotecan 1.5mg/m2 1.8mg NS 60mL 30min D3-5 (reduce dose for prevention thrombocytopenia after chemotherapy)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-06-06 - topotecan 1.5mg/m2 2.0mg NS 60mL 30min D1-5 (lower topotecan)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2023-05-12 - topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-5
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-5
  • 2022-08-09 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-07-06 - etoposide 80mg/m2 140mg 1hr D1-3 + carboplatin AUC 6 450mg 2hr D1
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-14 - etoposide 80mg/m2 137mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-16 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-04-07 - etoposide 80mg/m2 139mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-14 - etoposide 80mg/m2 140mg 1hr D1-3 + cisplatin 25mg/m2 40mg 24hr D1-3
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-13

According to the PharmaCloud database, there are no recent records of the patient seeking services from other medical facilities. In addition, Pentop (pentoxifylline) prescribed by our nephrologist on 2023-09-12 is currently being used without any discrepancies noted.

The 5FU bolus was omitted from the FOLFOX regimen during this hospital stay due to a reduced WBC count, recorded at 3.08K/uL on 2023-10-12.

2023-09-21

According to PharmaCloud, there are no records of this patient seeking medical care at other facilities in the past three months. Our nephrologist has issued a repeat prescription for Pentop (pentoxifylline) to manage his CKD, and the medication is currently being used with no discrepancies identified.

2023-07-28

[reconciliation]

On 2023-07-07, the patient renewed prescriptions for bisoprolol and valsartan. Currently, only bisoprolol is listed as an active medication, and valsartan has not been included. As the patient’s blood pressure has consistently remained within the normal range during this hospital stay, there may not be an immediate need to reintroduce valsartan. Nevertheless, it is crucial to continue monitoring the patient’s blood pressure to assess if any further adjustments to the medication regimen are necessary.

[renal function follow-up]

This month (July), compared to previous months, the serum creatinine has returned to the normal range, and currently, no medications require renal dosage adjustment.

[thrombocytopenia]

Since starting topotecan on 2023-05-12, the patient has experienced several episodes of thrombocytopenia. Blood transfusions were administered on 2023-06-14, 2023-06-28, and 2023-07-27 in response to these events. In addition, the dosage of topotecan was sequentially reduced from 2.5 mg to 2.0 mg and then to 1.8 mg. Despite these measures, thrombocytopenia has been observed to date, but no PLT less than 50K/uL has been observed.

2023-07-25 PLT 90 10^3/uL
2023-07-11 PLT 94
10^3/uL
2023-06-28 PLT 474 10^3/uL
2023-06-20 PLT 89
10^3/uL
2023-06-12 PLT 390 10^3/uL
2023-06-01 PLT 95
10^3/uL
2023-05-25 PLT 15 10^3/uL
2023-05-10 PLT 283
10^3/uL
2023-04-27 PLT 244 *10^3/uL

2023-07-13

[reconciliation]

The patient recently renewed his prescriptions for bisoprolol and valsartan on 2023-07-07. Currently, only bisoprolol is incorporated into the active medication list, while valsartan has been left out. Given that the patient’s blood pressure measurements have consistently fallen within the normal spectrum during this hospital stay, reintroduction of valsartan may not be mandatory at this point. However, it remains important to continually monitor the patient’s blood pressure to establish whether further alterations in his medication regimen are warranted.

2023-06-29

[reconciliation]

  • This patient regularly renews his prescriptions for Biso (bisoprolol) and Dafiro (valsartan, amlodipine) for his primary hypertension at a local pharmacy. Currently, the patient is only prescribed Concor (bisoprolol), with valsartan and amlodipine excluded. As the patient’s blood pressure readings have remained within the normal range during this hospitalization, it may not be necessary to reintroduce valsartan and amlodipine at this time. However, it is prudent to continue to monitor the patient’s blood pressure to determine if further adjustments to his medication regimen are necessary.

[thrombocytopenia]

  • This patient initiated topotecan therapy on 2023-05-12, with two additional cycles administered on 2023-06-06 and 2023-06-28. The platelet levels are compiled in the following table, where “*” represents PLT < 100K/uL and “**” represents PLT < 50K/uL.

    • 2023-06-28 PLT 474 x10^3/uL
    • 2023-06-20 PLT 89 x10^3/uL *
    • 2023-06-12 PLT 390 x10^3/uL
    • 2023-06-01 PLT 95 x10^3/uL *
    • 2023-05-25 PLT 15 x10^3/uL **
    • 2023-05-10 PLT 283 x10^3/uL
  • Intravenous Topotecan is linked with a considerable incidence of thrombocytopenia. As per UpToDate, Grade 4 thrombocytopenia occurs in 27% to 29% of patients. The lowest point (nadir) typically occurs around day 15, and the duration of the thrombocytopenia typically lasts for 3 to 5 days.

  • The dose of topotecan was reduced from 2.5g to 2.0g starting from the second cycle and was further reduced to 1.8g for the last three days of the five-day administration period. This was a strategy intended to prevent further thrombocytopenia in the patient. In addition, blood transfusions were conducted on 2023-06-14 and 2023-06-28 to alleviate the impact of this side effect.

  • Currently, the patient’s platelet count (PLT) is slightly above the ULN. Although there are no current signs of thrombocytopenia, it remains critical for the healthcare team to regularly monitor the patient’s CBC as is standard procedure.

2023-06-07

[reconciliation]

  • This patient recently visited a local clinic on 2023-06-05 for acute tonsillitis and was prescribed cimetidine, acetaminophen, fenoterol, glycyrrhiza extract, and cetirizine. In addition, he was prescribed mefenamic acid and cresolsulfonate for his acute upper respiratory tract infection on 2023-06-01, with each prescription having a short duration of only 3 days. Since there are no related symptoms listed in the admission note or current medical problem list, there appear to be no medication reconciliation issues for these conditions.
  • In addition, the patient’s prescription for bisoprolol and valsartan for hypertension management was refilled on 2023-04-28 at a local pharmacy. Currently, valsartan is not listed on the active medication list, but according to the TPR panel, the patient had no record of elevated blood pressure during this hospitalization. Therefore, there is no evidence that the current regimen of Concor (bisoprolol 5 mg) 1# PO is inappropriate.

[assessment]

  • As the patient’s renal function is compromised, with a Cockcroft-Gault formula calculated CrCl of 44 mL/min, a review of the need of adjustment to the topotecan dose should be considered.
    • 2023-06-01 Creatinine 1.51 mg/dL
    • 2023-06-01 eGFR 50.02
    • 2023-06-01 BUN 39 mg/dL
  • Suggestions for modifying topotecan dosage:
    • Manufacturer’s labeling (calculate CrCl with Cockcroft-Gault method using ideal body weight): CrCl >= 40 mL/minute: No dosage adjustment necessary.
    • Kintzel 1995: CrCl 46 to 60 mL/minute: Administer 80% of usual dose.
    • O’Reilly 1996b: CrCl >= 40 mL/minute: No dosage adjustment necessary in minimally pretreated patients; however, due to an increased potential for dose-limiting toxicities, reduce the dose from 1.5 mg/m2 to 1 mg/m2 in heavily pretreated patients.
  • The dose of Topotecan given this time has been decreased by 20% from the 1.5mg/m2 administered on 2023-05-12. The current dosage appears to be without issue.

2022-08-10

  • 2022-08-09 blood creatinine 1.66 mg/dL => CrCl 40 mL/min
  • Etoposide for patients with CrCl 15 to 50 mL/minute: Administer 75% of normal dose.
  • Entecavir for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.

701090824

231013

[exam findings]

  • 2023-09-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, mild AR, mild TR
      • Impaired LV relexation
      • Preserved RV systolic function
  • 2023-08-09 PET
    • Glucose hypermetabolism in the left pleura and left pleural effusion, compatible with the metastatic sarcoma.
    • Glucose hypermetabolism in bilateral pulmonary hilar and mediastinal lymph nodes, the nature is to be determined (reactive or metastatic lymph nodes or other nature ?). Please correlate with other clinical findings for further evaluation.
    • Several small nodular lesions in the right middle and right lower lungs show no increased FDG uptake, suggesting no evidence of tumor metastasis by this F-18 FDG PET scan.
  • 2023-08-04 Patho - pleural/pericardial biopsy
    • Pleura, left, decortication — metastatic sarcoma
    • Sections show fibroadipose tissue with round tumor cells arranged in reticular network of lace-like strands and cords within myxoid stroma.
    • The immunohistochemical stains reveal CK(-), EMA(-), Vimentin(+), CD34(-), TTF-1(-), and S-100(focal +). The mucicarmine special stain is positive. The morphology is compatible with metastatic myxoid sarcoma.
  • 2023-08-01 CT - chest
    • left remnant lung fibrosis with volome loss and massive Lt pleural effusion, increased volume of pleural effusion.
    • nodular parietal or extrapleural fat space thickening.
    • suspect metastatic nodules in Rt lung.
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2023-05-02 CT - chest
    • left remnant lung fibrosis with volome loss and moderate Lt pleural effusion, increased volume of pleural effusion
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2023-03-23 Bronchodilator Test
    • mild restrictive ventilatory impairement, FEV1/FVC= 82%, FVC = 75%, FEV1= 78%, positive for provocation
    • negative for provocation
    • without significant reversibility
  • 2023-01-31 CT - chest
    • left remnant lung fibrosis with volome loss and small Lt pleural effusion, stable, post treatment related?
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2022-10-25 CT - chest
    • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion, stable.
    • suspect mild fibrosis at RLL and RUL, stable.
  • 2022-07-26 CT - chest
    • left remnant lung fibrosis with volome loss, post treatment related? and small Lt pleural effusion.
    • suspect mild fibrosis at RLL and RUL.
  • 2022-04-26 CT - chest
    • left remnant infection or inflammation (drug-related disease?)
    • with small Lt pleural effusion.
    • suspect mild fibrosis at RLL and RUL.
  • 2022-01-18 PET
    • Glucose hypermetabolism in the left lateral chest wall and posteromedial aspect of left lung. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in the right pulmonary hilar region and a mediastinal lower right paratracheal lymph node. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-01-17 MRI - brain
    • No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2021-09-29 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2021-12-29 Patho - lung total/lobe/segmental
    • Diagnosis
      • Lung, left lower lobe, VATS lobectom — Pulmonary myxoid sarcoma, FNCLCC grade 2
      • Lymph node, LN 5, left. dissection — Negative for malignancy (0/4)
      • Lymph node, LN 7, left. dissection — Negative for malignancy (0/7)
      • Lymph node, LN 9, left. dissection — Positive for tumor (3/3)
      • Lymph node, LN 11, left. dissection — Positive for tumor (2/2)
      • Lymph node, LN 12, left. dissection — Positive for tumor (1/2)
      • TNM Pathology stage: pT1N1(if cM0); AJCC prognostic stage: There is no recommended prognostic grouping at this time.
    • Immunohistochemical study: CK(-), EMA(-),CK(-), CK7(-), CK20(-), Vimentin (+), CD34(-), SMA(-), TTF-1(-), S100(-), Napsin A(-).

[MedRec]

  • 2023-08-22 SOAP Hemato-Oncology Xia HeXiong
    • S: For further management of the disease
      • Right hip chondrosarcoma 14 years ago, s/p OP, s/p R/T
      • Pulmonary myxoid sarcoma, Left lung, FNCLCC grade 2, s/p OP, s/p R/T
      • Metastatic sarcoma s/p decortication on 2023-08-02
    • A/P: Because R/T to residual metastic sarcoma of right lung is not feasible, palliative C/T with IA/IE will be considered. Arrange heart echo.
  • 2023-08-01 ~ 2023-08-11 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Left pleural effusion, suspect tumor recurrence status post thoracoscopis decortication of pleura on 2023-08-02
      • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
      • Hypertensive heart disease with heart failure
    • CC
      • progressing dyspnea for one month
    • Present illness
      • This 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29 and radiotherapy.
      • According to the patient himself, he suffered from left chest pain after the operation, sometimes radiated to back, neck, and head. He took pain-killer if needed for almost two years. In the rescent one month, he had progressing dyspnea. Accompanied with poor appetite, body weight loss 5kg in one month was also told. He also complaint about constipation.
      • He was under regular follow up at chest and CS OPD, CT done on 2023-08-01 showed left remnant lung fibrosis with volome loss and massive left pleural effusion, increased volume of pleural effusion, nodular parietal or extrapleural fat space thickening, suspect metastatic nodules in right lung.
      • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for thoracoscopis decortication of pleura on 2023-08-02.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of thoracoscopis decortication of pleura was performed smoothly on 8/2. No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cmH2O and left pig-tail were done.
      • Tumor recurrence was suspected so Hema doctor was consulted. The chest tube was removed on 8/7 and the pig-tail was removed on 8/11 before discharge. The pathology report revealed metastatic sarcoma. PET scan showed glucose hypermetabolism in the left pleura and left pleural effusion, bilateral pulmonary hilar and mediastinal lymph nodes, suspect metastatic sarcoma.
      • We followed up chest x-ray which revealed improvement of left pleural effusion. Under stable condition, he discharged today and CS, HEMA OPD follow up were arranged.
    • Discharge Prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Sindine (povidone iodine aq soln) 1# QD
      • MgO 250mg 1# TID
      • Actein 200mg 1# TID
  • 2022-03-28 SOAP Radiation Oncology Chang YouKang
    • RT dose: 6600cGy/33 fractions (6 MV photon) to LLL sacrcoma bed, bronchial stump & lymphatics, 2022/02/07 to 3/28.
    • RT Side effect evaluation, 3/28: Radiation dermatitis, grade 0; N/V, grade 0; esophagitis, grade 0; pneumonitis, grade 0.
    • Plan: Adjuvant RT finishes today.
  • 2022-01-17 SOAP Radiation Oncology Chang YouKang
    • O: Conclusion of Multidisciplinary Cancer Team Meeting, Meeting Date: 20220111
      • Suggest adding a PET scan.
    • IMP:
      • Pulmonary myxoid sarcoma, FNCLCC grade 2 with group 9, 11, 12 LN metastasis (6+/18) s/p LLL lobectomy and LN dissection on 2021/12/29.
      • Favoring second primay malignancy.
    • Plan:
      • Adjuvant RT to LLL bronchus and regional lymphatics for 6600cGy/33 fractions is suggested for locoregional control.
      • CT simulation on 2/08 13:30. Possible esophagitis and pneumonitis is told. Diet education.
  • 2022-01-13 SOAP Thoracic Surgery Xie MinXiao
    • A: Pulmonary myxoid sarcoma, FNCLCC grade 2. Primay or meta.??
    • P: refer to radio-oncologist for adjuvant RT.
  • 2021-12-28 ~ 2021-12-31 POMR Thoracic Surgery Xie MinXiao
    • Discharge diagnosis
      • Left lower lung carcinoma status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29
      • Hypertensive heart disease with heart failure
      • Hyperlipidemia, unspecified
    • CC
      • Left chest wall pain and coughing intermittently.
    • Present illness
      • This 67-year-old man with a history of hypertension and hyperlipidemia under medication control.
      • According to the patient complained of he finished the COVID-19 vaccine on 2021/10/26. Because of general malaise,so he went to the emergency room of MacKay memorial hospital for medical treatment. Chest CT showed lung nodule in left lower lobe and biopsy showed chronic imflamation in MacKay memorial hospital.
      • He because have ​left chest wall pain and coughing intermittently, so he refer to chest surgeon for further evaluation and treatment.
      • After discussing with the patient and his family on the benefits of surgical treatment as well as subsequent risks and possible complications, he was admitted for VATS left lower lobe wedge and lymph node dissection under lung nodule in left lower lobe.
    • Course of inpatient treatment
      • After admission, pre-op assessment was done. Operation of video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis at 2rd admission day (2021/12/29). No complication was noted. Prophylactic antibiotics was prescribed for 1 day. Left chest tube with LPS -18 cm H2O was done. Chest tube was removed at post-op 2rd day. He was discharged under stable hemodynamics at post-op 2th day. Continue to follow up at the chest surgical clinic.
    • Discharge prescription
      • Actein (acetylcysteine 200mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Deflam-K (diclofenac 25mg) 1# TID
      • MgO 250mg 1# TID
  • 2021-12-18, 2018-08-04, -08-30 SOAP Orthopedics Yao DingGuo
    • Diagnosis: Malignant bone neoplasm, lower limb, short bones [C40.20]

[consultation]

  • 2023-08-04 Hemato-Oncology
    • Q
      • This is a 69-year-old man with the history of hypertension, heart failure and hyperlipidemia under medication control. Left lower lung pulmonary myxoid sarcoma, FNCLCC grade 2 status post video-assisted thoracic surgery left lower lung lobectomy and radical lymph node dissection and pneumolysis on 2021-12-29. He also underwent radiotherapy.
      • This time, he was admitted for thoracoscopis decortication of pleura on 2023-08-02 due to pleural effusion, suspect tumor recurrence. Multiple tumor seeding over left pleural cavity and pericardium was found. Bloody effusion was noted about 1650mL. We plan to remove chest tube and arrange PET scan next week. We need your help for further evaluation and treatment suggestion. Thank you very much.
    • A
      • Primary pulmonary sarcoma is extremely rare and mostly metastatic, and primary pulmonary myxoid sarcoma PPMS is a rare low-grade malignant sarcoma.
      • Suggestion:
  • Pending pathology result (Recurrent? De novo?).
  • We will follow up this case. Thanks for your consultation.

[surgical operation]

  • 2023-08-02   - Op Method: VATS decortication+ close drainage.
    • Finding:
      • Multiple tumor seeding over left pleural cavity and pericardium. Bloody effusion was noted about 1650mL.
      • One 28 Fr. straight chest tube was inserted via left 8th ICS, another one pig-tail was inserted via left 7th ICS.
  • 2021-12-29
    • Op Method: VATS LLL lobectomy + RLND + pneumolysis .
    • Finding:
      • One tumor mass was noted over LLL, size about 3.0cm in diameter.
      • Some adhesion was noted over left pleural cavity, especially around the tumor site.
      • Frozen section: carcinoma.
      • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[radiotherapy]

[chemotherapy]

  • 2023-09-04 - mesna 800mg NS 250mL 1hr (before ifosfamide) D1-5 + ifosfamide 1500mg/m2 2400mg NS 500mL 1hr D1-5 + doxorubicin 37.5mg/m2 60mg NS 500mL 24hr D1-2 + mesna 800mg NS 250mL (4hr after finishing ifosfamide) D1-5 + mesna 800mg NS 250mL (8hr after finishing ifosfamide) D1-5
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1 + NS 250mL D1-5 + aprepitant 125mg PO D1-3

==========

2023-10-13

[reconciliation]

The patient was prescribed a 28-day course of Concor (bisoprolol) and Livalo (pitavastatin) at Taipei City Hospital on 2023-09-27. While the former is currently being administered, the latter does not appear on the list of active medications. Please verify that the use of pitavastatin is no longer necessary.

[hypercalcemia]

Observed hypercalcemia warrants an evaluation of the PTH level to assess the likelihood of hyperparathyroidism.

  • 2023-10-13 Ca (Calcium) 4.07 mmol/L
  • 2023-10-12 Ca (Calcium) 3.85 mmol/L
  • 2023-08-01 Ca (Calcium) 3.11 mmol/L

Recommended Actions:

  • Hydration with Isotonic Saline: Replenishes intravascular volume and enhances the excretion of calcium in the urine.
  • Calcitonin Administration: Disrupts bone resorption by interfering with osteoclast activity and encourages the excretion of calcium in the urine.
  • Loop Diuretic Usage: Amplifies the excretion of calcium in the urine by inhibiting its reabsorption in the loop of Henle.
  • Glucocorticoid Therapy: Reduces the absorption of calcium in the intestines and curtails the production of 1,25-dihydroxyvitamin D by activated mononuclear cells in patients suffering from granulomatous diseases or lymphoma.

If the initial interventions are ineffective, the following alternatives could be contemplated:

  • Bisphosphonate: Disrupts bone resorption by interfering with the recruitment and functionality of osteoclasts.
  • Calcimimetic: Acts as an agonist for calcium-sensing receptors, diminishing PTH (useful in cases of parathyroid carcinoma or secondary hyperparathyroidism in CKD).
  • Denosumab: Curbs bone resorption through the inhibition of RANKL.

2023-09-21

[pancytopenia]

Pancytopenia was noted in mid-Sep, likely attributed to the initiation of the doxorubicin + ifosfamide regimen on 2023-09-05, approximately 10 days after its commencement. Following treatment with a blood transfusion on 2023-09-18, and the initiation of a consecutive 5-day course of Granocyte (lenograstim) on the same day, pancytopenia has shown successful improvement.

2023-09-20 WBC 3.63 x10^3/uL
2023-09-18 WBC 0.20 x10^3/uL 2023-09-15 WBC 0.66 x10^3/uL 2023-09-11 WBC 8.43 x10^3/uL
2023-09-01 WBC 8.80 x10^3/uL

2023-09-20 HGB 10.3 g/dL 2023-09-18 HGB 7.4 g/dL ** 2023-09-15 HGB 9.4 g/dL * 2023-09-11 HGB 10.9 g/dL 2023-09-01 HGB 13.2 g/dL

2023-09-20 PLT 138 10^3/uL 2023-09-18 PLT 25 *10^3/uL ** 2023-09-15 PLT 65 *10^3/uL ** 2023-09-11 PLT 141 10^3/uL 2023-09-01 PLT 259 *10^3/uL

700575779

231009

[exam findings]

  • 2023-09-28 L-spine flex. & ext. (including sacrum)
    • Presence of spondylolisthesis at L3/4, L4/5, grade I.
  • 2023-09-28 C-spine flex. & ext. view
    • There is no evidence of spondylolisthesis or subluxation
  • 2023-09-13 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/06/09.
      • Prior CT identified malignant lymphoma (confluent lymphadenopathy) in the abdomen and pelvis, encasing all visceral artery and vein, are noted again, decreasing in size that is c/w lymphoma S/P C/T with partial response.
      • Prior CT identified lymphoma 2.8 cm in S8/4 of the liver dome is noted again, decreasing in size to 1.2 cm that is c/w liver lymphoma S/P C/T with partial response.
      • Prior CT identified splenomegaly (the greatest anterior-posterior dimension: 14 cm) is noted again, mild decreasing in size to 12 cm.
    • Impression:
      • Malignant lymphoma S/P C/T show partial response.
      • Liver and spleen lymphoma S/P C/T show partial response.
  • 2023-09-11 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-07-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 18) / 81 = 77.78%
      • LVEF (%) = 78
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Normal LV diastolic function.
      • Normal RV systolic function.
      • Mild MR; trivial TR.
  • 2023-07-13 EGD
    • Reflux esophagitis LA Classification grade A
    • Bile reflux
    • Superficial gastritis
  • 2023-06-15 PET
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm.
    • Increased FDG uptake in some focal areas in both lobes of the liver and in a focal area in the left lobe of the thyroid gland. Lymphoma involving the liver and left lobe of the thyroid gland should be considered. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mildly increased FDG uptake in some focal areas in the spleen and in the bone marow of the skeleton. Lymphoma involving the spleen and bone marrow can not be ruled out.
  • 2023-06-15 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy— Positive for B cell lymphoma
    • Microscopically, it shows aggregations of B lymphomatous cells. .
    • Immunohisotchemical stain reveals CD34(-), CD117(-), CD20 (l+), CD138 (focal +, 1~2%), MPO(+), CD71(+ at erythroid cells), CD10(+), TdT(-), CD61(+ at megakaryocytes).
  • 2023-06-14 Patho - peritoneum biopsy
    • Lymph node, abdomen, CT-guide biosy — follicular lymphoma with focal high grade transformation
    • Section shows predominent small to medium sized lymphoid cells with focal large lymphoid cells (mainly in one strip).
    • The immunohistochemical stains of small to medium sized lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(+), BCL2(+), BCL6(-), and Cyclin D1(-).
    • The immunohistochemical stains of large lymphoid cells reveal CD3(-), CD5(-), CD20(+), CD10(-), BCL2(+), BCL6(+), Cyclin D1(-), MUM1(+), C-MYC(-), and Ki-67 is about 50%.
  • 2023-06-09 CT - abdomen
    • Findings:
      • There is huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Please correlate with PET scan.
      • There is a poor enhancing mass 2.8 cm in S8/4 of the liver dome that may be liver lymphoma. Please correlate with MRI.
      • There is splenomegaly and the greatest anterior-posterior dimension measuring about 14 cm.
        • Lymphoma with spleen involvement is highly suspected.
      • Left side Pleura effusion is noted.
      • There is mild ascites in the cul-de-sac.
    • Impression:
      • Malignant lymphoma is highly suspected. Please correlate with PET scan.
      • Liver and spleen lymphoma is also suspected.
  • 2023-06-09 SONO - nephrology
    • Interpretation:
      • Mild bilateral hydronephrosis
      • Splenomegaly
      • Gall stones
      • Ascites
      • r/o abdominal mass lesion with bilateral ureter compression
    • Suggestion:
      • Contrast CT scan for further investigation
  • 2023-05-12 Gynecologic ultrasonography
    • Findings
      • Uterus Position : AVF
        • Size: 72 * 43 mm
        • Myometrum: Anterior/Posterior wall: / cm
        • Myoma: Myoma: 19 x 17 mm ,
        • Congenital Anomaly:
      • Endometrium:
        • Thickness: 9.7 mm , Fluid: , Type:
        • Endometrial polyp: * mm , Doppler Flow : S/D: RI:
      • Adnexae:
        • ROV:
          • SIZE: 24 * 22 mm , Doppler Flow : S/D: RI: * mm
        • LOV:
          • SIZE: * mm , Doppler Flow : S/D: RI: * mm
        • FOLLICLE R:
        • FOLLICLE L:
      • CUL-DE-SAC: with fluid
      • Other: LT adnexae:free
    • IMP: Uterine myoma

[MedRec]

  • 2023-06-13 ~ 2023-06-19 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Follicular lymphoma with multiple lymph nodes on both sides of the diaphragm, liver and left lobe of the thyroid gland, spleen and bone marrow, Lugano stage at least III, FLIPI score:2 ,Intermediate Risk, PS:0
      • COVID-19, virus identified
      • Low back pain
    • CC
      • left flank pain for one week and body weight loss 4kg in one month.
    • Present illness
      • This 50 year-old denied any systemic disease before. She had suffered from left flank pain for one week and also body weight loss 4kg in one month. Therefore, she came to nephrology OPD for help on 2023/06/09.
      • Renal echo showed: 1) Mild bilateral hydronephrosis, 2) Splenomegaly, 3) Gall stones, 4) Ascites5. r/o abdominal mass lesion with bilateral ureter compression.
      • CT of abdominal was performed on 2023/06/09 which revealed A huge mass (confluent lymphadenopathy) in the abdomen and pelvis, measuring 22 cm (the largest dimension), with encasing all visceral artery and vein that is c/w lymphoma. Malignant lymphoma is highly suspected. Liver and spleen lymphoma is also suspected.
      • She was referred to ONC OPD today and was admitted for further management
    • Course of inpatient treatment
      • After admission, CT guide biopsy on 2023/06/14 showed follicular lymphoma with focal high grade transformation. Bone marrow aspiration and biopsy on 2023/06/15 and pending. PET scan on 2023/06/15 showed there was increased FDG uptake in some focal areas in both lobes of the liver, in a focal area in the left lobe of the thyroid gland, in some focal areas in the spleen and in the bone marow of the skeleton.
      • Pain control with Sketa 1 tab Q8H. However, sorethroat and cough with sputum was noted on 2023/06/18 and the Covid-19 showed positive. We applied the Paxlovid for 5days since 6/19.
      • With the relatively stable condition, she was discharged on 2023/06/19 and will OPD follow up later.
    • Discharge prescription
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Actein Effervescant (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQID
  • 2023-06-13 SOAP Hemato-Oncology Gao WeiYao
    • O: 2023/06/09 CT: ABD - whole abdomen, pelvis
      • Malignant lymphoma (10x17 cm) is highly suspected. Please correlate with PET scan.
      • Liver and spleen lymphoma is also suspected.

[immunochemotherapy]

  • 2023-10-06 - rituximab 375mg/m2 690mg NS 500mL D1 + cyclophosphamide 750mg/m2 1380mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-09-11 - rituximab 375mg/m2 685mg NS 500mL D1 + cyclophosphamide 750mg/m2 1375mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-08-17 - rituximab 375mg/m2 700mg NS 500mL D1 + cyclophosphamide 750mg/m2 1400mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-24 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + doxorubicin 50mg/m2 90mg NS 50mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CHOP Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-07-03 - rituximab 375mg/m2 680mg NS 500mL D1 + cyclophosphamide 750mg/m2 1360mg NS 250mL D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg PO D1 + NS 250mL D1-2 + palonosetron 250ug D2

==========

2023-10-09

Based on the PharmaCloud database, the patient has no records of visiting other clinics. Additionally, after consultations in our medical departments, no repeat prescriptions were issued, and no medication discrepancies were identified.

On 2023-09-13, a CT scan indicated a partial response after the patient underwent 4 treatment cycles (1 R-COP followed by 3 R-CHOP). The treatment appears to remain effective to date.

700720541

231006

[lab data]

2023-02-14 Anti-HBc Nonreactive
2023-02-14 Anti-HBc-Value 0.14 S/CO
2023-02-14 Anti-HBs 0.00 mIU/mL
2023-02-14 Anti-HCV Nonreactive
2023-02-14 Anti-HCV Value 0.06 S/CO
2023-02-14 HBsAg Nonreactive
2023-02-14 HBsAg (Value) 0.33 S/CO

[exam findings]

  • 2023-05-04 Patho - uterus with or without SO non-neoplastic/prolapse Y1
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma
      • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
      • Cervix, uterus, ditto — Stromal invasion
      • Ovary, left, ditto — Free of tumor invasion
      • Fallopian tube, left, ditto — Free of tumor invasion
      • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/8)
      • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/7)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/3)
      • Lymph node, R’t oburator, ditto — Tumor metastasis (0/7)
      • Lymph node, L’t paraaortic, ditto — Free of tumor metastasis (0/2)
      • Lymph node, R’t paraaortic, ditto — Free of tumor metastasis (0/7)
      • Parametria, bilateral — Free of tumor invasion
      • Omentum, partial omentectomy — Free of tumor invasion
      • AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: radical hysterectomy
      • Specimens include: uterus with bilateral adnexa, partial omentum, pelvic and paraaortic lymph nodes
      • Specimen size:
        • uterus: 6.7 x 5.2 x 5.0 cm in size, 72 gm in weight
        • right ovary: 1.8 x 1.6 x 0.7 cm
        • left ovary: 1.9 x 0.9 x 0.6 cm
        • right fallopian tube: 6.3 cm in length, 0.4 cm in diameter
        • left fallopian tube: 5.5 cm in length, 0.5 cm in diameter
      • Tumor site: low uterine segment
      • Tumor size: 3.7 x 2.7 x 2.4 cm
      • The myometrium: 1.2 cm in thickness, tumor invasion less than half thicknes
      • The cervix: endocervical stroma is invaded by tumor
      • Bilateral adnexa: no remarkable change
      • Omentum: 5.5 x 4.5 x 1.0 cm, no remarkable change
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs, right obturator LNs, L’t paraaortic LNs and R’t paraaortic LNs
      • Representative sections as A: L’t iliac LNs, B: L’t obturator LNs, C: R’t iliac LNs, D: R’t obturator LNs, E: L’t paraaortic LNs, F: R’t paraaortic LNs, G1: R’t F-tube, G2: R’t ovary, G3: L’t F-tube, G4: L’t ovary, G5: R’t parametrium, G6: L’t parametrium, G7-G8: uterine corpus to cervix, G9-G15: tumor, G16: cervix and H: omentum
    • MICROSCOPIC EXAMINATION
      • Histology type: endometrioid undifferentiated carcinoma
      • Histology grade: undifferentiated
      • Depth of invasion: less than half thickness of myometrium
      • Lymphovascular invasion: Not identified
      • The cervical stroma involvement: Present
      • Resection margins of the cervix: Free, 1.7 cm away from tumor
      • Additional pathologic findings: moderate tumor-infiltrating lymphocytes
      • Lymph nodes: free of tumor metastasis (0/35) in total number
      • Vaginal stump: free of tumor invasion
      • Perineural invasion: Not identified
      • Ascites: Negative for malignancy
      • Immunohistochemistry: CK7(+), PAX-8(+), Vimentin(+), ER(+), P16(-), P40(-) and P53(wild type) for tumor
  • 2023-04-20 MRI - pelvis
    • Findings: Soft tissue tumor in the uterine cervical region, regression size (from 4.8cm to 3cm) as compare with MRI study on 2023-02-09. Clinical biopsy proven cervical malignancy.
    • Impression: Cervical malignancy with regression size.
  • 2023-02-20 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 26 dB HL; LE 13 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to mild mixed type HL.
  • 2023-02-09 MRI - pelvis
    • Finding: Soft tissue tumor in the uterine cervical region, 4.8cm. Clinical biopsy proven cervical malignancy.
    • Imaging Report Form for Cervical Carcinoma
      • Impression ( Imaging stage ) : T:T1b3(T_value) N:N0(N_value) M:M0(M_value) STAGE IB3 (Stage_value)
    • Impression: Cervical malignancy, cstage T2a2N0M0.
  • 2023-01-31 CT - abdomen
    • Finding: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma.
    • Impression: Cervical region tumor, myoma?
  • 2023-01-30 Patho - cervix biopsy
    • Labeled as “cervix”, biopsy — poorly differentiated carcinoma.
    • Section shows poorly differentiated carcinoma with solid nests and papillary-like structures.
    • IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
  • 2023-01-30 Gynecologic ultrasonography
    • A mass:47x31mm, RI:0.59

[MedRec]

  • 2023-07-07 SOAP Rheumatology Chen JunXiong
    • S: 2023 0707 urticaria flare last day first attack over limbs, trunk, under regular chemothrapy
    • O: acute urticaria
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# HS
      • Allegra (fexofenadine 60mg) 1# TID
      • Compesolon (prednisolone 5mg) 2# PRNBID
  • 2023-06-15 SOAP Hemato-Oncology Xia HeXiong
    • Plan: CCRT with weekly carboplatin (due to impaired renal function, and self pay) followed by TP x 3 cycles
  • 2023-06-01 SOAP Radiation Oncology Huang JingMin
    • A: Undifferentiated carcinoma of the uterine cervix, stage cT2a2N0M0, s/p neoadjuvant chemotherapy and surgery (Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy).
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT2a2, s/p neoadjuvant chemotherapy and surgery
      • Goal: curative
      • Treatment target and volume: pelvic area
      • Technique: VMAT/IGRT +/- IVRT
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, +/- 1200cGy/3 fractions of the vaginal cuff mucosa surface by IVRT.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her husband. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2023-06-08.
  • 2023-05-02 POMR Obstetrics and Gynecology Huang SiCheng
    • Discharge diagnosis
      • Malignant neoplasm of endometrium
      • Endometrial cancer,stage II, post radical hysterectomy on 2023-05-03
      • Paralytic ileus
    • CC
      • intermittent postmenopausal bleeding for 6 months        
    • Present illness
      • This 55 y/o woman, G0P0, sex +, menopause in 2021. She had MEDICAL history of hyperlipidemia without control. She denied any food or drug allergy, and anticoagulants or hormone use. She had regular pap smear in 2021 and the result showed WNL.
      • Abnormal postmenopause bleeding was noted by patient for 6 months. According to patient statement, the discharge was pink initially. Then, the color change to brown and pus-like content, with increasing volume. No pain or burning sensation. She denied fever, weight loss, poor appetite, urinary frequency or urgency, dysuria, nocturia.
      • She came to our GYN OPD for help on 2023/01/30. PV revealed necrotic tissue and mass at os.
      • Biopsy was done and showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-).
      • CT in 2023/01/31 showed 5.3 cm tumor in cervical region. She was diagnosed as poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • After 3 cycles of neoadjuvant chemotherapy (Intaxel + Carboplatin), she was admitted for radical hysterectomy on 2023/05/03.   - Course of inpatient treatment
      • The patient was admitted on 2023-05-02 due to cervical cancer.
      • She underwent Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon 2023-05-03.
      • The pathology stage: Endometrium, low uterine segment, radical hysterectomy — Undifferentiated carcinoma. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II.
      • The GYN tumor board conference suggest the patient to receive CCRT on 2023-05-11.
      • Postoperative course was uneventful. Self voiding was smooth. She was discharged on 2023-05-24. Her follow up appointment is scheduled on 2023-06-01.
    • Discharge prescription
      • Naproxen (naproxen 250mg) 1# PRNQ6H
      • Anxiedin (lorazepam 0.5mg) 1# PRNHS
      • cephalexin 500mg 1# QID
      • MgO 250mg 1# QID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
  • 2023-02-17 ~ 2023-02-22 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3
    • CC
      • for chemotherapy
    • Present illness
      • The 54 y/o woman has been well in the past. Menopause on 2021.
      • This time, her vagina has yellow-green discharge since 2022/09/09. Due to symptoms persisted for a while without improvement, so she came to our GYN OPD for help and pelvis MRI showed Cervical malignancy, cstage T2a2N0M0 on 2023/02/09.
      • Pathology showed poorly differentiated carcinoma. IHC stains: CK7 (+), CK20 (-), P40 (-), p16 (-), vimentin (+), ER (+, 90%, strong intensity), GATA-3 (-) on 2023/2/3.
      • Port-a insertion on 2023/2/9. Under the impression of poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • Plan as Neo-adjuvant x 3th then radical surgery then adjuvant treatment, so she was admitted for first chemotherapy as self paid of TP on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received 24H CCr and PTA before neo-adjuvant x 3th then radical surgery then adjuvant treatment.
      • Premedication as Dorison 20mg q6h x 2 dose since 2/20 2300 and 2/21 0500.
      • C1 selfpaid of Intaxel (175mg/m2) + Carboplatin (AUC 6) on 2023/2/21.
      • Under the stable condition, she can be discharged on 2023/2/22. OPD follow up is arranged.
    • Discharge prescription
      • Mopride (mosapride citrate 5mg) 1# TID
      • Roumin (prochlorperazine maleate 5mg) 1# TID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2023-02-14 SOAP Hemato-Oncology Xia HeXiong
    • P: Admission for C/T with PF or TP
  • 2023-02-10 SOAP Obstetrics and Gynecology Huang SiCheng
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-02-09. Neo-adjuvant x 3th then radical surgery then adjuvant treatment
  • 2023-02-07 SOAP Urology You ZhiQin
    • S: cervical cancer, for r/o bladder invasion
    • O: CUS: no bladder invasion
  • 2023-02-06 SOAP Obstetrics and Gynecology Zhu ChunHong
    • O: 2023/01/31 CT ABD: Soft tissue tumor, 5.3cm in the uterine cervical region, r/o cervical myoma. Impression: Cervical region tumor, myoma? - interpretation about report, most possibility was cervical cancer

[consultation]

  • 2023-09-14 SOAP Neurology
    • Q
      • This 55-year-old woman patient is a case of Endometrial undifferentiated carcinoma with cervical invasion status post Radical hysterectomy on 2023/05/03, pT2N0, if cM0, stage II, FIGO stage II, s/p neoadjuvant chemotherapy with TP for 3 cycles, s/p Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomyon on 2023/05/03 and concurrent chemoradiotherapy with Carboplatin from 2023/06/21~2023/08/10, and adjuvant chemotherapy with TP from 2023/08/24~. She was admitted for adjuvant chemotherapy with TP(C2). This time, for dezziness in 2023/05. No hypertension and chest pain was noted. Now, for evaluate dizziness examine and therapy. Thank you.
    • A
      • She complained of intermittent dizziness during turning head to left or right since May, 2023. She denied headache, double vision, facial palsy, slurred speech, focal weakness or clumsiness, sensory deficit, and unsteady gait.
      • NE
        • GCS: E4V5M6
        • EOM: free and full
        • pupil 3mm/3mm, light reflex +/+
        • no facial palsy
        • No tongue deviation
        • No dysarthria
        • MP: upper 5/5, lower 5/5
        • Sensory: intact
        • FNF and HKS: no dysmetria
        • Romberg test: negative
        • Gait: steady, no falling
        • Tandem gait: steady
      • Asssessment
        • peripheral vertigo while head turning left-right
        • anemia
      • Suggestion
        • Keep observation of neurological signs. There was no focal neurological deficit currently.
        • Arrange BAEP.
        • Add Diphenidol 1# TIDPRN if dizziness.
        • Consult ENT doctor for vestibular system survey and treatment.
        • Treat anemia.

[surgical operation]

  • 2023-05-03
    • Surgery
      • Diagnosis: poorly differentiated carcinoma of cervical, pT1b3N0M0, stage 1b3.
      • Procedure: Radical hysterectomy + Bilateral Salpingo-oophorectomy + Bilateral Pelvic Lymph nodes Dissection + Bilateral paraaortic Lymph nodes Dissection + omentectomy
    • Finding
      • Uterus: Avfl, 5x3 cm; cervix:enlarged with multiple papillary tissues.
      • RAD: grossly normal.
      • LAD: grossly normal.
      • CDS: little ascites s/p washing cytolgy, no adhesion bands.
      • Right parametrium: size : 3 cm, Induration (-);
      • Left parametrium: size : 3 cm, Induration (-);
      • Vagina cuff: 3 cm , gross tumor (-), section margin free (+)
      • Bilateral pelvic/ paraaortic lymph nodes: Enlarged
      • Omentum: multiple hard, infracolic omentectomy was done.
      • Adhesion between pelvic wall and bowels, s/p adhesiolysis
      • Estimated blood loss: 600ml
      • Blood transfusion: pRBC 2u
      • Complication: none  

[radiotherapy]

[chemotherapy]

  • 2023-10-06 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-09-15 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-24 - paclitaxel 175mg/m2 260mg NS 250mL 3hr + carboplatin AUC 5 550mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-03 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-26 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-06 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-23 - carboplatin AUC 2 130mg D5W 250mL 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-08 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-18 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-21 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-10-06

There was no medication reconciliation issue identifed.

Leukopenia (WBC 1.16K/uL) was noted on 2023-09-07, approximately 2 weeks after the patient received the paclitaxel + carboplatin regimen on 2023-08-24. With Granocyte (lenograstim) administered for 3 days in early Sep, 4 days in mid-Sep, and 4 days in late Sep, the WBC finally reached above 3K/uL. Close monitoring of the WBC count may be necessary at this time.

2023-10-04 WBC 3.15 x10^3/uL 2023-09-28 WBC 2.66 x10^3/uL 2023-09-13 WBC 3.33 x10^3/uL 2023-09-07 WBC 1.16 x10^3/uL * 2023-08-23 WBC 3.41 x10^3/uL

2023-08-24

After examining both PharmaCloud and HIS5 records, no medication discrepancies were found.

700731401

231006

[exam findings]

  • 2023-09-18 Nasopharyngoscopy
    • NPC recurrence
    • ant. mild epistaxis
    • mucositis with condidiasis
  • 2023-09-11 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : >100 dB HL, severe to profound mixed type HL
      • L’t : >109 dB HL, profound mixed type HL.
  • 2023-08-04 Patho - nasopharyngeal/oropharyngeal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Nasopharynx, right and left, biopsy — Keratinizing squamous cell carcinoma, well differentiated
      • Nasal cavity, #1 and #2, right, biopsy — Keratinizing squamous cell carcinoma, well differentiated
    • MICROSCOPIC EXAMINATION
      • The sections all five parts show a picture of keratinizing squamous cell carcinoma, composed of irregular islands of well differentiated squamous cells with keratinization, mild nuclear atypia, and focal stromal invasion.
  • 2023-07-19 PET
    • Increased FDG uptake in bilateral nasopharyngeal regions, highly suspected tumor recurrence.
    • Increased FDG uptake in lymph nodes in the right neck and right supraclavicular fossa, probably metastatic (priority) or reactive nodes.
    • Increased FDG uptake in a level III level lymph node of the left neck, probably reactive node.
    • Increased FDG uptake at the C1 spine, highly suspected tumor invasion.
    • increased FDG uptake in the stomach, probably benign in nature, suggesting follow-up.
    • NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.

[MedRec]

  • 2023-08-17 SOAP Hemato-Oncology Xia HeXiong
    • Plan:
      • TPC x3 -> CCRT (Dr. Wang)
      • Admission on 2023-09-04 for 24 hours CCr and Audiometry and TPF
  • 2023-08-16 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S: Pre-CCRT dental evaluation
    • O:
      • Panoramic findings:
        • Missing: 36,37,45,46
        • Impaction: nil
        • Crown and Bridge: 15,26,47
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • Periodontitis of tooth 46, mobility Gr(II), widened PDL space
    • Problem:
      • Squamous cell carcinoma of nasopharynx
      • periondontitis of tooth 47
    • Plan:
      • Explain the risk/benefit of the treatment to the patient (Inform about the risk of inferior alveolar nerve numbness and inform that if the tooth is not extracted, subsequent tooth infection may lead to cellulitis.)
      • Sign informed consent.
      • Block anesthesia of right mandible.
      • Complicated extraction of tooth 47
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and cephalexin
      • Teach the patient how to do home care and OPD follow-up.
  • 2023-08-02 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Bilateral nasopharyngeal tumor status post bilateral nasopharyngeal tumor biopsy on 2023/08/03
      • Chronic osteomyelitis with draining sinus, unspecified site
      • Chronic sinusitis, unspecified
      • Essential (primary) hypertension
    • CC
      • Right otorrhea and purulent rhinorrhea for one month.
    • Present illness
      • This 67-year-old man has history of nasopharyngeal cancer post CCRT 30 years ago at TSGH. He is regular follow up at our ENT OPD. The patient complaint purulent rhinorrhea and right otorrhea noted for one month. At our ENT OPD, physical examination revealed right external auditory canal granular tumor, biopsy was done. The pathology revealed squamous cell hyperplasia with acute and chronic inflammation. We arrange whole body PET scan shwoed NPC s/p treatment with tumor recurrence, by this F-18 FDG PET scan.
      • Under the impression of nasopharyngeal granular tumor suspect recurrence cancer, surgical biopsy was suggested.
      • After well explanation about the surgical details, he was admitted for the operation.
    • Course of inpatient treatment
      • After patient was admitted, pre-operative evaluation was done. The patient underwent the operation of bilateral nasopharyngeal tumor biopsy. Post the operation, cool soft diet, pain control with Ultracet 1# po q6h were given. There was no active tongue bleeding. Appetite and amount of food intake improved day by day. Under relative stable condition, the patient was discharge today and continue OPD follow up.    

[chemmotherapy]

  • 2023-09-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 70mg/m2 120mg NS 500mL 24hr D2 + MgSO4 10% 20mL 1hr furosemide 20mg 30min NS 500mL (after CDDP) D3 + fluorouracil 1000mg/m2 1800mg D5W 500mL 24hr D3-7 (TPF Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

[the possibility of fever associated with the drugs being used]

Based on UpToDate database, it’s noted that Tapimycin (piperacillin, tazobactam) and Ulstop (famotidine), which the patient is currently taking, have been reported to be associated with fever as an adverse reaction. The incidence rate for the former is 2%, while for the latter, it is less than 1%.

2023-10-02

[Dipeptiven dosage and administration]

(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)

Dipeptiven 100 mL (alanyl glutamine 20g) can be diluted with NS 250-1000 mL. After dilution, it can be stored at room temperature for 24 hours.

A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.

  • Patients with total parenteral nutrition
    • The rate of infusion depends on that of the carrier solution and should not exceed 0.1 g amino acids/kg body weight per hour.
    • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration.
  • Patients with total enteral nutrition
    • Dipeptiven is continuously infused over 20-24 hours per day. For peripheral venous infusion, dilute Dipeptiven to an osmolarity ≤ 800 mosmol/L (e.g. 100 mL Dipeptiven +100 ml saline).
  • Patients with combined enteral and parenteral nutrition
    • The full daily dosage of Dipeptiven should be administered with the parenteral nutrition, i.e. mixed with a compatible amino acid solution or an amino acid contained in infusion regimen prior to administration.

If the patient is still on port-A, based on his body weight of about 70kg, IV infusion is recommended not less than 3 hours (20g / (0.1g/kg/hr x 70kg)), 4 to 6 hours would be even better.

700030886

231005

[exam findings]

  • 2023-09-19 Patho - bone marrow biopsy
    • Bone marrow, iliac, clinically recurrent T cell lymphoma, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • IHC stains: CD30: (-); CD3: 5 %; CD20: 1%, CD4 and CD8: no predominant subpopulation. CD68: 25 %.(of the nucleated cells).
  • 2023-09-12 PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm, liver, spleen and multiple bones/bone marrow of the skeleton (stage IV).
    • In comparison with the previous study on 2023/03/17, more new FDG avid lesions are noted, suggesting lymphoma in progression.
  • 2023-07-12 CT - abdomen
    • Findings: Comparison prior CT dated 2023/03/08.
      • Prior CT identified a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image is not noted in the current CT.
      • Prior CT identified two cysts in S2/3 and S1 of the liver are noted again, stationary.
      • Prior CT identified multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, marked decreasing in size.
        • It is c/w angioimmunoblastic T-cell lymphoma S/P C/T with partial response.
      • There are several gallstones (< 1.8 cm).
    • Impression:
      • Angioimmunoblastic T-cell lymphoma S/P C/T show partial response.
  • 2023-03-30 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at both sides of the mediastinum is found.
        • Bilateral lower neck lymphadenopathy is also found.
      • Visible abdomen:
        • Low density lesion at S7 of liver measuring 1.46cm in largest dimension. Lymphoma is compatible.
        • Mild splenomegaly is found.
        • Enarlged lymph nodes are found near EG junction is noted.
    • Imp:
      • Lymphadenopathy at mediastinum. Bilateral lower neck and EG junction
      • Liver low density nodule. S7, lymphoma is favored.
  • 2023-03-30 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement
    • The sections show slightly hypercellular marrow (40%). The myeloid series show good maturation. The megakaryocytes are increased in number. Paratrabecular and interstitial micronodular infiltration with atypical cells, many small lymphocytes, scattered CD68+ histiocytes and eosinophils, and subtle fibrosis are evident.
    • IHC, the atypical cells reveal: CD20(-), CD3(+), CD30(focal+) and BCL6(+). The finding is compatible with angioimmunoblastic T-cell lymphoma with bone marrow involvement. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-03-23 Patho - bone marrow biopsy
    • Lymph node, right neck, excisional biopsy — Angioimmunoblastic T-cell lymphoma
    • Microscopically, the section shows a picture of totally effacement of nodal architecture and marked vascular proliferation associated with aggregates of atypical large lymphoid cells mixed with small lymphocytes, which immunohistocehmcial stains show CD30(+, focal), CD3(+, diffuse), CD20(-), Bcl-2(+, focal), C-MYC (+, 20%), CD10(-) , Bcl-6(+, scatter), CK(-), Ki-67: increased activity and PD-1(+, focal). According to above histopathologic findings, it indicates a case of angioimmunoblastic T-cell lymphoma.
  • 2023-03-17 PET
    • Prominently increased FDG uptake in multiple left neck and left supraclavicular lymph nodes. Lymphoma should be considered. Please correlate with the pathologic findings for further evaluation.
    • Mildly to moderately increased FDG uptake in multiple right neck lymph nodes, some mediastinal, left axillary and bilateral pulmonary hilar lymph nodes. Lymphoma can not be ruled out.
    • Mildly increased FDG uptake in some abdominal lymph nodes in the gastrohepatic ligament and para-aortic space. Lymphoma is less likely.
    • Increased FDG uptake in a focal area in the segment 7 of the liver. The nature is to be determined (inflammatory pseudotumor? neuro-endocrine tumor? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in the stomach. Inflammation is more likely. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mildly increased FDG uptake in the left adrenal gland and in a focal area in the pituitary fossa. Benign nature such as adenoma may show this picture.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
  • 2023-03-15 MRI - liver, spleen
    • Findings:
      • There is a well-defined homogeneous mass measuring 2.3 cm at S2 of the liver, showing isointensity on both T1WI and T2WI. Dynamic study, this mass reveals well enhancement on arterial phase images but rapidly return to be iso-intensity on portal venous phase and delayed phase images.
        • Focal nodular hyperplasia (FNH) is highly suspected.
      • There is a well-defined, homogeneous mass 1.5 cm in S7 of the liver, showing hypointensity on T1WI, mild hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows peripheral contrast enhancement in arterial phase and portal-venous phase images, and homogeneous enhancement in delayed phase images.
        • Sclerosing hemangioma is highly suspected.
        • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
        • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
      • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space. The largest one 1.9 x 1.3 cm in the hepatoduodenal ligament,
        • Reactive nodes are highly suspected.
        • The differential diagnosis includes lymphoma and metastatic nodes.
        • Please correlate with PET scan.
      • There are several gallstones (< 1.8 cm).
      • There is mild hyperplasia of left adrenal gland.
    • Impression:
      • FNH 2.3 cm in S2 of the liver is noted.
        • Follow up sonography is indicated.
        • Otherwise, please correlate with primovist-enhanced MRI.
      • Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected.
        • The differential diagnosis includes inflammatory pseudotumor and neuro-endocrine tumor.
      • Reactive nodes are highly suspected.
        • The differential diagnosis includes lymphoma and metastatic nodes.
        • Please correlate with PET scan.
  • 2023-03-13 Patho - stomach biopsy
    • Stomach, mid body, LC side, biopsy — chronic gastritis with intestineal metplasia and H.pylori infection
    • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and focal intestinal metaplasia. Mild Helicobacter-like bacilli are seen.
  • 2023-03-13 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test
      • Gastric xanthoma
      • Gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy
    • CLO test: Positive
    • Suggestion:
      • PPI therapy
      • Pursue CLO test and pathology
      • Endoscopic follow-up
  • 2023-03-08 CT - abdomen
    • Findings:
      • There is a homogeneous enhancing lesion 2.3 cm at S2 of the liver in arterial phase images but no contrast washout (isodensity) in portal venous phase and delayed phase images.
        • FNH is highly suspected.
        • The differential diagnosis includes HCC.
        • Please correlate with MRI.
      • There is a poor enhancing lesion 1.5 cm in S7 of the liver at portal venous phase image. However, this lesion is not identified in non-enhanced, arterial phase images and delayed phase images.
        • Please correlate with MRI.
        • In addition, there are two poor enhancing lesions in S2/3 and S1 of the liver that may be cysts.
      • There are multiple enlarged nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space.
        • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
      • There are several gallstones (< 1.8 cm).
    • Impression:
      • FNH 2.3 cm in S2 of the liver is highly suspected.
        • The differential diagnosis includes HCC. Please correlate with MRI.
      • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
      • Lymphoma is highly suspected.
        • The differential diagnosis includes metastatic nodes.
  • 2023-03-06 SONO - abdomen
    • Diagnosis:
      • Hepatic hypoechoic lesion, left lobe, nature?
      • Splenic lesion, nature?
      • Gall stone
    • Suggestion:
      • correlated with other images
  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 43) / 123 = 65.04%
      • M-mode (Teichholz) = 65
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH; impaired LV relaxation.
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS and AR; mild MR; mild TR; mild PR.
      • Dilated aortic root and ascending aorta; aortic root calcification.
  • 2023-02-07 SONO - abdomen
    • Gall stone
    • Splenic lesion?
  • 2023-02-05 CT - abdomen
    • Some LNs (up to 1.8cm) at retroperitoneum.
    • Gallbladder stones (up to 1.5cm).

[MedRec]

  • 2023-08-24 SOAP Cardiology Duan DeMin
    • Prescription x3
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
      • Through (sennoside 12mg) 2# HS
  • 2023-07-24 SOAP Oral and Maxillofacial Surgery He ChengHan
    • S: toothache for a while
    • O:
      • Panoramic findings:
        • Missing: 18-14,25,27,28,37,36,31,41
        • Impaction: nil
        • Crown and Bridge: 23,24-26
        • Caries: 32
        • Periodontal condition: chronic periodontitis
      • deep caries of tooth 32, poor prognosis.
    • A: deep caries of tooth 32
    • P:
      • Take panoramic film for evaluation
      • Explain the findings
      • Suggest removal of the lower left side premolar after the body condition stabilized post-chemotherapy.
  • 2023-07-19 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Arrange PET-CT for Re-stagingafter 6 cycles of C/T
      • Already mention PBSCT again
      • Request patient RTC by themself after removing tooth
  • 2023-07-06 SOAP Hemato-Oncology Xia HeXiong
    • P
      • Granocyte on D6-8
      • Strongly request him visit Endocrinologist for DM
    • Prescription
      • Smecta (dioctahedral smecitite 3mg) 1# TIDAC
  • 2023-06-28 SOAP Neurology Chen PeiYa
    • S: CC: involuntary mouth movement (compressing lips) noted since chemotherapy
    • Prescription
      • Switane (trihexyphenidyl 2mg) 0.5# BID
  • 2023-04-12 SOAP Hemato-Oncology Xia HeXiong
    • O: Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 2023-04-10.
      • Angioimmunoblastic T-cell lymphoma stage IV, IPI: 3(Age, stage, BM+Sella)
      • CHOP ± steam cell transplantation.
  • 2023-03-27 ~ 2023-04-07 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Angioimmunoblastic T-cell lymphoma of right neck with lymphadenopathy at mediastinum, with bilateral lower neck and EG junction and liver, bone marrow involvement, stage IV
      • Liver tumor, suspected focal nodular hyperplasia
    • CC
      • fever up to 39 degree for 3 days
    • Present illness
      • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia, hepatic tumor, suspected lymphoma, regularly followed up at our CV, GI and meta OPD.
      • This time, fever up to 39 degree for 3 days, after excisional biopsy of right neck on 2023-03-23. Otherwise, there was no URI or UTI symptoms, abdominal pain, diarrhea, dysuria, nausea or vomit. TOCC history was unremarkable.
      • Due to the fever, he came to our ED for help. At ED, vital signs showed BP:125/62mmHg; HR:93 bpm; BT:37.8’C; RR:16 bpm/min; Con’s:E4V5M6, SPO2:95%. The laboratory data showed normalized white count, elevated of CRP level(26.42mg/dl), hyponatremia were also noted. The urinalysis showed no UTI picture, such as pyuria or bacteriuria. The CXR film revealed no active lung lesion.
      • Under the impression of fever cause unknown, he was admitted to our INF ward for further evaluation and management on 2023-03-27.
    • Course of inpatient treatment
      • After admission we gave abx and survey for the cause of fever, atypical antigen, autoimmune disease, virus inf. were included. However, we connected with the pathologist and the patho of neck LN showed Angioimmunoblastic T-cell lymphoma.
      • Follow up Chest CT showed lymphadenopathy at mediastinum, bilateral lower neck and EG junction, liver low density nodule. S7, lymphoma is favored.
      • After explain with family and family, he received chemotherapy with CHOP (Endoxan 750mg/m2, Doxorubicin 50mg/m2, Vincristine 1.4mg/m2 (max 2mg), Compesolon 5mg/tab PO QD on 2023/4/3-3/7 60mg/m2) on 2023/04/03.
      • Primperan 1# po TIDAC and Primperan 1amp IVD PRNQ6H for nausea and vomiting. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/04/07 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-03-23 SOAP Ear Nose Throat Guo YanJun
    • S: for neck mass biopsy
    • O: R’t level V neck mass about 2x1.5cm excisision done
  • 2023-03-22 SOAP Ear Nose Throat Guo YanJun
    • S
      • Referred from ID OPD for arrangement of excisional biopsy for pathological confirmation of TB.
      • Serum TB antigen test positive noted on 3-18
    • O
      • PH: DM, HTN, lipid
      • Allergy(-)
      • External ear canal clean
      • Ear drum intact
      • Nasal septum: deviated to R
      • Nasal cavity: fair inf. turbinate
      • Oral cavity: N-P
      • Oropharynx :fair
      • Nasopharynx: smooth via scope
      • Larynx: epiglottis ok, vocal cords fail
      • Neck: R level V 1.5cm and L level V 1.7cm firm movable oval masses without tenderness.
      • Scope: smooth nasopharynx, oropharynx, hypopharynx.
  • 2023-03-22 SOAP Infectious Disease Peng MingYe
    • S
      • Referred from Onco OPD for positive IGRA report on Mar 18
      • suspect liver lymphoma case
      • Underlying DM, HCVD, thoracic aneurysm, GB stone
    • O
      • 20230318 IGRA (+)
      • 20230317 PET
      • 20230315 MRI of liver
      • 20230313 UGI PES
    • A
      • Positive IGRA suggest at least latent TB, can not be used for TB LN diagnosis, LN biopsy still necessary.
    • P
      • refer to ENT OPD for Neck LN excisional biopsy highly recommended for pathology, for TB-PCR and TB culture
  • 2023-03-21 SOAP Hemato-Oncology Xia HeXiong
    • A/P
      • MTB (+) -> Refer to Infection for further management
      • If TB i under control, then refer to ENT for LN Excisional Biopsy
  • 2023-03-10 ~ 2023-03-17 POMR Gastroenterology Chen HongDa
    • Discharge diagnosis
      • Suspected lymphoma
      • Liver tumor, suspected focal nodular hyperplasia
      • Reflux esophagitis LA Classification grade A
      • Chronic superficial gastritis with erosions and focal atrophic gastritis, rapid urease test:positive.
      • Mixed hemorrhoid, mild
    • CC
      • was scheduled for liver tumor study.
    • Present illness
      • This is a 73 years old male with underlying disease of hypertension, type 2 DM, hyperlipidemia. He is regularly followed up at our CV and meta OPD. He was just discharged from our hopital on 2/13 due to intra-abdominal infection.
      • Follow up abdominal echo on 3/6 reveal a hepatic hypoechoic lesion, left lobe, nature need to be ruled out.
      • He then receive CT and it reveal
        • Focal nodular hyperplasia 2.3 cm in S2 of the liver is highly suspected. The differential diagnosis includes HCC. Please correlate with MRI.
        • A poor enhancing lesion 1.5 cm in S7 of the liver, nature?
        • Lymphoma is highly suspected.
      • He denied fever, chillness, decreased appetite, cold sweating or recent body weight loss found. He also denied any discomfort in recent days.
      • PE show no icteric slcera, no murphy sign. Blood test showed no leukocytosis but elevated of CRP.
      • Tumor markers(CEA, CA19-9 and AFP) all showed negative finding. CXR show bilateral clear lung field.
      • Under the impression of 1.) Hepatic tumor 2.) Favor lymphoma. He was admitted to our ward for further survey and treatment.
    • Course of inpatient treatment
      • After admission, Antibiotic with Ciproxin IV form total three days then shifted to oral form used for infection control.
      • Tumor marker with AFP was checked and hepatitis markers with HBsAg, Anti HCV were all follow up that showed negative finding.
      • Oncologoist was consulted for management of favor lymphoma who suggested 1. check LDH level 2. consult the General surgen for intra-abdominal LN excisional biopsy 3. liver biopsy.
      • Upper GI endoscopy and colonscopy were all performed which revealed reflux esophagitis LA Classification grade A; chronic superficial gastritis with erosions and focal atrophic gastritis, s/p CLO test (+); Gastric xanthoma and gastric mucosal lesion, suspected intestinal metaplasia, mid body, LC, s/p biopsy on EGD. Colonscopy showed mixed hemorrhoid, mild. Oral form PPI with Nexium 1# po QDAC was used.
      • GS was consulted for lymph node biopsy and management of GB stones who explained the risk and possibility of surgery and may do PET by himself payment for further survey.
      • ID man was also consulted for management of elevated of CRP who suggested 1. Check U/A, urine culture, check PSA level. 2. Serum QuantiFERON-TB study for possible latent TB or active TB. 3. Consider laparoscopy for open biopsy.
      • Liver MRI with contrast was done on 3/15 that report showed 1.FNH 2.3 cm in S2 of the liver is noted. 2.Sclerosing hemangioma 1.5 cm in S7 of the liver is highly suspected. 3.Reactive nodes are highly suspected. The differential diagnosis includes lymphoma and metastatic nodes. Please correlate with PET scan.
      • on 3/16 AM: the medical condition was explained to the patient, his wife, and niece (although the patient had been informed of the explanation timing in the past couple of days, he still mentioned that his son and daughter were too busy to come to the hospital). explained EGD, Colonoscopy report. reply of consultation of oncologist, GS surgeon, infection physician. Liver MRI report.
      • for abdominal lymph adenopathy: both benign or malignant etiology was considered: we’ve suggested lymph node biopsy: but patient and family refused lymph node biopsy
      • we’ve also suggested percutaneous biopsy for liver tumor (FNH was suspected): but patient and family also refused liver biopsy; they requested for PET scan; arranged PET scan
      • PET scan was done on 3/17 without complications. There was no abdominal pain nor poor appetite found during admitted. Under a stable condition, he was discharged first and further GI/ID/Oncology OPD were arranged later.
    • Discharge prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Nexium (esopeprazole 40mg) 1# QDAC
  • 2017-02-09 SOAP Metabolism and Endocrinology Yu LiJiao
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Pure hypercholesterolemia [E78.0]
    • Prescription x3
      • Uformin (metformin 500mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# Q4D
      • Aprovel (irbesartan 300mg) 1# QD

[consultation]

[chemotherapy]

  • 2023-10-02 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-09-20 - gemcitabine 1000mg/m2 1800mg NS 250mL 1hr + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr (GemOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-08-16 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-26 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-28 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-19 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-03 - cyclophosphamide 750mg/m2 1400mg NS 250mL 30min + doxorubicin 50mg/m2 90mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL + prednisolone 60mg/m2 110mg PO QD D1-5 (CHOP Q3W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

The repeat prescription for Exforge (amlodipine, valsartan), Concor (bisoprolol), and Through (sennoside) was issued by our cardiologist on 2023-08-24, and the patient refilled these medications on 2023-09-11. The medications are currently in use with no discrepancies found.

700563689

231005

[exam findings]

[MedRec]

  • 2023-08-29 SOAP Rheumatology Chen JunXiong
    • Diagnosis
      • Rheumatoid arthritis [M05.70]
      • Essential hypertention, unspecified [I10]
      • Constipation [K59.00]
      • Peristent disorder of initiating or maintaining sleep [F51.09]
      • Other specified gastritis, without mention of hemorrhage [K29.30]
    • Prescription x3
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Salazine (sulfasalazine 500mg) 1# QD
      • Celebrex (celecoxib 200mg) 1# PRNQD
      • Plaquenil (hydroxychloroquine 200mg) 1# QD
      • MgO 250mg 1# QD
      • Compesolon (prednisolone 5mg) 1# QD
  • 2023-08-02 SOAP Hemato-Oncolgoy Xia HeXiong
    • O: Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 2023/07/13
      • Treatment Plan: 1. Adjuvant chemotherapy after surgery. 2. Staging consensus: T1c1N0M0.
    • P: Arrange admission for adjuvant chemotherapy with TP x6
  • 2023-07-04 ~ 2023-07-14 POMR Obstetrics and Gynecology Zeng LunNa
    • Discharge diagnosis
      • Malignant neoplasm of left ovary
      • Rheumatoid arthritis with rheumatoid factor of unspecified site without organ or systems involvement
      • Unspecified hydronephrosis
      • Debulking surgery on 2023-07-06
    • CC
      • Incidental computed tomography (CT) finding of left pelvic mass (105mmx68mm) on 2023/06/21
    • Present illness
      • This is a 62-year-old-woman, Gravidity2 Parity2 (G2P2) (vaginal delivery x2) with rheumatic arthritis and hypertension under medication. She came to our hospital this time due to incidental CT finding of left pelvic mass (105mmx68mm) on 2023/06/21.
      • She was in her ususal status until 2023/06/21, when Left upper qaudrant (LUQ) pain was noted. She visited our emergency department, where whole body CT with contrast was done. A 10cm well-defined pelvic mass with cystic and soft-tissue components and enhancement of solid parts was found. The tumor also caused compression of urinary bladder and left ureter, resulting in moderate hydronephrosis.
      • Gynecologist was consulted, and abdominal echo and tranvaginal echo showed a pelvic mass measuring 105mmx86mm with ascites, uterus: 5.8x3.6cm, endometrium: 1.12cm. She was first admitted to treat her acute problem of urinary tract infection, left percutaneous nephrostomy (PCN) was also performed. After compeleting the treatment, she came to our gynecology out patient department for surgical evaluation.
      • According to the patient, urinary frequency had been noted for about five years. She denied abodminal distension, no abdominal pain, no nausea or vomit, no constipation nor diarrhea, no bloody or tarry stool, no vaginal spotting or discharge. There was decrease appetite since last November, due to teeth problems, therefore a decrease of 12 kilogram (kg) was noted ever since.
      • Lab data showed normal CA125 (32.2 U/ml), normal CEA (2.08 ng/ml), normal CA199 (25.58 U/ml). Under the impression of pelvic mass, favor left ovarian origin, surgical intervention was suggested. After well explained and discussion with patient, she agreed operation.
      • Under the impression of pelvic mass, favor left ovarian origin, we will arrange admission for preoperative evaluation and preparation including panendoscopy and colonscopy as well as debulking surgery.
    • Course of inpatient treatment
      • After admission, the patient underwent upper GI panendoscope and colonoscope on 2023/07/05, both showed no signs of tumor lesions. On 07/06, she underwent debulking surgery (total hysterectomy + bilateral salphingo-ophorectomy + bilateral pelvic lymph node dissection + infracolic omentectomy) and insertion of bilateral double-J. Perioperative blood loss was 1400ml. therefore transfusion with 4u LPRBC, ferrum injection 2 amp ST, trasamin 500mg BID (07/06~07/07) were given.
      • Post-operation hemoglobulin: 8.9g/uL increased to 9.2g/uL. We checked KUB on 7/7, which showed intact left PCN and bilateral double-J, therefore, left PCN was removed in the afternoon. Left lower quadrant pain improved evidently afterwards.
      • Surgical wound was vertical, 13cm in total, there was no active woozing, no discharge.
      • Desaturation to SpO2 around 80% room air was noted on 7/9 evening, with tachypnea (22-24/min), so was fever up 39.1’C. Fever routine was performed, U/A showed pyuria, nitrite: 1+, bacteria:3+. Lab: leuocytosis with bandemia. Chest xray showed blunting of right CP angle, which resolved slightly on 7/10 CXR. Therefore empirical cravit 750mg QD was prescribed (7/9~7/10), tazocin to cover anerobes due to possible aspiration peumonia (7/11), doripenam as recommended by infection (7/12~7/13), oral cravit(7/14~).
      • Due to bilateral lung atelectasis with unstable SpO2, we consulted chest man. Aggressive chest percussion was recommended, and we also checked sputum culture, which later showed mixed growth and candida albicans. Abdominal distension with vomit were also noted, with improved a bit after abdominal massage. We also added primperan 10mg Q8H and MgO 1# QD to facilate bowel movement. Afterwards, the patient showed evident improvement in spirits and appetite. Flatus and defecation was smooth, wound pain also improved gradually.
      • Since 7/9, there had been no fever. Much yellowish sputum was still noted, so we continued actein treatment and gave oxygen support with nasal cannula when needed, and also encourage ambulation. We followed-up lab data on 7/12, CRP decreased from 16.6 to 6.4, no more bandemia. Chest Xray also showed no lower lung atelectasis.
      • Pathology report showed ovarian caner, clear cell adenocardinoma, high grade, pT1c1 pN0 (if cM0), FIGO stage 1C1. Therefore, tumor broad was arranged on 2023/07/13, and after discussion, consensus was reached to start chemotherpay for this patient. Therefore, oncolgist Dr. Shia visited the patient on 7/13 and explained on details regarding further treatment, including insertion of port-A.
      • Under stable conditions, the patient is discharged on 2023/07/14 with follow-up at gynecology and oncology outpatient department. We also arranged rheumatology follow-up for this patient to evaluate her ongoing rheumatic arthritis.
    • Discharge prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Gaslan (dimethylpolysiloxane 40mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H
  • 2017-01-16 SOAP Rheumatology Chen JunXiong
    • Diagnosis
      • Rheumatoid arthritis [M05.70]
      • Essential hypertention, unspecified [I10]
      • Constipation [K59.00]
      • Peristent disorder of initiating or maintaining sleep [F51.09]
      • Other specified gastritis, without mention of hemorrhage [K29.30]
    • Prescription x3
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Salazine (sulfasalazine 500mg) 1# BID
      • Exforge (amlodipine 5mg, valsartan 160mg) 1# QD
      • folic acid 4mg 4# QW
      • Trexan (methotrexate 2.5mg) 4# QW
      • Celebrex (celecoxib 200mg) 1# PRNBID
      • Plaquenil (hydroxychloroquine 200mg) 1# BID
      • MgO 250mg 1# QD
      • Compesolon (prednisolone 5mg) 1# QD
  • 2017-01-16 SAOP Obstetrics and Gynecology Xu YaoRen
    • O
      • 2016-12-23 cell-block pathology: Atypical squamous cells (ASCUS)
    • Diagnosis
      • Nonspecific abnormal papanicolaou smear of cervix [R87.610]
      • Erosion and ectropion of cervix [N86]
    • Prescription
      • Lindacin (clindamycin 150mg) 2# Q6H

[consultation]

[surgical operation]

[chemotherapy]

  • 2023-09-08 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 200mg NS 250mL 2hr (Q3W. carbo eGFR 36 CCr 23 AUC 4)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-17 - paclitaxel 175mg/m2 180mg NS 250mL 3hr + carboplatin AUC 4 360mg NS 250mL 2hr (Q3W. carbo eGFR 65 AUC 4)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-05

Most of the medications prescribed by our rheumatologist are immunomodulators and primarily immunosuppressive. As the patient is currently undergoing chemotherapy, it is advisable to monitor any changes in immune function or rheumatoid arthritis symptoms.

700906364

231005

[exam findings]

  • 2023-09-25 CT - chest
    • Comparison was made with CT on 2023/07/31
      • Lungs: s/p post op change with staple lines in lt lung and Rt lower lung.
        • multiple pleural-based solid nodular abnormalities in left lung, and nodular thickening at left interlobar fissure, stationary. several small soft-tissues nodules at RLL.
      • Mediastinum and hila: small LNs in vsceral space
      • Pleura: small Lt-sided effusion with loculation.
    • Impression:
      • lung and pleural metastases, stationary compared with CT on 2023/07/31
  • 2023-09-06 PET
    • Glucose hypermetabolic lesions in a celiac lymph node and in several left pulmonary hilar and mediastinal lymph nodes, highly suspected recurrent tumor with distant lymph nodes metastases.
    • Glucose hypermetabolic lesions in the right pulmonary hilar and mediastinal lymph nodes, probably metastatic or reactive nodes.
    • FDG-avid lesions in the right lower lung pleura, in the right upper and lower lungs with pleurae involvement, and in the left rib cage, highly suspected recurrent tumor with lung and bone metastases.
    • Glucose hypermetabolic lesions in the right fronto-temporal region of the skull, probably metastasis or post-traumatic change.
    • Recurrent rectal cancer s/p treatment with distant lymph nodes, lung and bone metastases, yrcTxNxM1b, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-08-15 Patho - stomach biopsy
    • Stomach, antrum, biopsy — chronic gastritis with Helicobacter infection
    • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate. Helicobacter-like bacilli are seen.
  • 2023-08-14 EGD
    • Reflux esophagitis LA Classification grade A
    • Suspect Barrett’s esophagus, EC junction, s/p biopsy(B)
    • Superficial gastritis, s/p biopsy(A)
    • Gastric subepithelial lesion, AW of high bpdy
  • 2023-07-31 CT - chest
    • Comparison was made with previous CT dated on 2023/04/26
      • Lungs: s/p post op change with staple lines in lt lung and Rt lower lower lung.
        • multiple pleural-based solid nodular abnormalities in left lung, and nodularity thickening at left interlobar fissure, stationary.
        • several small soft-tissues nodules at RLL.
      • Mediastinum and hila: small LNs in vsceral space
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Pleura: small Lt-sided effusion with loculation.
    • Impression:
      • lung and pleural metastases, stationary compared with CT on 2023/04/26
  • 2023-06-01 CXR
    • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2023-05-05 All RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 13 GGC>GAC, p.G13D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-02 L-spine flex & ext
    • Presence of spondylolisthesis at L3/4, grade I.
  • 2023-05-02 Bone densitometry
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.574 gms/cm2, about 2.5 SD below the peak bone mass ( 68 %) and 0.0 SD at the mean of age-matched people ( 100 %).
      • IMP: osteoporosis
    • L-spines BMD (AP view) performed by DXA revealed:
      • AP L-spines, BMD of L1-4 0.742 gms/cm2, about 2.5 SD below the peak bone mass ( 73 %) and 0.2 SD above the mean of age-matched people ( 105 %).
      • IMP: osteoporosis
  • 2023-04-26 CT - chest
    • lung and pleural metastases, in progresion compared with CT on 2023/01/18.
  • 2023-04-17 Colonoscopy
    • No definite mucosal lesion was seen except diverticula at S-colon
  • 2023-04-13 CXR
    • Few nodular opacity projecting in the left lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • 2023-01-18 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis and Scoliosis of the L-spine with convex to right side.
  • 2023-01-18 CT - abdomen
    • S/P LAR with autosuture retention over the rectum.
    • Prior CT identified two solid nodule in RLL and LLL of the lung are noted again, stationary.
  • 2023-01-18 CT - chest
    • lung and pleural metastases, stationary.
  • 2022-10-26 CT - chest
    • recurrent left lung and pleural metastases, stationary.
  • 2022-07-22 CT - chest
    • Left lower lobe meta. Stationary.
  • 2022-02-15 CT - chest
    • recurrent left lung and pleural metastases.
  • 2021-09-01 CT - chest
    • no new lung nodule.
  • 2021-05-06 CT - chest
    • s/p left upper lobe and left lower lobe op.
    • no evidence of recurrent tumor in the study.
  • 2020-12-30 Patho - lung wedge biopsy
    • pathologic diagnosis
      • Lung, left upper lobe (frozen section specimen), wedge — Metastatic colorectal adenocarcinoma
      • Lung, left lower lobe, wedge — Metastatic colorectal adenocarcinoma
      • Lymph nodes, LN 9, dissection — Negative for malignancy (0/3)
      • Parietal pleura, biopsy — Metastatic colorectal adenocarcinoma
    • microscopic examination
      • Tumor Focality: Multiple tumors over LUL, LLL, and parietal pleura
      • Histologic Type: Metastatic colorectal adenocarcinoma
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Present
      • Lymphovascular Invasion: Present
      • Lymph nodes, LN 9: Negative for metastatic carcinoma (0/3)
      • IHC for tumor cells: CK7(-), CK20(+), and CDX2(+)
  • 2020-12-29 Frozen resection
    • Lung, LUL, frozen section — Adenocarcinoma, compatible with metastatic colorectal carcinoma
  • 2020-12-11 CT - chest
    • Left upper lobe and left lower lobe nodules. suspected lung mets.
    • Focal Pleural thickening. suspected pleural seeding.
  • 2020-12-01 CT - abdomen
    • Left basal lung nodules. Nature? Suggest chest CT
  • 2020-09-01 CT - abdomen
    • Post-op at the colon.
    • Right adrenal tumor, suggest follow up.
    • Uterine tumor, suspected myoma.
  • 2019-12-30 CT - abdomen
    • Rectal cancer s/p operation. No evidence of tumor recurrence.
  • 2018-08-13 CT - abdomen
    • Status post LAR with stable condition.
  • 2017-08-31 CT - abdomen
    • Rectal cancer s/p operation. No evidence of tumor recurrence.
  • 2017-03-18 CT - abdomen
    • Rectal CA, s/p operation. No evidence of tumor recurrence
  • 2013-end pathology
    • adenocarcinoma, metastatic (7/34)
    • pathology stage: pStage IIIC, pT3N2b(cMx),
    • IHC stain of EGFR: weak positive on 30% to 40% of the neoplastic glands.
  • 2013-11-29 CT - abdomen
    • rectal cancer with LNs & lung mets (T2N1M1a)

[MedRec]

  • 2023-07-26 SOAP Neurosurgery Huang GuoFeng
    • O
      • There is pain in the lower back or buttocks, which can extend to one or both sides of the lower limbs while walking.
      • There is intermittent limping (Neurogenic Claudication), and after walking for a few minutes or steps, there is increased numbness and weakness in the lower limbs.
      • There are also symptoms such as shooting pain in the calf and numbness in the feet, which require rest for some time to obtain relief.
      • The patient reports a decrease in sensation and severe numbness in the L5-S1 dermatome, as well as muscle weakness (rated 4-5) with no increase in deep tendon reflexes. Bladder and sphincter function are normal, and gait is slow. Hip joint and both lower limb pulses are normal. The root tension sign is positive, and the patient experiences worsening pain (rated 6 out of 10) that can reach 8 out of 10, making walking difficult. The pain is relieved when lying down but is exacerbated when standing up, preventing the patient from walking. The patient has been experiencing severe back pain and sciatica for a long time, and conservative treatment, including rehabilitation and medication, has been ineffective. Clinical instability is being ruled out, and SLRT is positive on the left side. Fabor test is negative, and deep tendon reflexes are decreased. The patient can walk on their toes and heels without issue.
    • Diagnosis
      • [M48.56XA] Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture
    • Prescription x3
      • U-Ca (calcitriol 0.25ug) 1# QD 84D
      • Evista (raloxifene 60mg) 1# QD 28D
  • 2021-01-12 SOAP Hemato-Oncology Zhang ShouYi
    • S: 68 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, recurrence wt lung mets & pleura mets s/p lung metastasectomy in Dec 2020.
  • 2017-03-25 SOAP Hemato-Oncology Zhang ShouYi
    • S: 64 y/o female. a pt of Rectal CA, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR on 12/24 13 by Dr Xiao GuangHong, s/p CCRT by Dr Huang JingMin & Post-CCRT adjuvant C/T wt sLV-5FU (2 days) Q2W x 12 finishing in Oct 2014, was noted to have the CA by physical checkup without particular discomfort in Dec 2013.

[consultation]

  • 2023-06-05 Nephrology
    • Q
      • For hyponatremia & poor appetite
      • This 71-year-old woman, a patient of Rectal cancer, pT3N2b (7/34) M0, stage IIIC, s/p Laparoscopic LAR in 12 2013, s/p CCRT, adjuvant sLV-5FU Q2W x12 in 10 2014, recurrence with lung, pleura metastasis, s/p lung metastasectomy in 12 2020, s/p palliative FOLFIRI/Avastin x12 in 07 2021, recurrence with lung metastasis in 02 2022, s/p palliative mFOLFOX x12 in 01 2023, in progresion in 04 2023, s/p palliative FOLFIRI. She was admitted for C/T. She complained of general weakness, poor appetite post C/T and Na report from 136 -> 116 -> 111 mmol/L was noted. We need expertise to evaluate her condition thanks!
    • A
      • We visited the patient at the bedside and evaluated her condition. Her consciousness was clear, and not in respiratory distress. All four of her limbs were not edematous. The patient said she did not want to eat with nausea sensation since 2023-06-02, and she did not have vomiting or diarrhea. The caregiver observed that the patient speaked inherencetly recently.
      • Chemotherapy: FOLFIRI
      • Blood test showed severe hyponatremia.
        • 2023-06-05 Na (Sodium) 111 mmol/L
        • 2023-06-04 Urine osmolarity 542 mOsm/Kg
        • 2023-06-04 Na (Urine) 136 mmol/L
        • 2023-06-04 Blood Osmolality 241 mOsm/Kg
        • Cortisol, TSH, free T4 WNL
      • Our impressions are as follows:
        • Hypo-osmotic hypo/euvolemic hyponatremia, suspected to be SIADH related to irinotecan
        • Hypomagnesemia, hypokalemia, hypocalcemia, hypophosphatemia also identified
      • Our advices are as follows:
        • Check BUN, Cr, Uric acid
        • Record daily I/O and BW; - Restrict free water intake to 1000mL/day
        • Keep 3% NaCl 10ml/hr and monitor serum Na Q6H ~ Q8H; change in Na levels should not exceed 6-8 mEq/L within any 24-hour period
        • DC 0.298% IV fluid, adjusted to Constat-K 1# QID
        • Check serum K, Mg, P and urine K, Mg, P, Cr, urinalysis simultaneously on 2023-06-06
      • Please be assured that we will continue to follow up on this patient. Feel free to contact us should you require further assistance. Thank you.

[surgical operation]

  • 2020-12-29 VATS, LUL and LLL wedge + lymph node sampling
    • multiple scattered whitish to translucent nodules about 5mm~10mm on visceral and parietal pleura suspected rectal metastasis parietal biopsy, LLL wedge biopsy and lymph node sampling
    • a volcano like solid nodule about 1.5cm in diameter in LUL S1 segment after wedge biopasy
  • 2013-12-24 Laparoscopic LAR + Thoracoscopic wedge or Partial resection of the Lung

[radiotherapy]

  • early 2014

[chemoimmunotherapy] (not completed)

  • 2023-09-05 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 480mg NS 250mL 2hr + fluorouracil 2400mg/m2 2850mg 46hr (FOLFIRI Q2W, 20% off)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-15 - FOLFIRI

  • 2023-07-17 - FOLFIRI

  • 2023-07-03 - FOLFIRI

  • 2023-06-01 - FOLFIRI

  • 2022-03-08 ~ 2023-01-13 - FOLFOX

  • 2021-02-01 ~ 2021-07-27 - FOLFIRI plus bevacizumab

  • 2021-01-18 - FOLFIRI

  • 2014-04-03 ~ 2014-10-07 - PF, post CCRT adjuvant, 12 cycles

  • 2014-02-10 ~ 2014-03-13 - 5-Fu based

==========

2023-10-05

Vemlidy (tenofovir alafenamide 25mg) 1# QD prescribed by our gastroenterologist on 2023-09-30 is currently in use. No medication discrepancy was found.

Please note that both tumor markers CA-199 and CEA have started to show a slight upward trend after bottoming out in August. This may indicate a change in the balance of the treatment and the disease.

2023-09-22 CA-199 (NM) 1277.40 U/ml 2023-08-25 CA-199 (NM) 1125.26 U/ml 2023-08-18 CA-199 (NM) 743.66 U/ml 2023-08-01 CA-199 (NM) 931.32 U/ml 2023-07-18 CA-199 (NM) 1470.34 U/ml 2023-06-20 CA-199 (NM) 867.59 U/ml

2023-09-22 CEA (NM) 96.979 ng/ml 2023-08-25 CEA (NM) 87.270 ng/ml 2023-08-18 CEA (NM) 81.753 ng/ml 2023-08-01 CEA (NM) 61.346 ng/ml 2023-07-18 CEA (NM) 98.554 ng/ml 2023-06-20 CEA (NM) 66.050 ng/ml 2023-04-25 CEA (NM) 47.692 ng/ml 2023-01-18 CEA (NM) 5.127 ng/ml 2022-10-28 CEA (NM) 5.562 ng/ml

2023-09-06

No medication reconciliation issues were identified after reviewing the PharmaCloud database and hospital HIS5 records.

2023-07-18

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were found.

2022-04-20

  • This patient diagnosed with rectal cancer with LNs and lung mets in late 2013, recurrence monitored in late 2020, patient receives FOLFIRI (plus bevacizumab) from 2021-02-01 to 2021-07-27, following VATS, LUL and LLL on 2020-12-29, and recurrence detected again in early 2022. She is currently treated with FOLFOX since 2022-03-08.
  • Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal. The nursing note does not indicate any intolerances so far since this hospitalization.
  • Depending on the patient’s financial situation and there are no contraindications, targeted and/or immunotherapy treatments might also be considered.

701499491

231005

[MedRec]

  • 2023-10-03 SOAP Medical Emergency
    • S: (the following text seems to be from Sun Yat-Sen Cancer Center earlier CT)
      • CT Scan #A
      • Clinical History and Indications: metastatic neuroendocrine carcinoma of the pancreas with LNs of retroperitoneum, mediastinum, pleura and pericardial, with right 10th rib bone and liver metastasis, on palliative C/T.
      • Findings comparison CT: 2023/04
        • lung, airway: reticular opacities, right lower lung, no obvious change
        • lower neck, axilla: small lymph node(s), short axis <10mm
        • mediastinum, pulmonary hila: small lymph node(s), short axis <10mm
        • pleura, pericardium, chest wall: right pleural effusion; no pericardial effusion;
        • heart, great blood vessels: atherosclerosis;
        • hepatobiliary system: multiple metastasis in both lobes, size and number increase; dominant tumor 6cm right lobe S7, bigger; gallbladder wall thickening; minimal dilatation of bilateral intra-hepatic ducts;
        • mass lesion 77mm, replacing pancreatic body, bigger; atrophy of pancreatic tail;
        • enlarged lymph nodes, 39mm and 20mm, gastro-hepatic space, bigger;
        • spleen, adrenal glands: left adrenal gland metastasis, no obvious change
        • kidneys: no hydroneprhosis;
        • retroperitoneum: tumor involvement of upper retroperitoneum, tumor encasement of celiac trunk and SMA root, no obvious change; metastasis in left para-aortic space 42mm, no obvious change; tumor compression of left renal vein;
        • peritoneum, mesentery, GI tract: no evident ascites; small nodular lesion(s) in peritoneal cavity, no obvious change
        • pelvis: no enlarged lymph node; no evident mass lesion
        • bone: right chest wall mass lesiond <= 48mm with bony destruction of right ribs, more evident;
      • Impression and Suggestions
        • progression of liver metastasis;
        • progression of right chest wall metastasis;
        • bigger of tumor at pancreatic body;
        • bigger of gastro-hepatic space lymph nodes; no obvious change of retroperitoneum metastasis;
        • the overall picture suggests progressive disease
      • CT Scan #B
      • Clinical History and Indications Pancreatic carcinoma with multiple metastases, on palliative C/T.
        • Findings
          • Lymph nodes: a. in the mediastinum, less than 10 mm: — the node in the subcarinal region is smaller as compared with previous CT scan on 2023/01/31, probably metastasis. — other nodes are less than 10 mm and show no obvious change.
            • metastatic lymph nodes in the gastrohepatic ligament, up to 22 mm, larger.
            • in the para-aortic region, up to 15 mm, larger.
            • in the hepatic hilum, 12 mm. No obvious change.
          • Small right pleural effusion, stable.
          • Lung: minimal reticular opacities/atelectasis in right lower lobe. No obvious change.
          • Liver:
            • multiple metastasis with progression.
            • intrahepatic bile duct dilatation. No obvious change.
          • Pancreas: ill-defined soft tissue infiltration in the body, compatible with pancreatic cancer. No obvious change.
            • dilatation of the pancreatic duct, more obvious
            • tumor involves the left adrenal gland and encases the celiac artery, superior mesenteric artery, left renal vein.
          • Kidney:
            • suspicious a subcentimeter cyst in left kidney, stable.
            • subcentimeter stones in both kidneys. No hydronephrosis.
          • Spleen: no focal lesion.
          • Gallbladder: suspicious small stones.
          • Nodules in the right peritoneum and renal hilum, up to 10 mm, either stable or smaller, probably metastasis. (scan 7/80, 84)
          • Bone:
            • focal mixed density change in right 9th and 10th rib, probably metastasis, already noted on previous CT.
            • soft tissue around the right 10th rib, newly demonstrated, probably extraosseous tumor extension. (scan 7/63-73)
          • Back region: soft tissue defect in right lower back, at the level of right 9th and 11th ribs. Suggest clinical correlation.
        • Impression and Suggestions
          • Pancreatic carcinoma. No obvious change.
          • Metastatic lymph nodes in the gastrohepatic ligament and the para-aortic region, larger.
          • Hepatic metastasis with progression.
          • Peritoneal metastasis, either stable or smaller.
          • Suspicious bony metastasis in the ribs, already note d on previous CT.

==========

2023-10-05

This patient has been receiving treatment at the Koo Foundation Sun Yat-Sen Cancer Center in the past. The only prescription medication from that center that is still valid to date is Megest Oral Suspension (megestrol acetate). This drug is not currently included in the active medication list. If the patient continues to experience cachexia or poor appetite, it is advisable to reintroduce this medication.

700301189

231003

[exam findings]

  • 2023-10-03 CT - brain
    • Mild swelling of left parietal and occipital scalp.
  • 2023-10-02, -08-30, -08-02, -07-21, -07-12, -06-14, -06-01, -05-27 CXR
    • Bilateral Pleura effusion is noted.
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Spondylosis of the T-spine
    • Enlargement of cardiac silhouette.
  • 2023-06-26 CT - chest
    • PH: adenocarcinoma of low rectum s/p transanal local excision (2019/04/15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p radiotherapy & C/T
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • Nodular and cavitatory lesion at left lower lobe is found. In comparison with CT dated on 2023-03-21, the lesions decreased in size or became less compact
        • S/p port-A placement with its tip at left brachiocephalic vein.
        • Minimal bilateral pleural effusion with pleural thickening is found.
      • Visible abdomen:
        • Low density nodule at uncinate process of the pancreas is found measuring 1.2cm. Another mass like lesion at pncreatic tail measuring 2.7cm is noted. In comparison with CT dated on 2023-03-21, the lesion enlarged.
    • Imp:
      • Diffuse lung meta. In regression.
      • Bilateral pleural meta.
      • Pancreatic tail tumor and uncinate process nodule. In enlargmennt. Pancreatic cancer is favored.
  • 2023-03-28, -03-27, -03-24, -03-22 CXR
    • Pneumo-mediastinum is highly suspected.
    • Left Pleura effusion is noted.
    • Focal pneumothorax at right CP angle.
    • Subcutaneous emphysematous change over bilateral lower neck, bilateral axillary and right lateral chest wall.
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
    • S/P pigtail catheter implantation at right CP angle with focal pneumothorax.
  • 2023-03-22 SONO - chest
    • Pleural effusion, moderate, right
    • Atelectasis, RLL
    • Organized pleurae, left
  • 2023-03-21 CT - chest
    • Comparison was made with previous CT dated on 2022/08/26
      • Lungs: multiple randomly distributed pulmonary nodules of varying sizes, consistent with metastatic lesions.
        • dependental partial relaxation atelectasis of RLL.
        • massive Rt and moderate Lt, bilateral pleural effusions, with parietal pleural thickening.
        • multiple subleural bulla lung cyst in bilateral apical lungs
      • Mediastinum and hila: no enlarged LN or mass.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents: hypodense lesions in pancreatic tail up to 19mm.
        • several small hepatic cysts.
        • unremarkable of the spleen, GB, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • no obvious bowel wall thickening of colon and rectum based on CT images.
        • extensive spondylosis and degenerative spinal canal and lateral recesses stenosis at L4-S1 levels.
    • Impression:
      • bilateral pulmonary metastases and exudative pleural effusion, in progression and new pancreatic tail tumors (metastases d/d primary cancer) as compared with previous CT study on 2022/08/26
  • 2023-03-21 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Septal infarct, age undetermined
  • 2022-09-23 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated, metastatic, consistent with colorectal origin
    • Sections show neoplastic cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CK7(-), CK20(+), TTF-1(-), and CDX2(+). The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-08-26 CT - chest
    • Bilateral lung meta. Stable
    • Consolidation over left lower lobe, please monitor superimposed pneumonitis.
  • 2022-05-13 CT - chest
    • Multiple lung meta with necrotic or solid nodular appearance. In progression.
    • Small lymph nodes are found in the mediastinum.
  • 2022-04-06 CXR
    • Multiple nodules at RLL.
  • 2022-01-07 CT - abdomen
    • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
  • 2022-01-07 Colonoscopy
    • Previous surgical scar at low rectum was found. No recurrent.
  • 2020-12-04 CT - abdomen
    • There is no evidence of wall thickening in the rectum. Please correlate with colonoscopy.
  • 2020-12-04 Colonoscopy
    • No definite mucosal lesion was seen from rectum to cecum. Previous surgical scar at low rectum was seen without recurrent evidence
  • 2019-12-10 CT - abdomen
    • Clinical history: 73 y/o male patient with
      • 2019-04-08: He had been to KFSYSCC for second opinion, but they suggest him to receive surgery at our hospital, he refused APR, thus, transanal local excisin + CCRT is first choice
      • 2019-05-03: adenocarcinoma of low rectum s∕p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+)
      • 2019-06-14: for CEA report (suggest CTC), s∕p 22th R∕T, refuse chemotherapy, anal pain, 2019-07-19: finished R/T, no discomfort, refuse C/T
      • 2019-11-01: no discomfort, for follow-up programs.
    • With and without contrast enhancement CT of abdomen - whole:
      • Small gallbladder stone.
      • Liver cysts, up to 0.8cm in left lobe.
      • Unremarkable change of the spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Clnical lower rectal cancer s/p, suggest follow up.
      • Small gallbladder stone.
      • Liver cysts.
  • 2019-04-16 CT - abdomen
    • There are few small gas bubbles in the perirectal space, near anal verge. please correlate with clinical condition.
    • Few tiny gallstones are suspected.
  • 2019-04-16 Surgical pathology Level IV
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, rectum, transanal local excision —- Adenocarcinoma, moderately differentiated
      • Resection margins: involved, left
      • Lymph node, mesocolic, dissection —- Not received
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage I, pT2Nx(if cM0)
    • MACROSCOPIC EXAMINATION
      • Operation procedure: transanal local excision
      • Specimen site: rectum
      • Specimen size: 2.8 x 1.7 x 1.4 cm
      • Tumor size: 1.5 x 1.0 cm
      • Tumor location: anterior: 0.3 cm; right: 0.4 cm; posterior: 0.6 cm; left: involved; deep: 0.8 cm
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: congestion
      • Two separated tissue fragments measuring up to 2.0 x 0.7 x 0.5 cm are found.
      • All for section and labeled as: A1-2: cross section from right (green) to left (blue); A3: anterior; A4: posterior; A5: separated tissue fragments.
    • MICROSCOPIC EXAMINATION
      • Histology: adenocarcinoma; The immunohistochemical stains reveal CK(+) and CD56(-).
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Not identified.
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 8 mm from the margin,
      • Lymph node metastasis, mesocolic: not received
      • Lymph node metastasis, IMA / SMA: not received
      • Extranodal involvement: not received
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT2:Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): Nx
        • Distant Metastasis (pM): if cM0
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings: S2019-3459: IHC stain— PMS2(+), EGFR(+), MSH-2(+), MSH-6(+), MLH-1(+)
      • TNM descriptors: unknown
      • Tumor regression grading S/P CCRT: patient not received
  • 2019-04-15 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • ST abnormality, possible digitalis effect
    • Abnormal ECG
  • 2019-03-28 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • TxN0Mx

[consultation]

  • 2023-03-27 Thoracic Surgery
    • Q
      • This is a 77 years old male with adenocarcinoma of low rectum s/p transanal local excision in 2019 with lungs metastases, stage IVa.
      • Complained about shortness of breath for 15+ days, exertional dyspnea. He came to ER on 2023/03/21, and was admitted on 2023/03/22.
      • Pig tail was inserted on 2023/03/22 for pleural effusion, output:1400 on 2023/03/22.
      • However, patient complained about exertional coughing/pain in the evenging, CXR showed focal pneumothorax. at 23:38 on 2023/03/22.
      • Symptom improved with rest. Educated about emptying air from the bag to the patient and caretaker.
      • Subcutaneuos emphesema was observed on 2023/03/24 over right lower neck and right axillary and right lateral chest wall.
      • After discussing with our VS, he suggested to put local compression over the pig tail insertion spot due to relatively asymptomatic manifestation.
      • Patient tolerated the situation well excpet exertional shortness of breath, until 2023/03/26 evening when he complained about enlarged area of subcutaneuos emphysema
      • LPS 18cm H2O was connected to pig tail on 2023/03/26, 22:57
      • His SpO2 remained 94-99%, stable TPR.
      • We would like to consult your expertise, thank you!
    • A1
      • S
        • This 77 y.o male was a case of Rectal Ca, Adenocarcinoma, post OP in 2019 with lung metastasis, stage IVa now. This time, he was admitted due to progressive dyspnea and bilateral pleural effusion noted on CXR on 2023-03-21. Chest echo + right pig-tail insertion for effusion drainage was done on 2023-03-22. Unfortunately, little subcutaneous emphysema and right focal pneumothorax was noted since 2023-03-24 by CXR. This condition not improvement after conservative treatment and LPS 18cm H2O. Follow up CXR on 2023-03-27 showed prograssive right subcutaneous emphysema and we were consulted for further treatment.
      • O
        • 2023-03-27 CXR: bilateral subcutaneous emphysema, pneumomediastinum, left CP angle blunting due to pleural effusion and right pig-tail in position.
      • Suggestion
        • keep right pig-tail drainage with LPS 15-20cm H2O, if necessary, may try two bottle drainage system
        • please consult Chest surgeon to evaluate his subcutaneous emphysema condition and the indication of surgical treatment or not
    • A2
      • may replace pigtail with chest tube. Bigger calibre would offer adequate chest drainage to release patient’s subcutaneous emphysema.

[SOAP]

  • 2022-08-19 Colorectal Surgery
    • A
      • adenocarcinoma of low rectum s/p transanal local excision (2019-04-15), pT2NxM0, stage I, at least, G2, LVI(-), PNI(+), left margin involved (+), s/p R/T
    • P
      • APR is refused, so arrange CCRT (R/T + UFUR by patient choice, BUT he refuse chemotherapy!)
      • F/U CEA + CXR (2022-07), CT (2022-12), colonoscopy (2022-12)
      • 2022-08-19 he did not receive CT-gioded biopsy for lung lesions (personal reason), re-check chest CT

[surgical operation]

  • 2019-04-15
    • Diagnosis: Adenocarcinoma of low rectum, cT1N0M0
    • PCS code: 74211B - Extensive excision of sacrococcygealrectal villous adenoma or malignacy
    • Finding
      • A 1.5cm tumor was identified at 3-5cm above anal verge of anterior aspect of low rectum.
      • Friable tumor pieces was pelling off after putting anal retractor.
      • Full-thickness local rectal excision was performed as possible to gain a safe margin.
      • Normal saline irrigation and hemostasis was done. Blood loss was about 10-20ml.
      • The wound was closed with 4/0 vicryl.
  • 2017-10-12
    • Diagnosis: back tumor
    • PCS code: 62011C - Excision of skin or subcutaneous tumor (Except face) - 2 to 4 cm
    • Finding: back tumor 3cm, x1
    • Procedure: Under LA, the tumor was excised. The wound was closed with 3-0 viryl and 4-0 Nylon.

[immunochemotherapy]

  • 2023-10-02 - Avastin + FOLFIRI
  • 2023-08-31 - Avastin + FOLFIRI
  • 2023-08-02 - Avastin + FOLFIRI
  • 2023-07-12 - Avastin + FOLFIRI
  • 2023-06-23 - Avastin + FOLFIRI
  • 2023-06-02 - Avastin + FOLFIRI
  • 2023-05-05 - FOLFIRI
  • 2023-04-07 - FOLFIRI

==========

2023-08-04

The recently refilled repeat prescription for Vemlidy (tenofovir alafenamide) on 2023-07-05 is being utilized without any reconciliation issues detected.

2023-03-29

On 2023-03-24, a Port-A was inserted for the patient who previously refused chemotherapy.

All the oral/inhaled medications in the active prescription are appropriate for his respiratory symptoms, including Sodicon (dextromethorphan), Butanyl (terbutaline), and Ipratran (ipratropium bromide).

700547380

231003

[exam findings]

  • 2023-09-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (75.9 - 14.9) / 75.9 = 80.34%
      • M-mode (Teichholz) = 80
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-08-25 Nerve Conduction Velocity, NCV
    • Findings
      • Slowed NCVs in bilateral ulnar CMAPs above elbow.
      • Normal sensory NCV study in both arms.
    • Conclusion
      • This abnormal NCV study suggestd bilateral ulnar neuropathy acrossed elbow.
  • 2023-08-22 C-spine AP + Lat
    • mild anterior and posterior spur formation at the middle C-spine.
    • moderate decreased disc spaces in the C4/5 and C5/6 discs.
  • 2023-08-09 CT - brain
    • No definite intracranial abnormality.
  • 2023-07-26 CT - chest
    • Findings
      • Lungs: a part solid nodule, solid component < 5mm (6.4mm) at RLL, and 5mm granuloma at S9 of the same lobe. normal appearance of RUL, RML, and left lung.
      • Chest wall and visible lower neck: an enhancing tumor (28.3x28mm) at upper portion of the Rt breast, a 9.2mm lymph node at Rt axilla.
    • Impression:
      • Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla.
      • RLL part solid nodule 6.4mm,possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
  • 2023-07-17 Patho - breast biopsy (no need margin)
    • Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 90%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2023-07-17 Patho - lymphnode biopsy
    • Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67 (20%), E-cadherin (+).
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.

[MedRec]

  • 2023-09-05 ~ 2023-09-08 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of right female breast
      • Right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR (-, 0%, intensity), Her2/neu: negative (score = 1+), Ki-67 (20%), E-cadherin (+)
    • CC
      • for prepare chemotherapy.
    • Present illness
      • This 59 years old female had denied any underlying disease. According to the patient and family, the patient suffered from suspect L’t breast lesion form mammography on 2017/05/11. Due to sign and symptom exacerbation, the patient called at our OPD for help. Mammography and breast sono were done on 2017/07/12 showed regional microcalcifications in left breast, upper portion, probably benign finding-short interval follow-up suggested.
      • Sono showed Bil. fibroadenomas as described. Due to bilateral breast lump with calcification for several years, long-term follow up until 2022 loss follow up.
      • Last half year, feel discomftable, visted to our GS OPD follow up. Breast SONO was done on 2023/07/07 showed highly suspicious of malignancy, with sonographic positive axillary LAP, suggested core-needle biopsy was arranged on 2023/07/17.
      • Pathology showed Lymph node, right, axillary, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+); Breast, right, 12/2, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
      • Then, CT image was done on 2023/07/26 showed Rt breast cancer (28.3x28mm) and a 9.2mm lymph node at Rt axilla, RLL part solid nodule 6.4mm, possibly early ca d/d inflammation, suggest F/U low dose CT at 6-12 months later. RLL 5mm granuloma too.
      • Brain CT was survey on 2023/08/09 shoaed No definite intracranial abnormality. Diagnosis was right breast invasive carcinoma, cT1N1M0, stage IIA, no special type, NST. IHC stains: ER(+, 100%, strong intensity), PR(-, 0%, intensity), Her2/neu: negative(score=1+), Ki-67(20%), E-cadherin(+).
      • This tims, she was admitted for prepare chemotherapy.
    • Course of inpatient treatment
      • After admission, arrange 2D echo before chemotherapy with Epirubicin + Cyclophosphamide on 2023/09/06 showed LVEF:80%, Normal chamber size, Adequate LV and RV systolic function, Mild MR, TR and PR, No regional wall motion abnormalities. Then, she received chemotherapy with Epirubicin (90mg/m2) + Cyclophosphamide (600mg/m2) on 2023/09/06 smoothly. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. BP drop was noted, IVF for support. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, she was discharged on 2023/09/08 and OPD followed up later.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC

[chemotherapy]

  • 2023-10-02 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-09-06 - epirubicin 90mg/m2 120mg NS 100mL 30min + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-10-03

[leukopenia]

2023-09-28 WBC 5.63 x10^3/uL 2023-09-21 WBC 1.66 x10^3/uL * 2023-09-13 WBC 4.32 x10^3/uL 2023-09-05 WBC 5.12 x10^3/uL

The leukopenia observed on 2023-09-21 at 1.66K/uL occurred approximately 2 weeks after her first administration of epirubicin and cyclophosphamide. Granocyte (lenograstim 250ug) was administered for 3 consecutive days beginning on 2023-09-21.

The second dose of epirubicin and cyclophosphamide was administered on 2023-10-02 and prophylactic G-CSF was considered and prescribed in advance for 2023-10-09 to 2023-10-11 during the double tenth consecutive holidays. Leukopenia is expected to be less severe this time.

701060439

231003

[exam findings]

  • 2023-09-18 Tc-99m MDP bone scan
    • Increased activity in the skull base, maxilla, L2 -3 spines, bilateral sternoclavicular junctions and right scapula, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions at bilateral shoulders, S-I joints, and hips.
  • 2023-09-16 CT - facial bone
    • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
    • No involvement of the nasal bone by this tumor.
  • 2023-09-15 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side

[MedRec]

  • 2023-09-14 SOAP Hemato-Oncology Gao WeiYao
    • O: She was found to have skin tumor during her stay at nursing home at Taichung (Nursing head 5A mother)
    • A: Nose skin tumor
  • 2023-09-14 SOAP Radiation Oncology Huang JingMin
    • S:
      • For radiotherapy due to squamous cell carcinoma of the nose skin.
      • PI: the patient suffered from squamous cell carcinoma of the nose skin. She was transferred from TaiZhong
    • O:
      • ECOG: 2
      • PE: neck and bil SCF: neg; nose: a huge tumor over left side nasal area. Sit on a wheelchair.
      • Pathology (SE22304418, 2023-08-09):
        • Skin, 3 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, 6 o’clock, biopsy - severe dysplasia.
        • Skin, 9 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, 12 o’clock, biopsy - involved by invasive carcinoma.
        • Skin, tumor body, biopsy - squamous cell carcinoma, moderately differentiated.
      • A: Squamous cell carcinoma, moderately differentiated of the left nasal area.
      • P: Radiotherapy is indicated for this patient with the following indicators: unresectable tumor over left nasal area
        • Goal: pallaition
        • Treatment target and volume: left nasal area and possible involved area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 6000cGy/30 fractions of the left nasal tumor bed area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-09-20.
  • 2023-09-13 SOAP Plastic and Reconstructive Surgery Lu ChunDe
    • S: SCC, protrusion mass
    • O:
      • 8cm protrusion mass
      • radiotherapy first,
      • waiting for shrinkage of tumor, then considering surgery excision
  • 2017-07-13 SOAP Psychosomatic Medicine Li JiaFu
    • Diagnosis
      • Chronic fatigue syndrome [R53.82]
      • Generalized anxiety disorder [F41.1]
      • Major depressive disorder single episode, unspecified [F32.9]
      • Nonorganic sleep disorder, unspecified [F51.9]
      • Dementia in conditions classified elsewhere without behavioral disturbance [F02.80]
      • Senile dementia, uncomplicated [F03.90]

[consultation]

  • 2023-09-22 Gastroenterology
    • Q
      • The 79 y/o woman living in TaiChung nusring home, who is 5A HN’s mother. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for percutaneous endoscopy gastrostomy.
    • A
      • 79 years old female with SCC of nose, stage II and plan to CCRT. However, for PEG insertion, we are consulted.
      • O
        • conscious: E4VaM4
        • chest: smooth breath pattern, N/C: 3L
        • abdomen: soft and flat
        • Lab
          • 2023-09-21 S-GOT/AST 15 U/L
          • 2023-09-21 S-GPT/ALT 11 U/L
          • 2023-09-21 Creatinine 1.16 mg/dL
          • 2023-09-21 WBC 8.93 x10^3/uL
          • 2023-09-21 PLT 154 *10^3/uL
        • CT scan impression:
          • One large protuding mass (3.4cm) arising from left-side of the nose, showing heterogeneous enhancement. Highly suspect malignancy. Suggest tissue proof.
          • No involvement of the nasal bone by this tumor.
      • Impression
        • Dysphagia
        • SCC of nose, stage II
      • Suggestion
        • Complication of PEG was informed to family
          • Minor: Wound infection, Tube leakage to abdominal cavity (peritonitis), Stoma leakage, Inadvertent PEG removal, Tube blockage, Pneumoperitoneum, Gastric outlet obstruction, Peritonitis
          • Major: Aspiration pneumonia, Hemorrhage, Buried bumper syndrome, Perforation of bowel, Necrotizing fasciitis, Metastatic seeding
        • Plan for PEG insertion on 10/4.
        • Please also discuss gastrostomy with the general surgery
  • 2023-09-21 General and Gastroenterological Surgery
    • Q
      • The 79 y/o woman living in TaiChung nusring home. Newly diagnosis of SCC of nose, stage II. Due to she easy choking and can’t NG insertion, so we need your help for gastrostomy.
    • A
      • O:
        • vital signs: stable, no fever
        • abdomen: soft, ovoid, decrease bowel sound, no tenderness, no rebounding pain
        • lab data: see chart
      • A: SCC of nose, stage II.
      • P: Due to no operation room available and less general anesthesia and surgical risk, consult GI for percutaneous endoscopy gastrostomy is suggested.
  • 2023-09-15 Oral and Maxillofacial Surgery
    • Q
      • The 79 y/o woman living in TaiChung nusring home. This time, her left nose has mass and pathology showed squamous cell carcinoma, moderately differentiated of the left nasal area. Due to RT Director Huang suggested tooth extraction, so we need your help for management.
    • A
      • We are consulted for pre-RT dental evaluation.
      • O
        • General appearnce:ill looking
        • dementia was observed, uncooperative
      • intraoral examination:
        • multiple deep carious retained root of tooth 24, 25, 44 and 45 was noticed.
      • Plan:
        • Because the patient cannot cooperate, the tooth may not be extracted under local anesthesia.
        • It is recommended that cancer treatment be given priority. If the family considers tooth extraction before radiotherapy, another explanation will be arranged.

==========

2023-10-03

[tube feeding]

Concor 5mg — Please use the Simple Suspension Method (SSM) to place the tablet in warm drinking water and leave for 5-10 minutes, possibly stirring or gently shaking the container, until the tablet is dissolved, then can be passed through a feeding tube. This method involves dissolving tablets and capsules in warm water before suspending them for administration. This method could be used to administer Concor tablets through a feeding tube.

Const-K 750mg — The potassium content in fruits is relatively low, such as only about 2.2 mEq/inch or 0.9 mEq/cm in bananas. This means that consuming about two to three bananas is required to provide 40 mEq. Const-K is a type of extended-release tablet that contains 10 mEq/tab. One Const-K tablet provides less potassium than a single banana. If injectable potassium supplementation is not preferred, the tablet should be crushed into fine particles and taken with water.

701277889

231003

[exam findings]

  • 2023-04-24 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, left, partial mastectomy with frozen section (F2023-187) — invasive carcinoma, NST, no special type.
      • Margin: free
      • Lymph node, left, axillary sentinel, biopsy (S2023-187) — Free
      • pT2 pN0 (if cM0); anatomic stage: IIA, at least, pathology prgnostic stage group: IIA, at least.
      • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).
    • Gross Description
      • Procedure- partial mastectomy:10.5 x 8 x 3 cm. Skin: 5.5 x 2.0 cm. No nipple..
      • Lymph node sampling (if lymph nodes are present in the specimen)- Sentinel lymph node(s)
      • Specimen laterality- left
      • Sections are taken and labeled as:
        • Tissue for frozen section: F2023-187FS: deep margin.
        • Tissue for formalin fixation: F2023-187: A1-4: 12, 3, 6, 9 o’clockmargins; A5-6: tumor; A7: skin. S2023- 7821: sentinel lymph node.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma, NST
        • Size of invasive carcinoma (mm): 27 mm
        • Histologic grade (Nottingham histologic score): grade II (score 6,7)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue.
      • For Ductal Carcinoma In Situ- no DCIS.
        • Tumor size (mm)- no DCIS.
        • Nuclear grade- no DCIS.
        • Architectural pattern- no DCIS.
        • Tumor necrosis- no DCIS.
      • Margins:
        • Negative, Closest margin (10 mm from deep margin)
      • Nodal status: Negative (sentinel)
        • No. examined: 1
        • No. macrometastases (> 2 mm): 0
        • No. micrometastases (> 0.2 ~ 2 mm and/or > 200 cells): 0
        • No. isolated tumor cells (<= 0.2 mm and <= 200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)- no presurgical chemotherapy.
      • Immunohistochemical Study
        • IHC stains: (using block: F2023-187A5): ER (-), PR (-), Her2/neu: positive (score=3+), Ki-67: 90%, p53 (-).

[MedRec]

  • 2023-12-08 ~ 2023-12-09 POMR General and Gastroenterological Surgery Li ChaoShu
    • Discharge diagnosis
      • Left breast invasive carcinoma, pT2N0M0, stage IIA. ER (-), PR (-), Her2/neu: positive (3+), Ki-67: 90%. ECOG:0.
      • Post adjuvant chemotherapy with Ogivri (trastuzumab)
      • Carrier of viral hepatitis B
      • Agranulocytosis secondary to cancer chemotherapy
      • Dermatitis, unspecified
    • CC
      • adjuvant treatment for breast cancer
      • Two weeks after chemotherapy, multiple blisters and abscesses appeared on the soles of both feet.
    • Present illness
      • This 43-year-old female patient had Carrier of viral hepatitis B, but denied diabetes mellitus, hypertension, heart disease. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at the left breast over 1 month. She came to Dianthus MFM Clinic for help. She accepted core needle biopsy and diagnosis of left breast cancer at Dianthus MFM Clinic. She didn’t return Dianthus MFM Clinic for the report. Thus, she came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o’/ 6 cm, size: 2.34 x1.36 cm, rule out malignancy suggesting biopsy.
      • She underwent of left partial mastectomy + sentinel lymph node dissection on 2023/04/24. The pathology showed invasive carcinoma, pT2N0M0, stage IIA. ER:(-), PR:(-), Her2/neu: positive (score=3+), Ki-67: 90%.
      • Tc-99m MDP whole body bone scan revealed no evidence of bone metastasis. Chest CT showed liver is intact. CEA:0.428 ng/ml、CA-153: 14.102U/ml on 2023/4/21. After well explain including pathology and the possible treatment modality were well explained to the patient.
      • She completed 8 courses adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles since 2023/05/19 then shift to Taxotere 75mg/m2 and Ogivri 8mg/m2 since 2023/08/18~2023/10/23. We refer to CGMH for R/T(proton) since 11/20.
      • Under the impression of left invasive carcinoma, pT2N0M0, stage IIA. This time, she was admitted to 6th target therapy with Ogivri (trastuzumab) 6mg/m2.
    • Course of inpatient treatment
      • After admission, 6th target therapy with Ogivri (trastuzumab) was given. No discomfort after chemotherapy.
      • Consult dermatology department for severe hand-foot syndrome who suggst 1. predinisolon 1 / Bid, 2. Zaditen (ketotifen) 1 / Bid, 3. Sinpharderm x 1 tube/bid, 4. Mycomb x 2 tubes/bid use.
      • Under the stable condition, she was discharged today and arrange next admission three weeks later.
    • Discharge prescription
      • Asthan (ketotifen 1mg) 1# BID
      • Compesolon (prednisolone 5mg) 1# BID
      • Sinpharderm Cream (urea) BID TOPI
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI
  • 2023-04-23 ~ 2023-04-26 POMR General and Gastroenterological Surgery Li ChaoShu
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left breast cancer, cT1aN0M0, stage IA status post left partial mastectomy+sentinel lymph node dissection on 2023-04-24; ECOG 0
      • Carrier of viral hepatitis B
    • CC
      • She noted a palpable mass at left breast over 1 month.
    • Present illness
      • This 48-year-old female patient denied any systemic disease. She denied a cancer history. She denied any TOCC histories in recent 3 months.
      • She noted a palpable mass at the left breast over 1 month. Then she came to Dianthus MFM Clinic OPD for help, Dianthus MFM Clinic diagnosis that she got left breast cancer. She came to our hospital for a second opinion. Breast sonography showed a lesion, left 1.5 o‘/ 6 cm, size: 2.34 x1.36 cm, r/o malignancy suggesting biopsy. She accepted Core needle biopsy at Dianthus MFM Clinic, but she doesn’t return Dianthus MFM Clinic for the report. She had no dizziness, dyspnea, chest pain, chest tightness, nausea, vomiting, bowel habit change, or body weight loss. PE: symmetrical bilateral breasts. A hard, non-tender, movable mass and irregular margin at left breast around 2 x1.5 cm without discharge. The nipple was dimpling without exudative nor bloody discharge and no retraction. The right left skin had no cellulite change.
      • Under the impression of left breast invasive carcinoma, she was admitted for surgery of partial mastectomy + SLNB.
    • Course of inpatient treatment
      • This is a 48-year-old woman who underwent partial mastectomy + SLND today. During the surgery, IOUS was used to define the margins and location and partial mastectomy was done without complications. After admission, patient education with wound care was done. Due to her stable condition, she will be be discharged and followed up at our OPD.
    • Discharge prescription
      • MgO 250mg 1# TID
      • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
      • Acetal (acetaminophen 500mg) 1# TID

[consultation]

  • 2023-12-08 Dermatology
    • Q
      • for skin rush over bilateral foot
      • Adjuvant chemotherapy with Lipo dox + Endoxan for 4 cycles then Taxotere 75mg/m2 for 4 cycles with ogivri injection were suggest.
      • Under impression of left breast invasive carcinoma, she was admitted for 6th adjuvant chemotherapy with ogivri.
      • This time, she complained of multiple broken skin wounds and pain on the soles of both feet. We need your help with treatment and management.
    • A
      • This patient suffered from multiple vesicles on bil soles for days.
      • Imp: dyshidrotic dermatitis
      • Suggestion:
        • predinisolon 1 / Bid
        • Zaditen 1 / Bid
        • Sinpharderm x 1 tube/bid
        • Mycomb x 2 tubes/bid

[surgical operation]

  • 2023-04-24
    • Operation
      • BCT + SLND   
      • IOUS     
    • Finding
      • IOUS: a tumor mass over left breast, 1 o’clock/3cm location, was encountered.
      • Clinical tumor status:
        • Tumor size: 2cm (cT1c)   - Gross skin invasion: No   - Gross pectoral fascia invasion: No   - Tumor location: right side, lateral upper quadrum (1’/3cm)   - Clinical T stage: cT1c (<3 cm)
      • Clinical nodal status:   - Axillary dissection: SLND using isotope detection   - Gross LNs: negative LAPs   - Clinical N stage: cN0(sn)
      • OP status:   - Procedures: BCT + SLND   - Pre-OP tissue prove: CNB   - Nerve preservation: not encountered   - Drainage: nil   - PostOP elastic bandage: Yes   - PostOP skin flap: No   - Closure of wound: two-layer, 3-0 Vicryl and 5-0 Nylon
      • Path of frozen section: free margins
      • Biobank: blood + normal tissue + tumor

[chemotherapy]

  • 2023-12-08 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

  • 2023-11-18 - trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

  • 2023-10-23 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 400mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastin 150ug SC + glutathione 1500mg NS 200mL 20min
  • 2023-10-02 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 395mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL + filgrastim 150ug SC + glutathione 1500mg NS 200mL 20min
  • 2023-09-08 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 6mg/kg 389mg NS 250mL 90min (maintenance dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-08-18 - docetaxel 75mg/m2 120mg NS 250mL 1hr + trastuzumab 8mg/kg 514mg NS 250mL 90min (loading dose)

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-07-28 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-06-30 - liposome doxorubicin 30mg/m2 49mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 986mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-06-09 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 990mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL
  • 2023-05-19 - liposome doxorubicin 30mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr

    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + pyridoxal phosphate 20mg + NS 250mL

==========

2023-12-11

This patient has received six doses of Ogivri (trastuzumab) on the following dates: 2023-12-08, 2023-11-18, 2023-10-23, 2023-10-02, 2023-09-08, and 2023-08-18. The initial four doses were administered in combination with docetaxel. The patient reported skin symptoms approximately two weeks after the fifth dose of trastuzumab (2023-11-18), suggesting a possible link to trastuzumab.

Trastuzumab is known to potentially cause dermatologic adverse reactions, including skin rash (4% to 18%), acne vulgaris (2%), nail disease (2%), and pruritus (2%).

The discharged medications include those recommended by our dermatologist; it is advised to continue monitoring for changes in symptoms.

[glutathione - peripheral neuropathy]

Additionally, the pre-chemotherapy medications on 2023-10-02 and 2023-10-23 included glutathione. The 2020 ASCO systematic review of neuroprotectants for prevention of chemotherapy-induced peripheral neuropathy (CIPN) concluded that glutathione should not be offered for prevention of CIPN to patients receiving treatment with paclitaxel plus carboplatin, and that N-acetyl cysteine should not be offered to patients receiving potentially neurotoxic chemotherapy [1]. This position was also taken in the 2020 joint ESMO/EONS/EANO guidelines [2].

[1] Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. [2] Systemic anticancer therapy-induced peripheral and central neurotoxicity: ESMO-EONS-EANO Clinical Practice Guidelines for diagnosis, prevention, treatment and follow-up. Ann Oncol 2020; 31:1306.

2023-10-03

[diarrhea]

Both docetaxel and trustuzumab have been reported to be associated with diarrhea (23% to 43% and severe diarrhea <= 6% for the former and 7% to 25% for the latter).

In the event of diarrhea, it is recommended that loperamide (2 mg/cap) be used with an initial 2# followed by 1# every 2 to 4 hours or after each loose stool; for diarrhea persisting > 24 hours, administer 1# every 2 hours (or 2# every 4 hours). Continue until 12 hours have passed without loose stools. Doses > 8# per day may not provide benefit; consider alternative therapy if diarrhea persists >= 48 hours.

[leukopenia]

2023-10-02 WBC 6.23 x10^3/uL 2023-09-14 WBC 1.56 x10^3/uL 2023-09-08 WBC 6.62 x10^3/uL 2023-09-01 WBC 14.67 x10^3/uL 2023-08-25 WBC 1.67 x10^3/uL 2023-08-18 WBC 5.34 x10^3/uL 2023-07-28 WBC 7.35 x10^3/uL 2023-06-30 WBC 6.00 x10^3/uL 2023-06-09 WBC 6.17 x10^3/uL 2023-05-26 WBC 7.59 x10^3/uL 2023-05-12 WBC 11.26 x10^3/uL 2023-04-18 WBC 8.85 x10^3/uL

Leukopenia was observed on 2023-09-14 and 2023-08-25, approximately 1 week after the administration of docetaxel + trastuzumab (on 2023-09-08 and 2023-08-18), prophylactic G-CSF might be considered.

[G-CSF administration timing]

G-CSF is usually started no earlier than 24 hours after administration of chemotherapy. Continuation until the absolute neutrophil count following the nadir exceeds 10,000/microL, as specified in the G-CSF package insert, is known to be safe and effective. However, a shorter duration that is sufficient to achieve clinically adequate neutrophil recovery is a reasonable alternative, considering issues of patient convenience and cost. G-CSF should not be given in the day or days prior to the next cycle of chemotherapy, or on the same day as chemotherapy or radiation therapy is administered. Ref:

  • Supportive therapies in the prevention of chemotherapy-induced febrile neutropenia and appropriate use of granulocyte colony-stimulating factors: a Delphi consensus statement. Support Care Cancer. 2022 Dec;30(12):9877-9888. doi: 10.1007/s00520-022-07430-7. Epub 2022 Nov 5. PMID: 36334157; PMCID: PMC9715510.
  • Pegfilgrastim on the Same Day Versus Next Day of Chemotherapy in Patients With Breast Cancer, Non-Small-Cell Lung Cancer, Ovarian Cancer, and Non-Hodgkin’s Lymphoma: Results of Four Multicenter, Double-Blind, Randomized Phase II Studies. J Oncol Pract. 2010 May;6(3):133-40. doi: 10.1200/JOP.091094. PMID: 20808556; PMCID: PMC2868638.

700201636

231002

[exam findings]

  • 2023-09-11, -09-10, -09-07, -09-04, -09-01, -08-14, -08-08, -08-07, -07-20, -07-18, -07-13, -07-12, -06-26, -06-19, -06-01, -05-29, -05-25, 05-22, -04-19 Body fluid cytology - ascites
    • Negative
  • 2023-05-22 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 10 dB HL; LE 21 dB HL
    • R’t WNL.
    • L’t normal to mild CHL.
  • 2023-04-20 Patho - soft tissue biopsy/simple excision (non lipoma)
    • PATHOLOGIC DIAGNOSIS
      • Lesser omentum, excision — Metastatic serous carcinoma
      • Soft tissue, abdominal wall #1 and #2, excision — Foreign body granuloma
      • Soft tissue, LUQ, excision — Foreign body granuloma
    • MACROSCOPIC EXAMINATION
      • The specimen is submitted in four parts. Part (1) consists of six pieces of gray-white and firm soft tissue, labeled “abdominal wall tumor #2”, measuring up to 3.0 x 2.5 x 0.5 cm. All for section as: A1-A4. Part (2) consists of a piece of soft tissue, received for frozen section, labeled “abdominal wall tumor #1”, measuring 5.5 x 2.9 x 0.5 cm. On section, an white and firm nodule is noted, measuring 2.5 x 1.0 x 0.4 cm. Representative parts are taken for section as: F2023-00178 and FSA1. Part (3) consists of a piece of pinkish white soft tissue, received for frozen section, labeled “lesser omentum tumor”, measuring 1.2 x 1.0 x 0.3 cm. All for section as: F2023-00178FSB-ink green. Part (4) consists of a piece of soft tissue, received for frozen section, labeled “LUQ tumor”, measuring 1.0 x 0.9 x 0.3 cm. All for section as: F2023-00178FSB without ink.
    • MICROSCOPIC EXAMINATION
      • The sections of “lesser omentum tumor” show a picture of metastatic serous carcinoma, composed of pleomorphic polygonal tumor cells, arranged in solid and papillary patterns. The sections of “abdominal wall tumor #1 and #2” and “LUQ tumor” show a picture of foreign body granuloma, composed of foreign material surrounded by histiocytes and foreign body type giant cells.
  • 2023-04-17 SONO - abdomen
    • mild fatty liver
    • fatty infiltration of pancreas
  • 2023-03-08 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2023-02-08 PET
    • The left subphrenic lesion shown on the previous abdomen CT reveals increased FDG uptake, highly suspected tumor seeding.
    • Increased FDG uptake in bilateral pulmonary hilar regions, probably reactive nodes.
    • Increased FDG uptake in bilateral palatine tonsils, probably chronic inflammation/infection process.
    • Increased FDG uptake in the lower abdomen and left pelvis, probably physiological uptake of FDG in the colon. However, tumor seeding should be excluded.
    • Left ovarian cancer s/p treatment with highly suspected tumor seeding in the left subphrenic region, by this F-18 FDG PET scan.
  • 2023-01-31 CT - abdomen
    • History and indication: ovary cancer with peritonal seeding
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. S/P Port-A infusion catheter insertion. A nodule at left subphrenic region.
      • A calcified spot (3.7cm) at S6 of liver.
    • IMP: S/P hysterectomy. A nodule at left subphrenic region r/o tumor seeding.
  • 2022-09-17 Gynecologic Ultrasonography
    • Bilateral adnexae: free
    • ATH
    • No obvious uterine or ovarian lesion
  • 2022-08-10 CT - abdomen
    • History: Ovarian CA. pT3bN0Mx; FIGO stage IIIB, s/p debulking surgery on 8/26 19 by Dr Zhen LunNa, s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Jan 2020 & recurrence wt peritoneal seeding in Jan 2021, s/p debulking wt HIPEC on 3/24 21 by Dr Li ZhaoShu,
    • Impression: S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2022-02-17 CT - abdomen
    • History and indication: ovary cancer with peritonal seeding
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. S/P Port-A infusion catheter insertion.
      • A calcified spot (3.7cm) at S6 of liver.
    • IMP: S/P hysterectomy. No evidence of tumor recurrence.
  • 2021-10-06 CT - abdomen
    • History and Indication: Recurrent Ovarian CA.
    • Impression:
      • S/P hysterectomy
      • Prior CT identified several soft tissue nodules (up to 0.8cm) in the omentum of left upper abdomen are not noted again, that is compatible with tumor seeding S/P C/T show complete response.
  • 2021-03-25 Patho - soft tissue biopsy/simple excision (non lipoma)
    • DIAGNOSIS:
      • Soft tissue , greater omentum, left, cytoreductive surgery — High-grade serous carcinoma, recurrent
      • Soft tissue , omentum, frozen biopsy — foreign body suture granuloma
      • Description: Microscopically, the sections show high grade serous carcinoma composed of irregular branching and highly cellular of neoplastic papillae and solid sheets of tumor cells with small papillary clusters spearated by hyaline fibrous stroma. Section FSA shows a foreign body suture granuloma.
      • Immunohistochemical stain reveals PAX8(+), CK7(+), CK20(-), WT-1(+).
  • 2021-02-23 SONO - abdomen
    • Diagnosis: ovarian cancer s/p OP
    • Suggestion: further laparoscopy and maybe CRS
  • 2021-02-06 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2021-01-30 CT - abdomen
    • Clinical history: 49 y/o female patient with Ovarian CA s/p Op & C/T.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy and oophorectomy.
      • There are soft tissue nodules (up to 0.8cm) in mensentery of left upper abdomen
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • Soft tissue nodules in LUQ, r/o peritoneal carcinomatosis.
  • 2020-08-12 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2020-08-01 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2020-04-08 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2020-02-15 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
  • 2019-12-25 Gynecologic Ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2019-08-27 Surgical Pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, debulking surgery — High-grade serous carcinoma
        • Fallopian tube, left, ditto — Free from tumor invasion
      • Ovary, right, ditto — High-grade serous carcinoma
        • Fallopian tube, right, ditto — Free from tumor invasion
      • Cervix, uterus, ATH — Free of tumor invasion
        • Endometrium — Hyperplasia with nuclear atypia and free of tumor invasion
        • Myometrium — Free of tumor invasion
      • Omentum, omentectomy — High-grade serous carcinoma
      • Appendix, appendectomy — Involved by tumor in muscular wall
      • Soft tissue, “tumor”, excision — Carcinoma
      • Lymph nodes
        • Lymph node, R’t pelvic 1, dissection — Free of tumor metastasis (0/14)
        • Lymph node, R’t pelvic 2, ditto — Free of tumor metastasis (0/1)
        • Lymph node, L’t pelvic 3, ditto — Free of tumor metastasis (0/6)
        • Lymph node, L’t pelvic 4, ditto — Fat tissue only
      • AJCC Pathologic staging: pT3bN0Mx; FIGO stage IIIB at least
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: ATH, BSO, pelvic tumor excision, omentectomy, appendectomy, lymph node dissection
      • Specimen type: Uterus, bilateral adnexa, pelvic tumor, omentum, appendix & 4 bottles of lymph nodes
      • Specimen size:
        • R’t ovary: 2.2 x 1.4 x 1.3 cm
        • R’t fallopian tube: 4 x 0.7 x 0.6 cm
        • L’t ovary: 3.3 x 1.7 x 1.1 cm
        • L’t fallopian tube: 4 x 1.2 x 1.1 with paratubal cyst, 1.2 cm in diameter
        • Uterus: 9.1 x 6.2 x 5 cm in size and 125 gm in weight
        • Cervix: Nobothian cysts
        • Endometrium: thickness, 0.7 cm
        • Myometrium: No significant change
      • “Tumor” soft tissue: one small piece, 3.2 x 2.3 x 0.9 cm in size
      • Omentum: one piece, 17.5 x 6.3 x 3.3 cm in size
      • Appendix: 3.7 x 0.7 x 0.7 cm in size
      • Tumor site: bilateral ovary and peri-adnexal soft tissue
      • Tumor size: a few foci, up to 1.0 x 0.4 cm in dimension
      • Tumor appearance: Papillary and solid
      • Specimen integrity: Intact
      • Lymph nodes: R’t pelvic 1 (5 gm), R’t pelvic 2 (0.2 gm), L’t pelvic 3 (2 gm) and L’t pelvic 4 (0.2 gm)
      • Representative sections as: A1: R’t ovary, A2-A3: R’t F-tube, A4-A7: L’t ovary + F-tube, A8-A15: endometrium, myometrium, endocervix and cervix, A16: endometrium + myometrium, B1-B4: omentum, C: appendix, D: “tumor” soft tissue, E1-E2: R’t PLN1, F: R’t PLN2, G: L’t PLN3 and H: L’t PLN4
    • MICROSCOPIC EXAMINATION
      • Histologic type: High-grade serous carcinoma [IHC stains: CK7(+), WT-1(+), PAX-8(+), P53(+, 100%), ER(+)]
      • Histologic grade: High grade
      • Contralateral ovary involvement: Present
      • Tumor side ovarian surface involvement: Present
      • Contralateral ovary surface involvement: Present
      • Right tube involvement: Absent
      • Left tube involvement: Absent
      • In situ adenocarcinoma in right &/or left fallopian tube: Absent
      • Right adnexa soft tissue involvement: Present
      • Left adnexa soft tissue involvement: Present
      • Pelvic soft tissue involvement: Present (“tumor”)
      • Uterine serosa involvement: Absent
      • Omentum involvement: Present
      • Uterine Cervix involvement: Absent. chronic cervicitis with Nabothian cyst
      • Endometrium involvement: Absent. Hyperplasia with nuclear atypia
      • Myometrium involvement: Absent
      • Appendix: Involved by tumor
      • Lymph nodes metastasis: Free of tumor metastasis, total number: 0/21
  • 2019-08-10 Gynecologic Ultrasonography
    • Suspected RT ovarian mass

[chemotherapy]

  • 2023-09-28 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-09-07 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-08-31 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-08-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-08-04 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-07-14 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-07-10 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-06-23 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-06-16 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-05-29 - paclitaxel 60mg/m2 90mg NS 250mL 1hr IP (D8)

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-05-22 - paclitaxel 135mg/m2 210mg NS 250mL 24hr D1 + cisplatin 75mg/m2 100mg NS 500mL D2

    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + NS 250mL] D2 + aprepitant 125mg PO D2-4
  • 2023-04-19 - [liposome doxorubicin 30mg/m2 50mg D5W 100mL + carboplatin AUC 5 675mg NS 250mL] 90min IP (HIPEC)

  • 2022-07-25 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-06-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-04-21 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-03-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-03-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-02-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-01-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-01-05 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-10 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-02 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-31 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-27 - docetaxel 60mg/m2 95mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 500mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-23 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 600mg NS 250mL] 90min IP (LipoDox dose reduced)

  • 2020-01-14 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + acetaminophen 500mg PO + granisetron 2mg + NS 250mL

==========

2023-10-02

Leukopenia was observed in mid-Sep with a nadir of 1.31K/uL, occurring after the administration of paclitaxel + cisplatin through IV on 2023-08-31, and paclitaxel through IP on 2023-09-07. Granocyte (lenograstim 250ug) has been administered for 3 consecutive days beginning on 2023-09-14, and no instances of leukopenia have been reported thus far.

2023-09-28 WBC 4.17 x10^3/uL
2023-09-21 WBC 7.00 x10^3/uL
2023-09-14 WBC 1.31 x10^3/uL ** 2023-09-10 WBC 1.96 x10^3/uL *
2023-09-07 WBC 3.70 x10^3/uL

2023-09-01

According to data from both PharmaCloud and HIS5, the patient has only been treated in the hemato-oncology department at our facility. Consequently, no issues with medication reconciliation have been found.

2023-08-07

Based on the records from the PharmaCloud and HIS5, the patient exclusively utilizes healthcare services at the hemato-oncology department in our hospital. As a result, no medication reconciliation discrepancies have been detected.

2023-07-11

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-19

  • The PharmaCloud database reveals that all medical needs of this patient have been met at our hospital in the last three months. Consequently, no medication reconciliation issues have been identified.

  • The patient’s serum potassium level was slightly low at 3.3mmol/L as of 2023-06-16, and it has been trending downwards. It might be helpful to recommend that the patient consume more potassium-rich foods.

    • 2023-06-16 K(Potassium) 3.3 mmol/L
    • 2023-06-07 K(Potassium) 3.7 mmol/L
    • 2023-05-29 K(Potassium) 3.9 mmol/L

700998220

231002

[MedRec]

  • 2023-07-06 SOAP Gastroenterology Chen JiangLin
    • S
      • 49 y/o
      • 2023/07/06 partial response (hiccup)
      • 2023/06/15 belching, and acid reflux, bloating (+), long time.
      • PH: nephrotic symdrome
      • ABC(-)
    • O
      • 2023/06/15 GERDa
    • Prescription
      • Mopride (mosapride citrate 5mg) 1# BIDAC
      • Gaslan (dimethylpolysiloxane 40mg) 1# BID
      • Dexilant (dexlansoprazole 60mg) 1# QD
      • Flupine (fludiazepam 0.25mg) 1# BID
  • 2023-07-04 SOAP Hemato-Oncology He JingLiang
    • P: Chemotherapy Velcade (bortezomib 3.5 mg/vial) 2 mg SC ST
    • Prescription
      • Thado (thalidomide 50mg) 1# HS
      • Limeson (dexamethasone 4mg) 5# QD
      • Ulstop (famotidine 20mg) 1# BID
  • 2023-05-19 SOAP Hemato-Oncology Wan XiangLin
    • P
      • Apply for major disease and approved
      • Chemotherapy with VTD (C1W1 20230526)
  • 2023-03-30 SOAP Nephrology Peng QingXiu
    • A
      • Renal biopsy 2023-03-20
      • R/O IgA nephropathy with amyloidosis
    • P
      • DC carvedilol
      • DO workup for Monoclonal gammopathy.
  • 2023-03-19 ~ 2023-03-21 POMR Nephrology Peng QingXiu
    • Discharge diagnosis
      • Nephrotic syndrome with other morphologic changes, s/p renal biopsy
    • CC
      • Foamy urine(+) for 3 months and both leg edema ++
    • Present illness
      • This is a 49 y/o female with history of GERD. She denied systemic diseases, operation history, pregnancy, or allergic history. TOCC(-)
      • This time, she suffered from bilateral lower limbs edema for 7 months since 2022/08. Her edema relived while legs elevation, and exacerbated while waking or sitting. There was also foamy urine noted recently.
      • She denied leg pain, abnormal sensation of bilateral limbs, neck swelling, dysuria, urinary frequency or medication history.
      • Due to above condition, she had visited LMD and our CV and Nephrologic OPD.
      • Cervical ultrasound was done and revealed normal volume of thyroid in LMD. Mildly elevated D-dimer (1448.20 ng/mL(FEU)) and NT-proBNP (1237 pg/mL) were noted, excluding deep vein thrombosis (DVT) or heart failure (HF) induced bilateral legs edema.
      • Cardiac ultrasound on 3/10 showed LVEF 63% and impaired LV relaxation with restrictive physiology.
      • Normal value of C3, C4, IgG, IgM, and IgM indicated negative antoimmune kidney disease.
      • However, her albumin was low (2.7 on 3/11 -> 2.9 on 3/18) and high urine microalbumin (1268.88 mg/dL) was noted, despite normal eGFR (122.29).
      • Her ACR = microalbumin(mg/dL)/ urine creatinine(mg/dL) was within normal range 7.63 (<30).
      • Under the impression of bilateral lower limbs edema with high microalbuminuria and normal ACR ration, r/o nephrotic diseases, she was admitted for kidney biopsy and further survey.
    • Course of inpatient treatment
      • During the hospitalization, the hemograms, biochemistry testing. Renal biopsy was done, for urine analysis revelaed protein 4+. Post biopsy an examination.
      • Renal echo was performed on 2023/03/20. Showed pelvic heterogenous mass, r/o uterine myoma or pelvic mass. Suggestion: GYN OPD follow up. No hematura.
      • Under stable condition, she can be discharge on 2023/03/21. OPD follow up is arranged.   
    • Discharge prescription
      • Crestor (rosuvastatin 10mg) 1# QD
      • Uretropic (furosemide 40mg) 1# QD

[chemotherapy]

VTd regimen

==========

2023-10-02

[tube feeding]

The potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred, please crush the tablet into particles and administer it with water.

[diarrhea]

2023-09-02 Lab showed triglycerides (TG) 394 mg/dL and LDL-C 168mg/dL, Atozet (ezetimibe, atorvastatin) was initiated by our nephrologist. Due to recent diarrhea, Atozet is discontinued today. However, the possibility that Velcade (bortezomib) in VTd regimen (2023-05-26 started) may also be associated with diarrhea cannot be completely excluded.

By the way, a statin can be administered as an alternate day frequency with a similar efficacy and may have a lower incidence of side effects. Ref: Efficacy and Safety of Alternate-Day Versus Daily Dosing of Statins: a Systematic Review and Meta-Analysis. Cardiovasc Drugs Ther. 2017 Aug;31(4):419-431. doi: 10.1007/s10557-017-6743-0. PMID: 28741244.

701067842

231002

[exam findings]

  • 2025-01-20 Body fluid cytology - ascites
    • 15 cc yellow-green turbid ascites — Malignancy
    • The smears show inflammatory cells, necrotic debris, mesothelial cells and many hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma.
  • 2024-12-31 Tc-99m MDP bone scan
    • Mildly increased activity in the lower C-spine. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2024-12-12 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some soft tissues in peritoneal cavity with massive ascites. A cystic lesion (3.4cm) at left pelvic cavity.
      • A cystic lesion (3.9cm) at left cardiophrenic region. Small patchy density at LLL.
  • 2024-08-31 CT - abdomen
    • Finding
      • Ovarian cancer, s/p debulking surgery.
      • Presence of ascites and peritoneal nodules.
      • Small bowel dilatation with wall thickening and increased enhancement.
    • Impression
      • Ovarian cancer, s/p debulking surgery.
      • Ascites and peritoneal carcinomatosis
      • Desmoplastic reaction of small bowel
      • Partial response as comparted with previous CT study on 2024/02/27
  • 2024-07-23 SONO - abdomen
    • Finding
      • Small amount ascites with echogenic substance in it was noted around liver surface.
    • Diagnosis:
      • Complicated ascites, small amount
  • 2024-07-04 SONO - gynecology
    • IMP:
      • Ascites
      • R/O LT Pelvis cyst: 39x29mm
  • 2024-05-25 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Increased intestinal gas is found. Ileus is favored.
      • Massive ascites is found.
      • s/p ATH and BSO.
      • The GB is well distended without soft tissue lesion
    • Imp:
      • Increased intestinal gas is found. Ileus is favored.
      • Massive ascites is found. Cancerous peritonitis is considered.
  • 2024-03-15 Ascites tapping
    • Course: Paracentesis was performed at RLQ and 1300ml cloudy and orange-colored ascites was drained out with 18Fr catheter
  • 2024-02-29 Body fluid cytology - ascites
    • 50 cc, orange, cloudy — Malignancy
    • Smears show clusters of pleomorphic tumor cells. Malignancy is favored. Please correlate with the clinical presentation and further examination is suggested.
  • 2024-02-27 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some soft tissues in peritoneal cavity with massive ascites.
      • A cystic lesion (3.9cm) at left cardiophrenic region.
    • IMP:
      • S/P hysterectomy. R/O peritoneal carcinomatosis with massive ascites.
  • 2024-02-27 Ascites tapping
    • Course: 18G needle was inserted at RLQ under echo guided insertion and total 2200ml was obtained for analysis.
  • 2023-11-25 CT - abdomen
    • IMP: S/P hysterectomy. No evidence of tumor recurrence. R/O left ovary cyst (3.1cm). A cystic lesion (3.9cm) at left cardiophrenic region.
  • 2023-09-28, 2023-09-26, 2023-09-01, 2023-08-31, 2023-07-26, 2023-07-25, 2023-07-03, 2023-06-13, 2023-06-12 Body fluid cytology - ascites
    • Negative
  • 2023-07-21 CT - abdomen
    • Findings
      • S/P hysterectomy. There is a cystic lesion 4.2 x 2.8 cm in left anterior pelvis sidewall that is c/w lymphocele.
      • S/P Tenckhoff tube insertion from right lower abdominal wall and the tip located at the right lower perihepatic space.
      • Prior CT identified a cystic lesion 3.9 x 2.4 cm in left cardiac-phrenic angle is noted again, stationary.
    • Impression
      • S/P hysterectomy.
      • There is no evidence of tumor recurrence.
  • 2023-07-10 MRI - sella
    • No evidence of intracranial lesion.
  • 2023-05-25, -05-23 Body fluid cytology - ascites
    • Suspicious malignancy
  • 2023-04-21 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovaries, bilateral, BSO — Clear cell carcinoma
      • Uterus, ATH — Parametrium involved by carcinoma
      • Cul-de sac, debulking — Involv ed by carcinoma
      • Omentum, infracolic omentectomy — Involved by carcinoma
      • Peritoneal mass, debulking — Involved by carcinoma
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/34)
      • AJCC 8 th edition, Pathology stage: pT3cN0; stage IIIC; FIGO stage IIIC
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + Cul-de sac and peritoneal tumor excision
      • Specimen Size:
        • Five pieces, up to 5.5 x 5.0 x 3.2 cm (Lt ovary, received for frozen section), four pieces up to 4.9 x 3.2 x 2.9 cm (Lt ovary), 3.5 x 0.6 cm (Lt tube), four pieces, up to 9.3 x 7.8 x 2.5 cm (Rt ovary), 4.0 x 0.6 cm (Rt tube), 7.1 x 6.0 x 3.8 cm and 95 gm (uterus), four pieces up to 1.8 x 1.5 x 0.5 cm (Cul-de sac), five pieces up to 3.6 x 0.8 x 0.4 cm (peritoneal mass), 28.5 x 8.8 x 1.5 cm (omentum)
      • Specimen Integrity
        • Right ovary: Capsule ruptured
        • Left ovary: Capsule ruptured
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Bilateral ovaries
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Can not be assessed because of fragmented tumor tissue
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
      • Representative parts are taken for section and labeled as: F2023-00181FSA1, FSA2, A1-A6= left ovary. S2023-07635A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G2= left ovary, G3= left fallopian tube, H1-H3= right ovary, H4= right fallopian tube, I1= cervix, I2-I3= uterine corpus, I4-I6= parametrium, J= Cul-de sac, K1-K2= omentum, L= peritoneal mass.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High grade
      • Implants: Present
      • Other Tissue/Organ Involvement: Parametrial involvement
      • Peritoneal Fluid: Positive for malignant cells
      • Regional Lymph Nodes: All lymph nodes are negative for tumor cells
        • number of lymph node examined: 8 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator), 6 (left para-aortic) and 7 (right para-aortic)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Cul-de sac: Involved by carcinoma
      • Peritoneal mass: Involved by carcinoma
      • Omentum: Involved by carcinoma
      • Pathologic Stage
        • Primary Tumor: pT3c (macroscopic peritoneal metastasis beyond the pelvis and > 2cm in size)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
        • Endometrium: Proliferative phase
        • Myometrium: Adenomyosis
        • Ovary, left: Endometrosis
        • Fallopian tube, right: Para-tubal cyst
      • IHC, tumor cells reveal: WT1(-), Napsin A(+), ER(-), and p53(no aberrant expression)
  • 2023-04-21 Body fluid cytology - ascites
    • 40 cc, pink, turbid — Malignancy
    • Smears show several clusters of atypical hyperchromatic and pelomorphic cells. Malignancy is favored. Please correlate with the clinical presentation.
  • 2023-04-20 Frozen Section
    • Ovary, left, frozen section — Malignant (carcinoma)
  • 2023-04-17 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Massive ascites is found.
      • Cystic change at bilateral ovaries measuring 11.7cm at right ovary and 5.4cm at left side is found. Some solid component is also found. Ovarian cancer is considered.
      • Tiny enhanced dots at mesentery is found. Mesenterric meta is favored.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Normal heart size.
      • The lung fields are clear.
      • No pleural effusion is found.
    • Imp:
      • Bilateral ovarian cystic tumors with largest one at right side msm 11.7cm. Ovarian cancer is considered.
      • Peritoneal seeding is also found.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-07 Gynecologic ultrasonography
    • R/O RT Ovarian mass: 109 x 85 (septum RI: 0.42)
    • Asites(+)
  • 2023-01-04 CT - abdomen
    • Indication
      • LMP: 2022-12-27, sex(+), dysmenorrhea sometimes, duration: 6 days
        • CA-125: 37.71
      • 20230104 sono: A cystic mass 7.3 x 5.4 cm in right adnexa with solid mural nodule 3.1 cm. R/O right ovarian mass.
        • Left ovarian cyst 2 cm.
      • 20230104 CA125, CEA, and CA199: normal
    • Findings:
      • There is a well-defined cystic lesion in right adnexa 7 cm in size (the largest dimension) with central solid mural nodule (2.6 cm in size).
        • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
      • There is a cystic lesion with wall thickening at left adnexa, measuring 4 x 2.4 cm in size.
    • Impression:
      • A cystic lesion with mural nodule at right adnexa, nature?
      • The differential diagnosis include cystic adenoma and cystic adenocarcinoma.
  • 2023-01-04 Gynecologic ultrasonography
    • R/O Lt Ovarian cyst
    • R/O RT Ovarian mass (septum RI: 0.63)

[consultation]

  • 2024-12-11 Nutrition
    • Q
      • Remarks
        • Diet for Cancer Patients
        • Expected Discharge Date: 2024-12-18
      • This is a 39-year-old female with a history of:
        • Bilateral clear cell carcinoma of the ovary, pT3cN0M0, Stage IIIC; FIGO Stage IIIC, status post debulking surgery on 2023/04/20. BRCA1/2 wild type, HDR negative.
        • Relapse with peritoneal carcinomatosis and massive ascites, Stage IV on 2024/02/07, undergoing C6 chemotherapy with Avastin/Taxol/Carboplatin.
      • She has had hypomagnesemia since 2024/03 and has been taking magnesium oxide (MgO) regularly. On 2024/12/02, her magnesium level dropped to 0.9, prompting a referral to nephrologist Dr. Lin. Several tests were performed, including serum Na, K, Ca, P, Mg and urine Ca, P, K, protein, creatinine, revealing hypercalcemia and hypomagnesemia.
      • At her next outpatient follow-up, her calcium level rose to 3.88, leading to her admission to the nephrology ward for hydration and further evaluation.
      • During hospitalization, she denied nausea, vomiting, or malaise, but complained of diarrhea associated with MgO use. Additionally, due to poor appetite and a tendency for abdominal fullness, she requested a nutrition consultation for dietary modifications and recommendations.
      • We appreciate your professional advice. Thank you.
    • A
      • Nutritional Diagnosis:
          1. Inadequate protein-calorie intake.
          1. Increased nutritional needs due to physiological conditions such as metabolic disorders and malabsorption.
          1. Decreased ability to consume adequate protein and calories.
          1. Estimated calorie intake is below the estimated or measured resting metabolic rate (RMR) or recommended intake.
      • Intervention:
        • The patient reported having various cancer-specific nutritional supplements at home but has grown tired of them and is reluctant to consume them.
        • She experiences nausea after consuming just 1-2 bites of desired foods.
        • Oral mucosa is beginning to show signs of irritation or ulceration.
        • Caloric intake is insufficient to meet basic energy requirements.
        • Discussed with the patient’s family to set dietary goals and provide a simple meal plan.
        • Non-caloric health supplements should be temporarily discontinued.
        • Biolectra magnesium solution can continue, but magnesium supplements (MgO) in food-based formulations are recommended to reduce gastrointestinal discomfort such as diarrhea.
      • Nutritional Goals:
        • Short-term goal: 1,500 kcal/day, 85g protein.
        • Long-term goal: 2,000 kcal/day.
      • Monitoring and Evaluation:
        • Digestive and absorption status
        • Bowel movement patterns
        • Protein intake
        • Caloric intake
        • Body weight
  • 2023-06-12 Dermatology
    • Q
      • A case of clear cell carcinoma of Bilateral ovarian, pT3cN0M0, stage IIIC; FIGO stage IIIC, status post debulking surgery on 2023/04/20
      • She was admitted for IP and IV chemotherapy with Taxol plus Carboplatin.However, she complained of skin rash over bilateral legs, we need your expertise for further management, thanks
    • A
      • This patient suffered from multiple erytheamtous papules on limbs for days.
      • Imp: Insect bite
      • Suggestion:
        • Dexamthson 1 / Qd
        • Ulex cream x5 tubes / bid
        • Zaditen 1 / Bid
  • 2023-05-22 Metabolism and Endocrinology

[surgical operation]

  • 2023-04-20
    • Surgery
      • Diagnosis: Huge ovarian mass, bilateral
        • Frozen section: malignant, suspect carcinom
      • Operation:
        • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy (BY GENERAL SURGEON))   - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, peritoneum and bilateral adnexa due to the tumor burden. Multiple papillary mass was noted over anterior wall.
      • Adnexa:
        • LOV: huge ovarian mass about 10 X 10 X 8 cm in size, with heterogeneous and rough surface, partial rupture with hemorrhagic content
        • ROV: ovarian mass about 6 X 5 X 5 cm in size
        • Fallopian tube: tensely connected to the bowel and adjacent tissues due to adhesion
      • CDS: massive ascites
      • Ascites: light yellowish, at least 4000 mL
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(+)
      • Omentum: multiple hard, variable nodules noted; infracolic omentectomy was done by general surgeon.
      • Optimal debulking was achieved, Residual tumor:R0.
      • Estimated blood loss: 850 mL
      • Blood transfusion: LpRBC 2U
      • Complication: nil
  • 2023-04-20
    • Operation
      • Excision of intraabdominal tumor: pelvic peritoneum + omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Several tumor seedins in pelvic peritoneum with massive ascites
      • Tenckhoff tube: over RLQ
    • Procedure
      • Under ETGA, GYN performed operation at first. Made omentectomy. Excised the seeding tumor in pelvic peritoneum. Inserted a Tenckhoff tube over RLQ. Finally, GYN commenced further operation.

[chemotherapy]

  • 2025-01-20 - bevacizumab 15mg/kg 735mg NS 100mL 1.5hr + liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-12-30 - bevacizumab 15mg/kg 785mg NS 100mL 1.5hr + liposome doxorubicin 40mg/m2 60mg D5W 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2024-11-22 - bevacizumab 15mg/kg 760mg NS 100mL 90min
    • NS 250mL
  • 2024-10-30 - bevacizumab 15mg/kg 900mg NS 100mL 90min
    • NS 250mL
  • 2024-10-04 - bevacizumab 15mg/kg 900mg NS 100mL 90min
    • NS 250mL
  • 2024-07-13 - bevacizumab 15mg/kg 900mg NS 100mL 1.5hr + paclitaxel 175mg/m2 295mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2024-06-19 - bevacizumab 15mg/kg 900mg NS 100mL 1.5hr + paclitaxel 175mg/m2 295mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2024-05-24 - bevacizumab 15mg/kg 900mg NS 100mL 1.5hr + paclitaxel 175mg/m2 295mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2024-04-22 - bevacizumab 15mg/kg 900mg NS 100mL 1.5hr + paclitaxel 175mg/m2 295mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2024-04-02 - bevacizumab 15mg/kg 900mg NS 100mL 1.5hr + paclitaxel 175mg/m2 295mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2024-03-08 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-09-27 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-08-31 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 64mg + cisplatin 30mg/m2 48mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-07-25 - paclitaxel 135mg/m2 215mg NS 250mL 3hr + carboplatin AUC 5 650mg NS 250mL 2hr + [paclitaxel 40mg/m2 63mg + cisplatin 30mg/m2 47mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-06-30 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-06-12 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-05-22 - paclitaxel 135mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 625mg NS 250mL 2hr + [paclitaxel 40mg/m2 65mg + cisplatin 30mg/m2 49mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr + NS 500mL 1hr (before chemotherapy) + NS 500mL 1hr (after chemotherapy)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2025-02-24

The patient, a 39-year-old woman with recurrent bilateral ovarian clear cell carcinoma (pT3cN0M0, FIGO stage IIIC), is admitted on 2025-02-23 for C3 chemotherapy with Avastin (bevacizumab) + Lipo-dox (liposomal doxorubicin). She has progressive peritoneal carcinomatosis with massive ascites (CT 2024-12-12), hypercalcemia (Ca 3.07 mmol/L on 2025-02-23), and cachexia (weight loss of 5 kg over one month).

Key issues include:

  • Progressive disease with worsening cachexia, ascites, and abdominal distention.
  • Hypercalcemia (Ca 3.07 mmol/L on 2025-02-23) managed with Xgeva (denosumab) and calcitonin.
  • Hematological changes: anemia (Hgb 9.0 g/dL on 2025-02-23) and thrombocytosis (PLT 655 ×10³/uL).
  • Electrolyte imbalances, including hyponatremia (Na 131 mmol/L) and mild hypokalemia (K 3.4 mmol/L).
  • GI symptoms: hiccups, nausea, GERD, and morning cough, possibly due to diaphragmatic irritation from peritoneal carcinomatosis and ascites.

Problem 1. Recurrent Ovarian Clear Cell Carcinoma with Progressive Disease

  • Objective
    • Diagnosis: Bilateral clear cell carcinoma of the ovary (pT3cN0M0, FIGO stage IIIC), post-debulking surgery (2023-04-20).
    • Evidence of progression to peritoneal carcinomatosis with massive ascites (CT 2024-12-12) and malignant cytology (ascites cytology 2025-01-20).
    • History of chemotherapy:
      • Initial treatment: IP/IV Taxol (paclitaxel)/Carboplatin/Cisplatin (2023-05 to 2023-09).
      • Recurrent disease: Paclitaxel/Carboplatin from 2024-03-08 to 2024-07-14.
      • Current regimen: Avastin (bevacizumab) + Lipo-dox (liposomal doxorubicin) since 2024-12-30.
    • Symptoms: Abdominal distention, weight loss (5 kg over one month), nausea, and hiccups (2025-02-23).
    • ECOG PS 2: Reduced performance status, likely due to disease progression.
  • Assessment
    • Disease progression is evident despite prior chemotherapy (CT 2024-12-12). Ascites and carcinomatosis indicate platinum-resistant disease.
    • Weight loss and cachexia suggest worsening systemic impact.
    • Symptomatic peritoneal carcinomatosis likely causing hiccups, GERD, nausea, and cough due to diaphragmatic irritation.
  • Recommendation
    • Continue chemotherapy (C3 Avastin + Lipo-dox) as scheduled.
    • Monitor response via tumor markers (CA-125, CEA) and repeat imaging (CT abdomen in 4-6 weeks).
    • Optimize supportive care:
      • For nausea/GERD: Proton pump inhibitor Ulstop (famotidine) BID, prokinetic Mosapride 5 mg TID.
      • For hiccups: Consider Baclofen 5 mg BID if persistent.
      • For cachexia: Consider nutritional support, high-calorie supplementation.

Problem 2. Hypercalcemia

  • Objective
    • Hypercalcemia worsening (Ca 3.07 mmol/L on 2025-02-23 vs. 2.98 mmol/L on 2025-02-04).
    • Related to malignancy: No bone metastases on bone scan (2024-12-31).
    • Treatment history:
      • Xgeva (denosumab) 120 mg SC Q1M (2024-12-24, 2025-01-24)
      • Calcitonin 100 IU SC Q8H (initiated on 2025-02-23)
  • Assessment
    • Likely malignancy-driven PTH-independent hypercalcemia (tumor-related cytokine secretion).
    • Current treatment (Xgeva + calcitonin) is appropriate but may require additional measures if refractory.
  • Recommendation
    • Continue calcitonin 100 IU SC Q8H for acute management.
    • Monitor Ca levels daily.
    • Ensure adequate hydration (IV fluids if necessary) to enhance renal calcium excretion.
    • Reassess Xgeva dosing frequency if calcium levels remain elevated.

Problem 3. Anemia and Thrombocytosis

  • Objective
    • Hgb 9.0 g/dL (2025-02-23), down from 10.8 g/dL (2025-01-24).
    • PLT 655 ×10³/uL (2025-02-23), increased from 562 ×10³/uL (2025-01-24).
    • Normal WBC 7.9 ×10³/uL (2025-02-23).
    • Previous trends show persistent thrombocytosis.
  • Assessment
    • Anemia likely multifactorial: chronic disease, chemotherapy-induced myelosuppression, possible iron deficiency.
    • Thrombocytosis may be reactive due to malignancy-related inflammation.
  • Recommendation
    • Check iron panel, ferritin, and reticulocyte count to assess for iron deficiency or bone marrow suppression.
    • Monitor for signs of thrombotic complications given persistent thrombocytosis.
    • Consider transfusion if symptomatic or Hgb <8 g/dL.

Problem 4. Hyponatremia and Hypokalemia

  • Objective
    • Na 131 mmol/L (2025-02-23), persistent hyponatremia (previously 132 mmol/L on 2025-02-04).
    • K 3.4 mmol/L (2025-02-23), slightly decreased from 3.5 mmol/L (2025-02-04).
    • Mg 1.6 mg/dL (2025-02-23), stable.
  • Assessment
    • Likely multifactorial hyponatremia: chronic malignancy, SIADH, or chemotherapy effect.
    • Mild hypokalemia may reflect GI losses or inadequate intake.
  • Recommendation
    • Monitor serum Na and K levels closely.
    • Correct potassium (KCl supplement if <3.0 mmol/L).
    • Assess urine osmolality and sodium excretion if hyponatremia worsens.

Conclusion (not posted)

  • The patient has progressive ovarian cancer with peritoneal carcinomatosis and worsening cachexia, requiring continued chemotherapy (C3 Avastin + Lipo-dox). Hypercalcemia needs ongoing Xgeva and calcitonin treatment, anemia and thrombocytosis should be monitored for underlying causes, and electrolyte imbalances (hyponatremia, hypokalemia) require correction. Close monitoring of tumor burden, response to treatment, and supportive care measures is essential.

2023-07-03

  • As per the PharmaCloud database and our in-house HIS5 records, our institution has been the sole provider of medical services to this patient over the past three months. In addition to our Hematology-Oncology department, the patient also attended appointments in our Metabolism and Endocrinology department on 2023-06-05 and our Obstetrics and Gynecology department on 2023-05-04. However, no prescriptions were issued by these two departments. All current medications were prescribed by our Hematology-Oncology department, with no medication reconciliation discrepancies detected.

701373808

231002

{why 2023-07-25 exemestane shifted to letrozole?}

[MedRec]

  • 2023-09-19 SOAP Hemato-Oncology Xia HeXiong
    • P: On 2023-09-19, because the tumor marker and size in progression, suggest admission for furrther evaluation and decide what CT regimen will be used. Admission for Heart Echo. CT scan.
    • Prescription
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Aromasin (exemestane 25mg) 1# QD [Steroidal AI]
      • Through (sennoside 12mg) 1# HS
      • Femara (letrozole 2.5mg) 1# QD [Non-steroidal AI]
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
      • Silverzine (silver sulfadiazine) BID EXT
  • 2023-07-25 SOAP Hemato-Oncology Xia HeXiong
    • P: Shift exemestaine (Steroidal AI) to letrozole (Non-steroidal AI) on 2023-07-25
    • Prescription x2
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD [forgot to be DC]
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
      • Femara (letrozole 2.5mg) 1# QD [newly added today]
      • Dulcolax (bisacodyl 5mg) 1# QN
      • Sinbaby Lotion (ZnO, diphenhydramine, dibucaine, etc) BID TOPI
      • Silverzine (silver sulfadiazine) BID EXT
  • 2023-05-30 SOAP Hemato-Oncology Xia HeXiong
    • A/P: On 2023-05-30, already mention
      • For dirty urine, need to change foley, need to do urine routine and culture
      • Antibiotics is for weeks. Patient should be back if urine is not clean and sent to ER
    • Prescription x2
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
      • cephalexin 500mg 1# Q6H (14D, not repeated)
  • 2023-05-02 SOAP Hemato-Oncology Xia HeXiong
    • A/P: Only sister in law shows up on 2023-05-02.
      • Already mention
        • Disease extent: local left breast, bone and regional LN mets
        • Should consider C/T with Anti-HER2
        • If they do not take C/T and Anti-HER2 -> consider Hormonal therapy. But I would say Hormonal therapy (Aromasin, tamoxifen or Faslodex) will be less effect because Her2 (+). Moreover, visceral crisis (spinal cord compression).
        • Already mention the R/T to local primary -> will control for some time and will be to and from during R/T. (Patient is bed-ridden)
    • Prescription
      • Stogamet (cimetidine 300mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Aromasin (exemestane 25mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • MgO 250mg 1# TID
  • 2023-04-14 ~ 2023-04-18 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Left breast invasive carcinoma, no special type, ER+, PR-, HER2/Neu 3+, with multiple bone metastasis and Rt breast metastases, status post palliative radiotherapy
    • CC
      • Left breast newly emerged lump for 2 months  
    • Present illnesee
      • Neurosurgeon was consulted and surgery was not recommended. Palliative radiotherapy 30 Gy/ 10 fx was administered for spine metastasis.
      • Tamoxifen 1# po bid was given during admission and due to nodule regrowth at Left breast, under suspicion of no response of tamoxifen, letrozole 1# QD was given from 2023/01/07.
      • The patient had not receive any chemotherapy till now.
      • From 2023-02, the patient started to note newly emerged, progressively enlarging left breast lump. Furthermore, on 2023/04/13 she started to feel pain in her left breast lump, therefore she came to our hospital for 2nd opinion and was admitted for lung contrast CT for evaluation of metastatic lesion.
    • Course of inpatient treatment
      • After admission, lung contrast CT done on 4/15 showed Left breast cancer with left axillary, intramuscular and chest wall lymphadenopathy and bone meta.
      • Biopsy for left breast newly emerged lump was done on 4/17, with pathology report pending.
      • Bone scan to follow up for metastatic lesion was done on 4/18.
      • The family hesitated to receive chemotherapy for fear of deterioration of the patient’s performance status.
      • The patient has been informed that because of HER2/Neu 3+, she must be treated with herceptin and perjeta, and that because the disease has progressed, target plus chemotherapy must be used for control, but the patient currently only wants to use hormone therapy (letrozole). The patient has been told to invite all family members to participate in a family meeting, but the patient’s sister-in-law insists on hearing the explanation of the disease and going home to discuss it with her family members. In the end, the patient was still unwilling to undergo targeted and chemotherapy treatments, so she was discharged. And further discussion with the patient will be in the outpatient appointment.
  • 2023-03-31 SOAP Hemato-Oncology Gao WeiYao
    • P: encourage ER admission for her breakthrough neuropathic pain (spinal cord compression ??) (20230331)
    • Prescription
      • Switane (trihexyphenidyl 2mg) 1# BID
      • Through (sennoside 12mg) 2# HS
      • Winsumin (chlorpromazine 50mg) 2# BID
      • Stogamet (cimetidine 300mg) 1# BID
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Xyzal (levocetirizine 5mg) 1# QD
      • Futisone Cream (fluticasone) BID EXT
      • Femara (letrozole 2.5mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
  • 2022-04-25 ~ 2022-05-11 POMR Hemato-Oncology Zhang ShouYi
    • Discharge diagnosis
      • Malignant neoplasm of unspecified site of left female breast
      • Left side breast cancer with multiple bone metastasis S/P radiotherapy, Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
    • CC
      • both lower legs weakness & parapleiga progression were also noted for 3-4 days.
    • Present illness
      • This 58-year-old female, a pt of suspected L breast CA with spine mets & cord compression with parapleiga since 4/22 22, s/p sent to Far Eastern H (FEMH) ER where image study done, T-spime MRI at FEMH showd spine mets & cord compression with parapleiga.
      • She suffered from initial presentation of L breast tumor for one years ago & paraplegia since 4/22 22. She came to our hemato-oncologic clinic on 4/25 22 for L breast tumor.
      • Owing to both lower legs weakness & parapleiga progression were also noted for 3-4 days.
      • Under the impression of suspected L breast CA with spine mets & cord compression with parapleiga. She was admitted for further survey.
    • Course of inpatient treatment
      • After admission, image study with breast sono (4/26 22) showed Left breast Size: 5.6x3.47 cm, Left breast tumor with left axillary lymph node, r/o malignancy suggest biopsy.
      • Sono-guided biopsy was done on 4/26 22 for left breast tumor.
      • The pathology (4/28 22) proved Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(-, 0%), Her2/neu: positive (score=3+), Ki-67(40 %), p63 (-), E-cadherin (+), stromal tumor infiltrating lymphocytes: <5%.
      • We consulted NS for operation evaluation and advisted to Surgical intervention will not be recommended for the patient.
      • Radiologist was consulted for radiotherapy evaluation and advisted to Plan to deliver 30 Gy/ 10 fx to the spine mets mentioned above. RT will start around 4/27 or 28. XRT started since 4/28 to 5/11 22 and intravenous Dexa 4mg qd was added.
      • The bone scan (4/28 22) showed Highly suspected cancer with bone mets in the skull, some T- and L-spine, and right acetabulum (the most prominent).
      • Tamoxifen 1# po bid was given since 5/3 22. She was discharged on 5/11 22 under stable condition and will follow-up at OPD.
  • 2022-04-25 SOAP Hemato-Oncology Zhang ShouYi
    • S: 58 y/o female, a pt of suspected L breast CA wt spine mets & cord compression wt parapleiga since 4/22 22, s/p sent to Far Eastern Memorial Hospital ER where image study done.

==========

2023-10-02

According to the PharmaCloud database, this patient just refilled a 28-day supply of Switane (trihexyphenidyl), Ativan (lorazepam), Winsumin (chlorpromazine), and Denosin (desloratadine) for her schizophrenia at the Bali Psychiatric Center of the Ministry of Health and Welfare on 2023-09-13. Except for lorazepam, all other medications are currently in use. If agitation, restlessness, or antipsychotic-induced akathisia continues to be observed, reintroduction of lorazepam may be considered.

700526788

231001

[exam findings]

  • 2023-10-03 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • T wave abnormality, consider inferior ischemia
    • T wave abnormality, consider anterolateral ischemia
  • 2023-09-09 SONO - abdomen
    • liver parenchymal disease, mild fatty liver
    • mild splenomegaly
    • gallbladder stones, sludge
    • mild gallbladder wall thickening
    • fatty infiltration of pancreas
  • 2023-08-08 SONO - nephrology
    • Bilateral chronic change with left small sized kidney.
    • Irregular bladder wall, cause?
  • 2023-08-02 ECG
    • Sinus tachycardia
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2023-07-12 ECG
    • Sinus tachycardia with Premature atrial complexes
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-07-12 CTA - chest
    • A calcification (4mm) at right lung.
    • Left pleural effusion with adjacent lung collapse.
    • Fat stranding at right perirenal region.
    • Grade 4 fatty liver.
    • Gallbladder stone (3.2cm).
  • 2023-07-12 CT - brain
    • Brain atrophy.

[MedRec]

  • 2023-09-09 SOAP Gastroenterology Wang JiaQi
    • S
      • RUQ pain for 1-2 wks. fever (-)
      • vomiting this morning (+). poor appetite.
      • GB stones with cholecystopathy
    • O
      • PE: abdomen: soft and flat
      • PH: DM (+), HT (+)
      • US: liver parenchymal disease, mild fatty liver, mild splenomegaly, gallbladder stones, sludge, mild gallbladder wall thickening, fatty infiltration of pancreas (2023, 9/9)
    • Prescription
      • Acetal (acetaminophen 500mg) 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Alusa (aldioxa 100mg) 1# TID
  • 2023-08-16 SOAP Infectious Disease Peng MingYe
    • A: Prolonged antibiotic for recurrent UTI, continue Ceficin for another 2 more weeks
    • P: Education and medications
    • Prescription
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-08-03 POMR Infectious Disease Peng MingYe
    • Discharge diagnosis
      • Sepsis due to Escherichia coli [E. coli]
      • Bacteremia
      • urinary tract infection
      • Pneumonia, unspecified organism
      • Type 2 diabetes mellitus with unspecified complications
      • obesity
      • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
      • Essential (primary) hypertension
    • CC
      • Fever since last night, Aug 01, with vomiting once with gastric juice.
      • No abdominal pain or diarhrea
    • Present illness
      • This 72-year-old female patient has underlying diseases of hypertension, diabetes mellitus, gall bladder stone. She was recently discharged from our Infection ward due to Escherichia coli UTI with sepsis on July 20, 2023. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently.
      • This time, she suffered from recurrent fever since the night of Aug 01 and vomiting once with gastric juice noted. She denied abdomianl pain or diarrhea, no any URI symptoms. She was taken to our ED for hlep in the early morning of yesterday, Aug 02. At ED, fever 39.8C detected. The laboratory data showed normal whote cell count and CRP 1.4 only. Urinalysis showed typical UTI picture with bacteriuria and pyuria. The CXR showed increase of bilateral lung marking, the influenza and COVID tests all showed negative result. Under the impression of recurrent urinary tract infection, she was admitted to our INF ward for further management on Aug 03, 2023.
    • Course of inpatient treatment
      • After admission, empirical antibiotic Brosym was given for ifnection control. Urine and blood culture all showed Escherichia coli that E.coli urosepsis confirmed.
      • There is no more fever after admission and gradual improvement with more spiritful and oral intake. Lab data rechecked on 8/8 shwoed normal white count and much lower CRP level, 2.1. Renal echo wass done on Aug 8, whcih showed small left kidney size, no renal stone or hydronephrosi. CxR showed no infiltration on 8/7.
      • She is discharged on 2023/8/10 with oral Ceficin back home. OPD follow up is arranged.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (if BT > 38)
      • Through (sennoside 12mg) 2# HS
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Const-K (KCl 10mEq 750mg) 1# QD
      • Bisadyl supp (bisacodyl) 2# PRNQOD RECT (if no stool passage)
      • Ceficin (cefixime 100mg) 2# Q12H
  • 2023-07-12 POMR Infectious Diesease Hong BoBin
    • Discharge diagnosis
      • Sepsis due to Escherichia coli [E. coli]
      • Urinary tract infection, site not specified
      • Calculus of gallbladder, 3.2 cm; ABD CT, 2023-07-12
      • Metabolic syndrome
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
    • CC
      • Fever, chills, chest pain, and cough for three days, then consciousness loss with hyperglycemia one day.
    • Present illness
      • A 72-year-old female has past medical history of hypertension, diabetes mellitus, gall bladder stone, and Escherichia coli sepsis. She has no allergies to food or drugs, no food allergy, no history of travel, occupation, contact or cluster recently. Unknown of job.
      • She presented in the emergency department with the symptoms of fever, chills, chest pain, and cough for three days, then she was found consciousness loss last night, the finger sugar showed 383mg/dL by the emergency medical technician. The temperature 41.4°C, the pulse 128 beats per minute, the blood pressure 164/82 mmHg, the respiratory rate 22 breaths per minute, and the oxygen saturation 97%, regain consciousness E4V4M6. The physical examination showed pale conjunctiva, normal light reflex of bilateral pupils, bilateral symmetric expansion of chest, coarse sound, soft abdomen without tenderness, no pitting edema, muscle power: right side 3, left upper 4, and left lower 3.
      • A blood serum tests showed leukocytes with neutrophil predominant 61.6%, band 3.5%, hyperglycemia, elevated C-reactive protein and creatinine and creatine kinase and prothrombin time and d-dimer and troponin-I and lactic acid. Urinalysis showed pyuria. Chest x ray showed ground glass opacities in bilateral lungs. A computer tomography of the brain showed brain atrophy. A computed tomography angiography of the chest revealed left pleural effusion with adjacent lung collapse, no aortic dissection. Brosym was given. She was hospitalized on 2023-07-12.
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral cefuroxime for empirical treatment of urosepsis. The foley catheter indwelling for monitor urine amount. The adequate fluid supplement. On critical condition. Insulin as sacle for hyperglycemia control.
      • Laboratory examination revealed improvemeent, but elevated CK noted. Sodium Bicarbonate was addition for urine alkalization. Blood culture yields Escherichia coli. We give de-escalation of antibiotics to cefazolin. Urine culture yields Escherichia coli.
      • Laboratory examinaiton revealed improvement, but anemia is noted. Blood transfusion with LPRBC one unit supplement for two days. Urinalysis showed no pyuria. Foley catheter was removal, urination voiding is smooth, residual urine showed 60 ml. No more fever occurs.
      • Glycemia under insulin control. She is discharged on July 20, 2023.
    • Discharge prescription
      • cephalexin 500mg 1# TID

==========

2023-10-04

The patient refilled the repeat prescription for Norvasc (amlodipine), Tulip (atorvastatin), Ankomin (metformin), and Ozempic Injection (semaglutide) on 2023-09-09. However, she is not currently taking these drugs. It is recommended that her serum glucose and blood pressure levels be monitored to determine if and when these medications should be reintroduced.

700372532

230928

[diagnosis] - 2023-03-15 admission note

  • Malignant neoplasm of rectum
  • Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema

[past history]

  • Type 2 diabetes mellitus and hyperlipidemia for 4-5 years under medications treatment.
  • Past operation: left middle finger post traumatic amputation 30+ years ago            

[allergy]

  • NKDA     

[family history]

  • Father died: AMI
  • Mother: diabetes
  • There is no family history of cancer, mental diseases or asthma

[exam findings]

  • 2023-07-10 Neurosonography
    • Mild atheromatous lesions in R subclavian artery, R CCA bifurcation, and L ICA.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
  • 2023-06-20 CT - abdomen
    • History and indication: ca of colon
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
      • Some calcifications in prostate.
      • Tiny gallbladder stones.
      • Degeneration and spondylosis of L-S spine.
      • Atherosclerosis of aorta, iliac and coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon and liver operation. A patchy density (2.3cm) at RML. Recurrent metastases at right liver operative margin (much regression).
  • 2023-02-13 Microsonography
    • Clinical Diagnosis: IRC and ME os
    • Report: 207/482 um, IRC and ME os
  • 2023-02-09 CT - abdomen
    • History and indication: colon cancer with recurrent liver mets S/P op & C/T
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
      • Some calcifications in prostate.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Degeneration and spondylosis of L-S spine.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac and coronary arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P colon and liver operation. Right pleural effusion with adjacent lung collapse. Recurrent metastases at right liver operative margin.
  • 2022-12-27 Patho - pleural/pericardial biopsy
    • Diaphragm, right, partial resection — Adenocarcinoma, moderately differentiated, compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of low columnar neoplastic cells arranged in tubular and cribriform patterns with dirty necrosis. The surgical margin is close to tumor. The finding is compatible with metastatic colonic adenocarcinoma of liver with diaphragm invasion.
  • 2022-12-27 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S7, S7 resection — Metastatic colonic adenocarcinoma
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • MACROSCOPIC EXAMINATION
      • Procedures: S7 resection
      • Specimen Size: 11 x 8.0 x 5.0 cm and 120 gm
      • Tumor Focality: Solitary
      • Tumor Site: S7
      • Tumor Size: 3.2 x 3.0 x 2.2 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2= tumor + margin, A3-A4= tumor + capsule
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colonic adenocarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Present
      • Tumor necrosis: Moderate (15%)
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 1.5 cm from resection margin
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      • Non-neoplastic liver parenchyma: Moderate lymphocytic portal inflammation and regeneration of hepatocytes
      • Fatty Change: Absent
  • 2022-12-26 ECG
    • Normal sinus rhythm
    • Left ventricular hypertrophy with repolarization abnormality
  • 2022-11-24 Whole body PET scan
    • A mild glucose hypermetabolic lesion in the segment 7 of the liver. Liver metastasis of low FDG uptake can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in a focal area in the right iliac bone. The nature is to be determined. Please follow up other imaging modalities for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders and hips. Inflammatory process may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-11-14 CT - abdomen
    • Indication: Malignant neoplasm of rectum
    • Abdominal CT with and without enhancement revealed:
      • Hepatic tumor at right liver surface with marginal enhancement and central necrosis is found. Hepatic metastasis is considered. In comparison with CT dated on 2022-04-25, the lesion enlarged.
      • Hypervascular hepatic tumor at S5/6 of liver up to 0.8cm in largest dimension. Hemangioma is considered.
      • s/p RAR.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
    • Imp: colon cancer s/p RAR with liver metastasis, in progression.
  • 2022-08-22 SONO - abdomen
    • Findings
      • Normal echogenicity of the liver.
      • Presence of gallbladder stones and polyps.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
    • Impression:
      • GB stones and polyps.
  • 2022-05-30 MRA - brain
    • Acute infarcts in right upper medulla oblongata. Intracranial artherosclerosis.
  • 2022-04-25 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2022-01-27 SONO - abdomen
    • Gallbladder stones (up to 0.56cm).
  • 2021-11-01 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2021-04-20 Patho - conjunctiva biopsy/pterygium
    • Labeled as “sclera od”, trabeculectomy od — fibrotic tissue
  • 2021-04-12 Patho - colorectal polyp
    • Intestine, large, cecum, 120 cm from anal verge, biopsy — tubular adenoma
  • 2021-04-09 CT - abdomen
    • Indication: rectal CA, pT3N2aM0, stage IIIB s/p CCRT from 2018-03 to 2018-05 and LAR wt protective ileostomy on 2018/06/07
      • 20180507 CT: hemangioma 0.8 cm in S5
      • 20190708 CT: hemangioma 0.8 cm in S5.
      • 20191230 CT: two metastases 0.7 cm in S7 and 1.3 cm in S6?
      • 20200204 MRI: two metastases in S7 and S6?
      • Metastases confirmed by pathology after resection
    • FINDINGS:
      • There are focal defect in S7 and S6 of the liver that are compatible with metastases S/P surgical enucleation.
        • There is no evidence of tumor recurrence.
      • S/P LAR with autosuture retention over the rectum.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, & both kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion in the mesentery and omentum.
    • IMP:
      • No evidence of tumor recurrence in the liver.
  • 2021-04-09 Colonoscopy
    • The scope reach the cecum under poor colon preparation.
    • Two small and sessile polyp was noted in the cecum size 0.7 cm. (120 cm from anal verge)
  • 2020-10-19 CT - abdomen
    • S/P colon and liver operation. No evidence of tumor recurrence.
  • 2020-02-25 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Liver, S7 with partial S6, segmental hepatectomy — Metastatic colorectal adenocarcinoma
      • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
    • MACROSCOPIC EXAMINATION
      • Procedures: Segmental hepatectomy of S7 with partial S6
      • Specimen Size: 12.0 x 7.5 x 5.5 cm and 180 gm
      • Tumor Focality: Solitary
      • Tumor Site: S6
      • Tumor Size: 2.2 x 2.0 x 1.7 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= tumor, A5- A6= non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic colorectal adenoarcinoma
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule:Absent
      • Tumor necrosis: Moderate (10%)
      • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.4 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor regression grade: Grade 4 (residual cancer cells predominate over fibrosis)
      • Non-neoplastic liver parenchyma: Perivenular congestion, regeneration of hepatocytes, and mild lymphocytic and neutrophil portal inflammation
      • IHC: CK7(-), CK20(+) and CDX2(+)
  • 2020-02-24 MRI - liver, spleen
    • History and indication: R/I recurrence of liiverr mets.
    • IMP: Progressive enlargement of right liver tumors (S6-7, 1.0cm, 1.7cm), metastases shoulde be ruled out.
  • 2019-12-30 CT - abdomen
    • Rectal cancer s/p operation. Right liver hemangioma (8mm). Poor enhancing tumors (6mm, 9mm) in S6-7 of liver suspected metastases.
  • 2019-01-21 CT - abdomen
    • Status post LAR with autosuture at the rectum.
    • There is no evidence of tumor recurrence.
  • 2018-06-08 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Rectum, s/p CCRT, laparoscopic assisted LAR and protective colostomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, s/p CCRT, dissection —- Metastatic adenocarcinoma (4/11) with extranodal extension (1/4).
      • Lymph node, IMA / SMA, dissection — N/A.
      • AJCC 8th edition Pathology stage: ypT2N2a (if cM0); ypStage: IIIB.
      • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
    • MACROSCOPIC EXAMINATION
      • Operation procedure: s/p CCRT, laparoscopic assisted LAR and protective colostomy
      • Specimen site: rectum
      • Specimen size: 9 cm in length
      • Tumor size: 3 x 2 cm
      • Tumor location: 3 cm and 2 cm away from the two resection margins, respectively
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: free
      • Tissue for sections: A1-4: tumor; A5-6: lymph nodes.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Present.
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin.
      • Lymph node metastasis, mesocolic: (4/11)
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT) ypT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN) ypN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM) (if cM0); ypStage: IIIB.
        • NOTE: cM might be the same or might be upgraded when additional clinical and image findings are available for evaluation.
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: y (Post-treatment).
      • Tumor regression grading S/P CCRT:
        • Grade 3 (dominant fibrosis outgrowing of 50% of the tumor mass).
  • 2018-02-06 Surgical pathology Level IV
    • Clinical diagnosis:
    • Neoplasm of unspecified nature of digestive system;
    • Pathological diagnosis:
      • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
    • Prescription x3
      • Toujeo (insulin glargine) 12 unit QDAC SC
      • Through (sennoside 12mg) 1# PRNHS
      • Crestor (rosuvastatin 10mg) 1# QD
      • Kludone (gliclazide 60mg) 1# BIDAC
      • Dibose (acarbose 100mg) 1# TIDAC
      • Olmetec (olmesartan medoxomil) 1# QD
      • Trulicity (dulaglutide) 1.5mg QW SC
      • Uretropic (furosemide 40mg) 0.5# PRNQD (hold if SBP < 100 mgHg)
      • Smecta (dioctahedral smectite 3mg) 1# TIDAC
  • 2023-08-28 SOAP Metabolism and Endocrinology Qiu QuanTai
    • A: 2023 ~ additional chemotherapy again (taking steroids will make the blood glucose as high as 3XX)

[consultation]

  • 2022-05-30 Neurology
    • Q
      • l’t arm weakness since this morning. unsteady sensation.
      • hx of DM, HTN.
    • A
      • S
        • This 58 y/o man with a Hx of DM, HTN, dyslipidemia, and rectal CA with liver mets, Dx in Jan 2018, s/p CCRT under regular OPD follow-up. He was in ADL independent status.
        • This time, he suffered from acute left side numbness at 2PM on 5/28 while driving with left neck pain. Left limbs weakness was noted on the next day morning on awakending. Due to persisted symptoms, he came to our ER. There was no vomiting, diplopia, choking, slrred speech, convulsion, headache, fever or recent head trauma.
      • O
        • NE
          • GCS: E4V5M6
          • VF: no hemianopia
          • light reflex: 3/3 -/+ (cata/cata (right eye glaucoma s/p OP
          • EOM: free
          • no nystagmus
          • no facial palsy
          • PPS: left face V-I,II,III hypoesthesia (equivocal
        • Muscle power:
          • RUE/LUE: 5/4
          • RLE/LLE: 5/4
        • PPS: left hypoesthesia
        • FNF & HKS: no dysmetria
        • gait: tilt to left
        • NIHSS 000 000 1010 01000 =3
        • Lab Bil 1.17, CEA 5.465
        • brain MRA: Acute infarcts in right upper medulla oblongata
      • Impression
        • Acute infarcts in right upper medulla oblongata
      • Suggestion
        • aspirin 100mg 1# ST and QD
        • clopidogrel 300mg ST and 75 mg QD
        • famotidine 1# ST and BID
        • N/S run 60 ml/hr
        • hold OPD anti-hypertensive medication and control BP < 220/120
        • admit to ward under Dr Xiao’s service
        • closely monitor neurological signs
  • 2020-09-10 Ophthalmology
    • Q
      • This 57-year-old man patient is a case of colon cancer with liver metastasis s/p operation. He was admitted for chemotherapy. This time, glaucoma with high intraocular pressure. Now, for follow-up. Thank you.
    • A
      • S: for f/u IOP
      • O
        • OPHx: DMR complicated with NVG s/p several IVILs ou and cryotherapy od and full PRP ou
        • recent IOP, od on 9/7 W1 up to 40 was noted –> diamox 1# qid + combigan + xalatan
        • PT: 10/12 mmHg
        • VAcNC: OD 20/200 OS 20/200
        • conj: not injected ou
        • K: cl ou
        • AC:deep/cell trace - 1+ od, deep /clear os
        • c/d: pale disc 0.6-7 od, 0.5 os
      • P:
        • tapper the diamox to 1# bid

[surgical operation]

  • 2022-12-26
    • Surgery
      • open S7 resection with rt diaphram partial resection and repair
    • Finding
      • S7 hepatic tumor 3.2 x 3.0 x 2.0 cm with direct invasion to diaphragm
  • 2020-07-27
    • Surgery: 0 IVI Lucentis    ou    
    • Finding: retinal edema    ou 
  • 2020-02-24
    • Surgery
      • S7 and partial S6 resection
      • laparoscope
    • Finding
      • AN illed define heteroechoic tumor at S7 1.7 cm and 1.5 cm tumor at S6
      • mild adhesion
  • 2019-08-16
    • Diagnosis: Exudative senile macular degeneration
    • PCS code: 86201B
  • 2019-07-05
    • Diagnosis: Proliferative diabetic retinopathy OU
    • PCS code: 86201B
  • 2019-05-24
    • Diagnosis: DME ou
    • PCS code: 86201B
  • 2019-04-19
    • Diagnosis: DME ou
    • PCS code: 86201B
  • 2018-11-22
    • Diagnosis: Rectal cancer s/p LAR and ileostomy
    • PCS code: 73020C
    • Findings: Loop-ileostomy was taken down and resection with re-anastomosis was achieved using GIA 75/4.8. The procedure was smooth.
  • 2018-06-07
    • Diagnosis: Adenocarcinoma of rectum, cT3N2M1 s/p CCRT
    • PCS code: 74205B
    • Finding
      • Rectal cancer s/p CCRT was noted at middle rectum.
      • The laparoscopy procedure was converted to open method due to difficult to apply endo-GIA instrument.
      • The anastomosis was then achieved using SDH-33. Cutting ends are intact and even. Air test is ok.
      • TISSEEL 2ml was used at anastomosis site.
      • Loop-ileostomy was done at LLQ abdomen. A drain in pelvos.
  • 2018-02-07
    • Diagnosis: Rectal Ca
    • PCS code: 47080B
    • Findings: We identify the cephaic vein & use cutdown method to insert the Echo Port 7 Fr cathter into it. We also use intra-operative EKG to check its position

[chemoimmunotherapy]

  • 2023-08-17 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-31 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 0.5mg IVD + NS 250mL + aprepitant 125mg D1-3
  • 2023-07-10 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + atropine 0.5mg IVD + NS 250mL
  • 2023-06-20 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5150mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-05-26 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5125mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-28 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5180mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-04-06 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 730mg NS 250mL 2hr + fluorouracil 2800mg/m2 5170mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-15 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 735mg NS 250mL 2hr + fluorouracil 2800mg/m2 5155mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-24 - irinotecan 170mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 729mg NS 250mL 2hr + fluorouracil 2800mg/m2 5100mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-09 - irinotecan 160mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-09-10 - oxaliplatin 85mg/m2 146mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4810mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-08-27 - FOLFOX
  • 2020-08-13 - FOLFOX
  • 2020-07-30 - FOLFOX
  • 2020-07-16 - FOLFOX
  • 2020-07-02 - FOLFOX
  • 2020-06-18 - FOLFOX
  • 2020-05-28 - FOLFOX
  • 2020-05-14 - FOLFOX
  • 2020-04-30 - FOLFOX

==========

2023-09-28

The drugs prescribed by our endocrinologist have been added to the active medication list with no discrepancies found.

2023-08-18

A 28-day supply of Ulstop (famotidine), Bokey (aspirin), Saline (nicametate), and Vemlidy (tenofovir alafenamide) are refilled on 2023-08-05, all added to the active formulary with no reconciliation issues found.

2023-08-01

Our neurologist prescribed Ulstop (famotidine), Bokey (aspirin), Saline (nicametate citrate) on 2023-07-17, our ophthalmologist prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), Alphagan (brimonidine) eye drops on 2023-07-31. These drugs are included in the active medication list without a reconciliation issue.

2023-07-11

[reconciliation]

The prescription of Alphagan (brimonidine tartrate), Azarga (brinzolamide), and Xalatan (latanoprost) eye drops were refilled at a local pharmacy on 2023-06-26, with a valid 28-day duration for his glaucoma diagnosis. However, these drugs are not currently included in the patient’s active medication list. Please check whether these medications are still required for the patient.

2023-06-21

  • This patient receives medical services exclusively at our hospital. In addition to hematology and oncology, the patient also sees metabolism and endocrinology for type 2 DM, hyperlipidemia, primary hypertension, constipation; ophthalmology for glaucoma; and neurology for previous stroke.
  • The patient received a refillable prescription from Metabolism and Endocrinology on 2023-06-05 for Toujeo (insulin glargine), Through (sennoside), Crestor (rosuvastatin), Kludon (gliclazide), Dobose (acarbose), Olmetec (olmesartan), and Trulicity (dulaglutide). From the ophthalmology department, the patient was prescribed Xalatan (latanoprost), Azarga (brinzolamide, timolol), and Alphagan (brimonidine) on 2023-05-08. The neurology department prescribed Ulstop (famotidine), Bokey (aspirin), and Saline (nicametate) on 2023-04-24.
  • All of these medications have been added to the current formulary, except for the eye drops from the ophthalmology department. Please remind the patient to continue using them to prevent his glaucoma from worsening.

2023-04-07

  • During this hospitalization, the patient received his first dose of Avastin (bevacizumab) as part of the FOLFIRI chemoimmunotherapy regimen. Although the patient had previously received 3 cycles of FOLFIRI, monitoring for bleeding and thrombosis may still be necessary as these symptoms may be related to the use of bevacizumab.
  • The preprandial FS glucose levels on 2023-04-06 and 2023-04-07 morning were 218 and 249, respectively. If the readings exceed 200 for more than two consecutive days, the insulin dose may need to be increased.

2023-03-16

  • The patient’s blood sugar level has been well controlled during his current hospitalization.
  • He has a history of acute infarcts in the right upper medulla oblongata and was found to have intracranial atherosclerosis on a brain MRA performed on 2022-05-30. On 2023-03-16 at 13:14, his SBP was measured to be 182mmHg. If the patient continues to have persistently high blood pressure, the addition of amlodipine may be considered.

700480867

230928

U-Vanco (vancomycin) was changed from 1000mg Q12H to 1500mg Q12H on 2023-09-24 because the trough was 4.9mg/dL on that day. Since the updated trough level is even lower today (2023-09-28) at 4.3mg/dL, it is recommended that the dose be increased to 2000mg Q12H (Cre 0.32mg/dL, eGFR 377).

700603106

230926

[exam findings]

  • 2022-12-21 PET
    • Glucose hypermetabolic lesions in the right chest wall, compatilbe with recurrent breast tumor s/p operation.
    • Glucose hypermetabolic lesions in bilateral tonsils, probably chronic inflammation/infection process.
    • Increased FDG uptake in bilateral kidneys and left ureter, probably physiological uptake of FDG.
    • Right breast cancer with tumor recurrence s/p operation, no evidence of residual or metastatic tumor, by this F-18 FDG PET scan.
  • 2022-12-19 Patho - breast simple/partial mastectomy
    • Diagnosis
      • S2022-22806: Skin, right chest wall, resection margin, second wide excision —- Negative for malignancy
      • F2022-00612: Skin and foft tissue, right chest wall, wide excision —- invasive carcinoma of no special type, recurrent
    • Gross Description
      • S2022-22806: The specimen submitetd in formalin consists of a rim of skin and soft tissue measuring 5.2 x 0.9 x 0.8 cm. The width of the rim is 0.4 cm. All for section in 4 cassettes: A1: from 12 o’clock to 3 o’clock; A2: from 3 o’clock to 6 o’clock; A3: from 6 o’clock to 9 o’clock; A4: from 9 o’clock to 12 o’clock.
      • F2022-00612: The specimen submitetd in fresh consists of a piece of skin and soft tissue measuring 4.3 x 2.7 x 1.6 cm. On cutting, a gray, invasive tumor, measuring 3.0 x 2.2 x 1.5 cm is seen. The tumor is very close (< 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins. Representative sections are taken and labeled as: FsA1: through section from 12 o’clock (ink black) to 6 o’clock (ink orange) resection margin; FsA2: 3 o’clock resection margin; FsA3: 9 o’clock resection margin. After formalin fixation, additional sections are taken and labeled as: X1-2.
    • Microscopic Description
      • S2022-22806: Sections show skin and soft tissue without malignancy.
      • F2022-00612
        • For Invasive Carcinoma
          • Histologic type: Invasive carcinoma of no special type, recurrent
          • Size of invasive carcinoma (mm): 30 x 22 x 15 mm
          • Histologic grade (Nottingham histologic score): grade II (score 7)
            • Tubule formation: score 3
            • Nuclear pleomorphism: score 2
            • Mitotic count: score 2
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Present (without ulceration)
            • Chest wall invasion deeper than pectoralis muscle: Invasion to superficial skeletal muscular tissue without deeper than pectoralis muscle
        • For Ductal Carcinoma In Situ: not applicable
        • Margins:
          • S2022-22806: Negative for malignancy
          • F2022-00612: The tumor is very close (< 0.1 cm) to deep and 6 o’clock resection margins and 0.1 cm away from the 12, 3, and 9 o’clock resectino margins.
        • Nodal status: not received
        • Treatment Effect: not applicable
        • Immunohistochemical Study
          • ER (Ab): Positive (90%, strong) (Internal control: positive)
          • PR (Ab): Positive (60%, moderate) (Internal control: positive)
          • Her-2/neu (Ab): Negative (1+)
          • Ki-67: 20%
  • 2022-12-18 CT - chest
    • Findings
      • S/P right breast operation. A soft tissue nodule (2.3cm) at right chest wall.
      • Some LNs at bil. neck.
      • A calcified spot (2.6mm) at right lung margin.
      • A hypodense nodule (0.9cm) at left hepatic lobe. Grade 4 fatty liver.
    • IMP:
      • A soft tissue nodule (2.3cm) at right chest wall.
  • 2019-04-23 Gynecologic ultrasonography
    • R/O RT ovarian cyst
    • Uterine myoma
  • 2018-10-23 MRI - breast
    • S/P right mastectomy.
    • Stipple enhancement in left breast, but no significant early enhancement. Suggest clinical correlation and follow up.
  • 2017-09-05 Gynecologic ultrasonography
    • Uterine myoma
    • EM: 3.6mm
  • 2017-03-07 Gynecologic ultrasonography
    • Uterine myoma

==========

2023-09-26

This patient has been consistently taking cyclin-dependent kinase inhibitor Verzenio (abemaciclib 150mg) 1# BIDCC and aromatase inhibitor Femara (letrozole 2.5mg) 1# QD for months.

Dyspnea, with a frequency ranging from 6% to 18%, has been associated with the use of letrozole. Abemaciclib, on the other hand, has been linked to interstitial lung disease (ILD) and/or pneumonitis, with the frequency not yet defined.

In the event that ILD is confirmed, the abemaciclib dosage should be adjusted as follows:

  • Grade 1 or 2: No abemaciclib dosage modification is required.

  • Persistent or recurrent grade 2 toxicity that does not resolve to baseline or grade 1 within 7 days (despite maximal supportive measures): Withhold abemaciclib until toxicity resolves to baseline or to ≤ grade 1 and then resume abemaciclib at the next lower dose.

  • Grade 3 or 4: Discontinue abemaciclib.

701186682

230926

[exam findings]

  • 2023-07-21 SONO - abdomen
    • Propable liver calcification, right
    • S/p cholecystectomy
    • Suspected fatty infiltration of pancreas
    • Small amount ascites
    • C/w ESRD
  • 2023-06-21 Joint soft tissue sonography
    • Finding: Ill-defined anechoic effusion with posterior enhancement and mild compressible just below the OP wound of the axilla site.
    • Impression And Suggestions: Right axilla post-OP wound effusion or serosanguineous mass accumulation.
  • 2023-05-31 Tc-99m MDP bone scan
    • A hot spot at a mid-T spine and increased activity at L2-4 spines, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, elbows, S-I joints, knees, and feet.
  • 2023-05-31 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, right, partial mastectomy — Free
      • Lymph nodes, sentinel and non sentinel, right axilla, lymphadenecomy — Negative for malignancy (0/8)
      • AJCC 8 th edition, Pathology stage: pT1cN0(cM0); Anatomic stage IA; Prognostic stage IA
    • MACROSCOPIC EXAMINATION
      • Breast Size: 10.5 x 6.0 x 3.5 cm
      • Skin Size: 5.0 x 1.0 cm
      • Nipple: Not included
      • Tumor Size: 1.8 x 1.4 x 1.2 cm
      • Resection Margin: Free, 2.4 cm from the deep margin
      • Lymph node: Sentinel (SLN1 and SLN2), and non-sentinel
      • Representative parts are taken for sections and labeled; A1= 12’ and 6’ margins, A2= 3’ and 9’ margins, A3-A4= skin + tumor, A5= tumor + base margin, B=SLN1, C= SLN2, D= non SLN.
    • MICROSCOPIC EXAMINATION
      • Histo
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma: 1.8 x 1.4 x 1.2 cm
        • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Present with intermediate nuclear grade; Extensive DCIS: Negative
      • Margins: Negative; Closest margin: >10 mm from closest lateral margins and 24 mm from deep margin
      • Nodal status: Negative (0/8)
        • number of lymph node examined: 3 (SLN1), 2 (SLN2), 3 (non SLN)
        • number with macrometastases (> 2mm): 0
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Absent
    • IMMUNOHISTOCHEMICAL STUDY (S2023-09128)
      • ER (Ab): Positive (weak, 10%)
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative (score= 1+)
      • Ki-67: 20%
  • 2023-05-30 Lymphoscintigraphy
    • Probably a sentinel lymph node at the right axillary region.
  • 2023-05-11 Patho - breast biopsy (no need margin)
    • Breast, right ( 2 / 3.5), core needle biopsy— Invasive carcinoma of no special type
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study:
      • ER (Ab): Positive (weak, 10%)
      • PR (Ab): Negative
      • Her-2/neu (Ab): Negative (1+)
      • Ki-67 index: 20%
      • CK5/6: Negative
      • p63: Negative
  • 2023-05-08 Mammography (magnification)
    • BI-RADS category 4C, High suspicion for malignancy. Tissue diagnosis is suggested.
  • 2023-04-21 Cardiac Catheterization
    • Past Medical History
      • The patient has a history of DM for years with OHA control, HCVD with antiHTN and ESRD with PD since 2022-09.
    • Indication
      • The patient was referred with Refrcatory angina and Th-201 scan (++). The procedure was explained in detail to the patient and family. Risks, complications and alternative treatments were reviewed. Written consent was obtained.
    • Approach
      • Percutaneous access was performed through the right radial artery
    • Catheters
      • Left coronary angiography was performed using 6Fr JL3.5 catheter and Right coronary angiography was performed using 6Fr JR4 catheter.
    • Procedure
      • The patient was taken to the cardiac catheterization laboratory in the TZU CHI Taipei Hospital. Heart institute and prepared in the usual sterile fashion. The contrast material used was Omnipaque 350 cc. The patient was treated with Heparin and NTG.
    • Finding Summary
      • Syntax Score = 2
      • Left Main : patent
      • Left Anterior Descending : heavy calcification at P- to M-LAD with mild atherosclerosis at P-LAD
      • Left Circumflex : patent
      • Right Coronary : about 50 % eccentric stenosis at M-RCA
    • In conclusion : CAD, SVD-RCA
    • Recommendation : Medical treatment
  • 2023-02-16 Myocardial perfusion SPECT with persantin
    • Probably mild to moderate myocardial ischemia at the apical anterolateral wall and posterior wall and mild myocardial ischemia at the septum and mid anterior wall.
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 29.3) / 119 = 75.38%
      • M-mode (Teichholz) = 75.4
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • AV sclerosis with mild AR
      • No regional wall motion abnormalities

[MedRec]

  • 2023-07-27 SOAP Gastroenterology
    • Prescription x3
      • Vemlidy (tenofovir alafenamide 25mg) 1# QDCC
  • 2023-07-20 ~ 2023-07-21 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Right breast invasive carcinoma, pT1cN0M0 stage IA. ER : Positive (weak, 10%), PR: Negative, Her-2/neu : Negative (1+), Ki-67 index: 20%. ECOG:0.
      • End stage renal disease
      • Type 2 diabetes mellitus
      • Papillary thyroid carcinoma status post left thyroidectomy, pT1aNx pStage I status post radical lateral neck lymph node dissection and right thyroidectomy and re-implant of parathyroid gland on 2020/04/28
      • Hypo-osmolality and hyponatremia
      • Abnormal results of liver function studies
      • Anemia in chronic kidney disease
      • Hypoalbuminemia
      • Hyperbilirubinemia
    • CC
      • for 2nd adjuvant chemotherapy
    • Present illness
      • This 55-year-old post menopausal woman has
        • Hypertension
        • Type 2 Diabetes Mellitus
        • Chronic kidney disease stage 5 status post implantation of continuous ambulatory peritoneal dialysis catheter on 2022/08/01
        • Uterine myoma status post
        • Bilateral thyroid papillary carcinoma, pT1aN0M0, stage I
        • Coronary artery disease with medicine control
        • Gallbladder stones status post.
      • She denied any TOCC histories in recent 3 months.
      • She was diagnosed with right breast cancer then underwent of right partial mastectomy and sentinel lymph node biopsy on 2023/05/30. The finally pathlogy revealed invasive carcinoma, pT1N0M0 stage IA. IHC revealed ER (Ab): Positive, PR (Ab): Negative, HER-2/Neu (Ab): Negative, Ki-67: 20%. Tc-99m MDP whole body bone scan showed no obvious lesion for metastasis.
      • Under the impression of right breast cancer, pT1cN0M0 stage IA, she was admitted to our ward for 2nd adjuvant chemotherapy.
    • Course of inpatient treatment
      • After admission, 5-Fu 1047mg in Saline 100ml, Lipodox 55mg in Saline 250ml and Endoxan 800mg in saline 500ml were administered. There was no special complaint. Under the stable condition, she was discharged today and will be arranged next course adjuvent chemotherapy 3 weeks later.
    • Discharge prescription
      • Emend (aprepitant 125mg) 1# QD
      • Limeson (dexamethasone 4mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • Through (sennoside 12mg) 2# PRNHS
      • Sinpharderm Cream (urea) BID TOPI
  • 2023-07-20 SOAP Cardiology
    • Prescription x3
      • Cardiolol (propranolol 10mg) 1# BID
      • Nirandil (nicorandil 5mg) 1# BID
      • Bokey (aspirin 100mg) 1# QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID

[consultation]

  • 2023-05-31 Nephrology
    • Q
      • This is a 55 years old female patient. She was under PD in our hospital. This time, she was admitted for surgery of partial mastectomy + SLNB on 2023/05/30. We need your consult for combine care. Thank you so much!!
    • A
      • We will arrange PD for the patient during the course of hospitalization.
      • If you need to remove more or less water, please feel free to contact us.
  • 2022-08-16 Urology
    • Q
      • For Tenckhoff catheter insertion.
      • This 54-year-old woman has history hypertenion under medical control for 20 years, diabetes mellitus under medical control for 20 years, chronic kidney disease, stage V, thyroid papillary carcinoma s/p left thyroidectomy and parathyroid hyerplasia s/p parathyroidecotomy of left side.
      • Due to progression renal function failure was noted (01/20, Cr: 4.68 mg/dl => 03/17, Cr: 7.32 mg/dl => 6/07, Cr:9.24 mg/dl => 7/05, Cr:9.71 => 8/16, Cr:14.66mg/dl ). Prepare Tenckhoff catheter insertion was suggested for prepare Peritoneal dialysis. After well explained his condition to the patient and his family, she was admitted for further management.
    • A
      • We will arrange PD tube insertion tomorrow, thank you!

[chemotherapy]

  • 2023-09-01 - fluorouracil 600mg/m2 1049mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-08-11 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-07-20 - fluorouracil 600mg/m2 1047mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-06-27 - fluorouracil 600mg/m2 1070mg NS 100mL 30min + liposome doxorubicin 30mg/m2 55mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 800mg NS 500mL 1hr (FAC Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-09-26

[anemia]

The last dose of FAC regimen was administered on 2023-09-01 and blood transfusion was performed on the same day, after almost 4 weeks on 2023-09-25 HGB was still below 7g/dL. The recovery of hematopoietic capacity may not be able to catch up, if anemia becomes symptomatic or considered severe, additional blood transfusion might be needed.

2023-09-25 HGB 6.4 g/dL
2023-09-22 HGB 6.8 g/dL
2023-09-01 HGB 6.0 g/dL

[oral mucositis]

For oral mucositis, ASCO recommends using normal saline or salt and soda rinses, 2% viscous lidocaine swish and spit, modifying the diet, using 2% morphine mouthwash swish and spit, and administering systemic opiates based on increasing symptom burden. Ref: Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020;16(3):103-109. doi:10.1200/JOP.19.00652

The patient may benefit from using Nincort Oral Gel (triamcinolone acetonide) as a means of relieving symptoms. Additionally, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available at this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

2023-09-05

[anemia]

  • Recent HGB lab results
    • 2023-09-01 HGB 6.0 g/dL
    • 2023-08-26 HGB 6.0 g/dL
    • 2023-08-11 HGB 6.2 g/dL
    • 2023-07-31 HGB 5.8 g/dL
    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
  • The patient received blood transfusions on 2023-08-11 and 2023-09-01 due to low hemoglobin levels.

2023-08-15

[anemia]

  • Recent HGB lab results
    • 2023-08-11 HGB 6.2 g/dL
    • 2023-07-31 HGB 5.8 g/dL
    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
  • In the table above, the patient received FAC (lipo) on both 2023-07-20 and 2023-08-11. In addition, a blood transfusion was performed on 2023-08-11 (a previous transfusion was performed on 2023-05-30). Following the transfusion, the patient’s HGB (hemoglobin) level is expected to have increased.

[restaging]

On 2023-05-31, a bone scan indicated the need for further monitoring of an active spot in the mid-T spine and heightened activity in the L2-4 spines to ascertain potential bone metastasis. Furthermore, an abdominal sonography on 2023-07-21 showed a slight presence of ascites. If the disease is ultimately confirmed to have metastasized, restaging may be necessary.

2023-07-24

[anemia]

  • Recent HGB lab results

    • 2023-07-20 HGB 6.8 g/dL
    • 2023-07-04 HGB 7.2 g/dL
    • 2023-06-26 HGB 8.1 g/dL
    • 2023-06-20 HGB 8.0 g/dL
    • 2023-06-01 HGB 8.6 g/dL
  • This patient received two cycles of FAC (5FU + LipoDox + Endoxan) on 2023-06-27 and 2023-07-20. Prior to treatment, the hemoglobin (HGB) level remained above 8 g/dL, but after the first cycle, the level decreased to 7.2 g/dL and further decreased to 6.8 g/dL on the day of the second cycle administration.

  • Pegylated liposomal doxorubicin is known to be associated with anemia (grade 3: 5%, grade 4: <1%), and anemia is also common in patients receiving cyclophosphamide and/or fluorouracil.

  • As the patient has end-stage renal disease (ESRD) with impaired hematopoietic function, appropriate administration of epoetin alfa is required in addition to iron supplementation. In emergency situations or as needed, blood transfusion should still be considered to maintain hemoglobin levels.

700930475

230925

[MedRec]

  • 2023-09-15 SOAP Hemato-Oncology Gao WeiYao
    • A
      • Suspected metastatic malignant tumor of left neck
      • Recurrent squamous cell carcinoma of left buccal mucosa, pT4aN0M0, psatge IVa post of operation with close surgical margin (2023) status post CCRT and target therapy
      • S/P NG feeding (20230915)
    • P
      • symptom relief
      • patient has already signed the DNR
      • SUGGEST admission for chemotherapy and explained the risk of palliative chemotherapy.
  • 2022-11-10 ~ 2022-11-14 POMR Oral and Maxillofacial Surgery He ChengHan
    • Discharge diagnosis
      • Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022.
      • Squamous cell carcinoma of left face skin, cT1NxMx, ctsage I post of excision of the soft tissue tumor on the left chin area on 2022/11/11.
      • Squamous cell carcinoma of left buccal mucosa, pT1N0M0 post of operation on 2015.
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus
      • Hyperlipidemia
    • CC
      • A firm mass of my left chin area for 3 months were noted .
    • Present illness
      • This 70 years-old male patient suffered from skin pigmentation of left face with local indurated mass on the left lower face and admitted to ward for surgery intervention.
      • According to his statement, he had was received series of treatment such as
          1. Squamous cell carcinoma of left buccal mucosa, pT1N0M0 s/p operation on 2015/08/31.
          1. Scar contracture of left buccal mucosa s/p operation on 2016/01/20, 2016/06/20 and 2016/08/31.
          1. Squamous cell carcinoma of left buccal mucosa, cT3N0M0 post of operation on 2022, with PNI invasion and close surgical margin.
      • He received post-op finished CCRT were also noted since 2022/03 ~ 2022/05. Then he is regular followed up to our O.S clinic.
      • This time, he found a firm skin skin around the left mouth angle for several mouths without infection sign or abnormal sensation. After discuss with himself and he was admitted to ward for further managemen.
    • Course of inpatient treatment
      • After admission, we had arrange operation and evaluation anesthesia was done. He received excision of the soft tissue tumor on the left chin area under GA on 2022/11/11. Postoperatively, empirical antibiotic agent with Cefa 1g q8h was prescribed. Intraoral and extraoral wound change dressing qd. Mouth gargling with Parmason solution q2h and cool high protein soft diet were educated. The frozen report showed SCC. We had well explained to patient the condition and choice of treatment options.
      • Because his general condition was acceptable after the this operation, he was discharged this morning and OPD follow up.
    • Discharge prescription
      • amoxicillin 250mg 2# Q8H
      • UFT (tegafur 100mg, uracil 224mg) 2# BID
  • 2017-03-02 SOAP Oral and Maxillofacial Surgery Xu BoZhi
    • Diagnosis
      • Malignant cheek mucosa neoplasm [C06.0]
  • 2017-01-31 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, IDDM Type, juvenile type, uncontrolled [E10.65]
      • Essential hypertension , malignant [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BID
      • Januvia (sitagliptin 100mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
      • NovoNorm (repaglinide 1mg) 3# TIDAC

[chemotherapy]

  • 2023-06-28 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-06-21 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-06-08 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-31 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-19 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-12 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-05-05 - cetuximab 250mg/m2 400mg 2hr (Erbitux)
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2023-04-28 - cetuximab 250mg/m2 400mg 2hr + cisplatin 28mg/m2 50mg NS 500mL 3hr (Erbitux + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-19 - cetuximab 400mg/m2 700mg 2hr + cisplatin 40mg/m2 70mg NS 500mL 3hr (Erbitux + cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-08 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-30 - docetaxel 40mg/m2 70mg NS 150mL 1hr D1 + cisplatin 40mg/m2 70mg NS 250mL 3hr D1 + fluorouracil 1000mg/m2 1700mg NS 1000mL 22hr D2 + leucovorin 100mg/m2 170mg in 5-FU (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-05-04 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-25 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-19 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-04-13 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-03-28 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-03-18 - carboplatin AUC 2 150mg NS 300mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

==========

701230006

230925

[MedRec]

  • 2023-08-24 SOAP Neurology Chen PeiYa
    • Prescription x3
      • Lixiana (edoxaban 30mg) 0.5# QD
      • Actein (acetylcysteine 600mg) 1# QD
      • Through (sennoside 12mg) 1# HS
      • Lanoxin (digoxin 0.25mg) 0.5# QD
      • Mesyrel (trazodone 50mg) 0.5# HS
  • 2023-07-28 SOAP Hemato-Oncology Gao WeiYao
    • S: The aged man was admitted for severe thrombocytopenia, but his family refused bone marrow exam during his hospitalization.
    • A:
      • Thrombocytopenia, unspecified
      • Heart failure, unspecified
      • Unspecified atrial fibrillation
  • 2023-07-23 ~ 2023-07-24 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Severe thrombocytopenia. nature to be determined.
      • Heart failure, unspecified
      • Unspecified atrial fibrillation
    • CC
      • generalized petechiae over 4 limbs for few days noticed
    • Present illness
      • This 94y/o male has past medical history of
        • Right MCA infarct s/p rt-PA
        • NSTEMI, Af with heart failure
      • This time, generalized petechiae over 4 limbs for few days noticed. Thus he was sent to ER for help. At ER, he denied trauma and any discomforts, except took medicine: edoxaben, cephalexin last week for toe infection, and chinese herbs for a while. Lab show WBC = 8.23 x10^3/uL; HGB = 12.0 g/dL; PLT = 2 x10^3/uL (5/2 PLT 159k). PT and aPTT is in normal range, thus r/o coagulation disorders. Under the impression of isolated thrombocytopenia, he is admitted for further survey.
    • Course of inpatient treatment
      • After admission, patient was arranged for LRP transfusion and repeating the complete blood count (CBC) and reviewing the peripheral blood smear, obtaining prior platelet counts if available, and assessing other hematologic abnormalities. We have consulted hospice care for families at the same time but there was no indication for hospice share care at current unless complication of thrombocytopenia in future. After explained the risk and benefit of bone marrow aspiration for families, they still refused for it and AAD was registered.
  • 2020-02-14 ~ 2020-03-23 POMR Neurology Chen PeiYa
    • Discharge diagnosis
      • Cerebral infarction, unspecified
      • Right middle cerebral artery territory large infarction post r-tpa (2020-02-14), with hemorrhagic transformation , follow by brain MRA on 2020-02-17
      • Modified ranking scale 4
      • Non-ST elevation (NSTEMI) myocardial infarction
      • Heart failure
      • Atrial fibrillation
      • Pneumonia
    • CC
      • Acute onset speechlessness and left limbs weakness for 1 day
    • Present illness
      • This 91-year-old male patiet denied of any past medical history. However, he fell down about half an year ago and poor gait was noted since then.
      • On 2/14 he was still normal around 7:00am. However, acute onset left limbs weakness was noted around 7:30am while he was in toilet. He was brought to ER.
      • For acute CVA call, neurologist was consulted. Initial NIHSS was 15 and right MCA infarction was impressed. For no contraindication of rt-PA therapy, IV TPA therapy was given at 10:00am. However, due to suspicious pulmonary edema and severe edema over bilateral legs were found, IAT was held due to high risk and possibilty of difficulty ET extubation. Initial EKG revealed AFIB RVR with unspecific TWI at lateral lead, and lab survey showed elevated trop-I (hs-Troponin I = 1600.6 ). CV doctor also consulted at ER and the impression and suggestion were NSTEMI with acute pulmonary edema and (AFIB, CHA2DS2-Vas = 4), follow-up cardiac enzymes and cardia echo, with gentle negative I/O therapy.
      • Hence he was admitted to neurology ICU for intensive monitor under impression of (1) Right MCA infarction s/p tPA therapy, (2) r/i NSTEMI with acute pulmonary edema, (3) Atrial fibrillations (CHA2DS2-Vas =4).
    • Course of inpatient treatment
      • During SICU stay, we closely monitored BP and gave adequate IV hydration to keep perfusion. Famotidine was used for stress ulcer prevention.
      • For NSTEMI, we followed once cardiac enzymes which showed improvement (Troponin I: 1600(ER)>1615), and clinically no chest discomfort were complained.
      • For Pulmonary edema and bilateral lower limbs pitting edema (3+~4+), we gave Lasix IV to keep I/O balance and added aldactin for hypokalemia.
      • Repeated brain CT on 2/15 showed no ICH and therefore we added aspirin. However, brain MRI on 2/17 disclosed right MCA large infarction with hemorrhagic transformation and thus Bokey was discontinued.
      • Digoxin #1 QD was given initially for AfRVR, and the dosage was tapered since 2/21 for bradyarrythmia. His spirit was rather lethargic since 2/17 but yet could still maintain GCS E3-4V4M6.
      • For hypoalbuminemia, we suggested transient self-paid albumin therapy (2/22~2/24) and the family agreed.
      • With relatively stablized condition, the patient was transfered to ward for further management on 2/24.
      • After transfer to ward, the patient was still presented with exertional dyspnea and positive I/O. We discussed with cardiologist for NSTEMI and associated heart failure management.
      • Busix was used to replace Lasix and Concor will be considered later if indicated.
      • With diuretics treatment, pulmonary edema was much improved and the patient could take off oxygen supplement.
      • For antiplatelet resumption, we repeated brain CT to follow up hemorrhagic transformation on 3/2 and then added back Plavix 1# QD for no hemorrhage noted.
      • For more stable condition, we used Lixiana 30 mg 1# QD since 3/13 for better stroke prevention.
      • Rehabilitation and acupuncture therapy were arranged.
      • However left hip pain at certain position was noted when doing rehabilitation activity and fell down history about 6 months ago was mentioned.
      • We did left hip plain film on 3/11 and found partial union of left femoral neck fracture. Orthopedist was consulted and suggested pain control and rehabilitation as usual CVA patient without indication for operation.
      • On 3/12 morning the patient complained chest tightness when rehabilitation, we arranged associated survey in case of heart ischemia but the results were normal.
      • In the afternoon we explained all the associated condition to the family and disccused about future discharge plan which would be PAC plan.
      • During the last week before discharge, we tried to taper diuretics and discussed with cardiologist to make sure heart condition. Follow-up laboratory survey and CXR showed fair results.
      • With stablized and improved condition, he was discharged on 2020/03/23 with oral medication and will be transferred to other hospital for intensive rehabilitation under PAC plan.

==========

2023-09-25

Mesyrel (trazodone) is the only oral medication on the list of active medications that can be fed by tube.

701486100

230921

[lab data]

2023-06-27 Anti-HBc Reactive
2023-06-27 Anti-HBc-Value 1.04 S/CO
2023-06-27 Anti-HCV Nonreactive
2023-06-27 Anti-HCV Value 0.10 S/CO
2023-06-27 Anti-HBs 229.48 mIU/mL
2023-06-27 HBsAg Nonreactive
2023-06-27 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-09-15 Bronchodilator Test
    • mild restrictive ventilatory impairment with small airway disease, FEV1/FVC = 76%, FVC = 62 -> 58%, FEV1 = 59 -> 52% , MMEF 44 -> 29%
  • 2023-09-08 CT - abdomen
    • History:
      • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
      • Hypertension. Thyroid ca post-thyroidectomy in 2017
      • Rectosigmoid colon cancer with para-aortic LAP cT3N2bM1a, stage IVA s/p LAR on 2020-03-31 at FuRen Univ Hospital, s/p FOLFIRI & A-FOLFOX
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • 20230522 CT: R/O multiple metastatic LNs in abdomen and pelvis.
      • 20230627 CT-guided biopsy: Metastatic adenocarcinoma, colon origin.
      • 20230721 CT: multiple metastatic LNs in abdomen and pelvis show progressive disease.
    • Findings: Comparison prior CT dated 2023/07/21.
      • Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, decreasing in size.
        • It is c/w multiple metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
      • S/P LAR with autosuture retention over the rectum.
      • S/P cholecystectomy.
      • There is a small poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
      • There are several renal cysts on both kidney and the largest one measuring 1.2 cm in size at left middle pole.
    • Impression:
      • Multiple metastatic nodes S/P C/T show partial response.
  • 2023-07-21 CT - abdomen
    • Imp: Prior CT identified multiple metastatic nodes in para-aortic space, para-cava space, bilateral common iliac chain, bilateral external iliac chain, and bilateral internal iliac chain are noted again, increasing in size. please correlate with clinical condition.
  • 2023-06-27 Patho - lymph node region resection
    • Lymph node, plevis, left, CT-guide biopsy — Metastatic adenocarcinoma, in favor of colorectal origin
    • Microscopically, it shows lymphoid tissue with presence of nests of metastatic adenocarcinoma.
    • Immunohistochemical stain of CK20 is positive at tumor cells.
  • 2023-06-09 Gynecologic ultrasonography
    • R/O Bilateral Ovarian cyst
    • Uterine myoma

[MedRec]

  • 2023-07-17 SOAP Hemato-Oncology Xia HeXiong
    • S
      • << GS-US-570-6015 (IRB No: 11-FS-150) ICF Process >>
        • The subject has been provided the informed consent form (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and were fully explained the content of the informed consent form on 2023/07/14 by investigator and study Coordinator. The subject had enough time to ask all questions regarding the study. The subject brought the consent form back to consider whether to participate.
        • The subject understood the (GS-US-570-6015_site 17413_Main ICF V6.1.1_02May2023_Chinese) and signed on 2023/07/17. A copy of the signed informed consent form was provided to the subject.
        • GS-US-570-6015_Emergency Medical Support and Subject Card_v2.0_04May2022_ZH-TW has dispensed to subject on 2023/07/17 by PI/SC.
    • O
      • 2023.07.17
        • Subject No.: 17413101_initial: BLS
        • Ethnicity: Not Hispanic or Latino
        • Race: Asian
        • Country: TAIWAN
        • Never use alcohol
        • Never use tobacco
        • BH : 156.1 cm / BW : 71.9 Kg
        • Vital signs (assessed in a seated position after resting): 35.9’C/72/20 BP: 119/70 mmHg at 09:44 AM
        • Physical Examination:
          • Head, eyes, ears, nose and throat - Normal, specify
          • Cardiovascular - Normal, specify
          • Dermatological - Normal, specify
          • Musculoskeletal - Normal, specify
          • Respiratory - Normal, specify
          • Gastrointestinal - Intermittent diarrhea and abdominal distention
          • Neurological system - Normal, specify
        • ECOG Performance Status: 0
        • Childbearing Potential: NA, menopause around 52 years.
        • Collect 12-lead ECG at 09:41 AM
        • Collect central Hematology & Coagulation & Chemistry &
        • Endocrine function and basal cortisol & Hepatitis serology & HIV serology at 08:53 AM
        • Collect U/A at 09:50 AM
    • P
      • 2023.07.17
        • Anticipate to arrange the freshly cut unstained FFPE slides on 2023.07.17.
        • Arrange Neck & Chest & Abd & Pelvis CT on 2023.07.21.
      • Actein for prevention of contrast-induced nephropathy.
    • Prescription
      • Actein Effervescent (acetylcysteine 600mg) 1# BID 4D, use 2 days before CT from 2023-07-19 to 2023-07-22
  • 2023-07-12 SOAP Hemato-Oncology Xia HeXiong
    • S: CRC with multiple LNs mets s/p OP and C/T
    • O: 2023/06/27 HGB = 8.3 g/dL
    • P: Blood transfusion with pRBC
    • Prescription
      • Benamine (diphenhydramine 30mg/amp) ST IVD before blood transfusion
      • furosemide 20mg ST IVD after 2U pRBC
      • NS 500mL ST IVD for drug and blood transfusion
      • Hepac Lock Flush 100 USP units/mL 10mL ST IRRI
  • 2023-06-27 ~ 2023-06-28 POMR Hemato-Oncology Xia HeXiong
    • Discharge diagnosis
      • Rectosigmoid colon ca with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 2020-03-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type, s/p FOLFIRI & A-FOLFOX 
      • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Chronic diarrhea
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for CT guide biopsy of left plevis LNs
    • Present illness
      • The 64 years-old woman has past history of
        • Beta-Thalassemia: IVS-2nt 654 (C to T), heterozygous
        • Hypertension. Thyroid ca post-thyroidectomy in 2017
        • Rectosigmoid colon cancer with para-aortic LAP CT3N2bM1a, stage IVA s/p LPS LAR on 109-3-31, pT3N2bM1a, stage IVA (21/22), EGFR positive, KRAS: wild type (2020), s/p FOLFIRI & A-FOLFOX
        • Right upper lobe lung adenocarcinoma pT1bN0M0, stage IA2
      • In the beginning, she suffered from bloody stool for 1 years on 2020/03, visited to FuRen University Hospital, colonoscopy was done showed Rectosigmoid colon tumor, s/p biopsy showed tubulovillous adenocarcinoma with high grade dysplasia at least. Chest to pelvic CT was done on 2020/03/28 showed CRC cT3N26M1a (para-A LN) stage IVA, s/p laparoscopic LAR: mod-differentiated LN (21/22) pT3N2bMx on 2020/03/31. She received chemotherapy with FOLFIRI x 8 (no avastin ?) from 2020/04/22 ~ 08/20. 2020/11/10 CEA / Ca-199 4.45 / 14.4. CT guide biopsy was done on 2020/11/12 showed adenocarcinoma, CK7, TTF-1(+), (-)CK20 & CDX2, c/w primary lung adenocarcinoma.
      • Follow up bone scan on 2020/12/09 showed focal uptake in ant aspec of Lt 4th rib. Chest to abd CT was done on 2021/01/25 showed post OP change of RUL no liver mets. PET was done on 2021/03/15 showed PD in left lower neck & mediastinal, paraaortic to elvic LN, rTON2M1a. Bone scan was done on 2021/03/17 showed 1. No apparently interval changes in areas mentioned above, benign natures could be considered first. Follow up Colonoscopy on 2021/11/15 showed polyps, and the Pathology showed adenocarcinoma, Hyperplastic. CT image was folloe up on 2022/02/08 showed LAP in PD. Then, she received capecitabine, C1D1 on 2021/11/06 ~. Denied TOCC history in recent three months. Accroding to the CT image at Taipei Medical University Hospital on 2023/05, report showed progression of pelvis LNs was found. This time, she admitted to our ONC ward for CT guide biopsy of left pelvis LNs on 2023/06/27.

[consultation]

  • 2023-06-28 Diagnostic Radiology
    • Q
      • The patient is an 64-year-old female with a history of colon cancer s/p in 2020 (TMUH), HTN, DM, Lung adenocarcinoma s/p in 2021 (TMUH), Thyroid cancer s/p in 2016 (XiYuan Hospital), Lymphoma of the left neck.
      • For CT guide biopsy of pelvis LNs, we need your further evaluation and management. Thanks a lot!!!
    • A
      • Dear Dr.: According to the clinical condition and imaging findings, biopsy is indicated.

[immunochemotherapy]

  • 2023-09-12 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
    • acetaminophen 500mg PO (1hr before GS-1811)
  • 2023-08-22 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr
    • acetaminophen 500mg PO (1hr before GS-1811)
  • 2023-08-01 - GS-1811 10mg 0.4mL D5W 99.6mL 1hr + zimberelimab 360mg 12mL D5W 238mL 1hr

==========

2023-09-21

The lab data indicate an elevated TSH, decreased T3, normal T4, and normal Thyroglobulin levels. This could potentially suggest a subclinical hypothyroidism. It’s noted that there are no records of hypothyroidism in this patient’s history in HIS5. Is there a connection to GS-1811?

2023-09-15 TSH (NM) 9.395 uIU/ml 2023-09-15 Free T4 (NM) 1.165 ng/dl 2023-09-15 T3 (NM) 66.083 ng/dl 2023-09-15 Thyroglobulin 0.322 ng/ml

2023-08-24 TSH (NM) 25.789 uIU/ml 2023-08-24 Free T4 (NM) 1.337 ng/dl 2023-08-24 T3 (NM) 87.021 ng/dl 2023-08-24 Thyroglobulin <0.3 ng/ml

2023-07-31

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results were as follows: HBsAg (-), anti-HBc (+), anti-HBs (+), indicating that she is immune due to natural infection but remains at risk for reactivation if exposed to immunosuppressive agents.

  • 2023-06-27 Anti-HBc Reactive
  • 2023-06-27 Anti-HBc-Value 1.04 S/CO
  • 2023-06-27 Anti-HBs 229.48 mIU/mL
  • 2023-06-27 HBsAg Nonreactive
  • 2023-06-27 HBsAg (Value) 0.32 S/CO

Given this information, if immunosuppressive agents are part of the treatment plan, it is recommended that prophylactic antiviral therapy be considered. Options include either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive measure can help reduce the risk of possible reactivation of HBV infection due to the immunosuppressive effects of treatment.

700523579

230918

[exam findings]

  • 2023-09-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (177 - 135) / 177 = 23.73%
      • M-mode (Teichholz) = 24
    • Conclusion:
      • Dilated LA, LV, RA, RV and IVC; severely abnormal LV systolic function with global hypokinesia
      • Mild to moderate MR, mild TR and mild PR
      • Minimal pericardiac effusion
      • Preserved RV systolic function

==========

2023-09-19

According to the PharmaCloud database, this patient has received Glivec (imatinib) prescribed at Cardinal Tien Hospital for at least the last 3 months. BCR-ABL tyrosine kinase inhibitors, such as imatinib, dasatinib, nilotinib, bosutinib, ponatinib, and asciminib, have been associated with varying degrees of cardiovascular adverse reactions. Taking imatinib as an example, its incidence includes chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%), and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction (ref: UpToDate). The discontinuation of the drug is considered to be appropriate in this case (LVEF 24%).

2023-09-18

Imatinib has been associated with various cardiovascular side effects, including: chest pain (7% to 11%), edema (11% to 86%; severe edema: 2% to 11%), peripheral edema (20% to 41%), cold extremity (≤1%), flushing, heart failure (≤1%), hypertension (4%), hypotension (≤1%), palpitations (5%), pericardial effusion (≤6%), Raynaud’s disease (≤1%), subdural hematoma (≤1%), syncope (≤1%), tachycardia (≤1%) and <1%: acute myocardial infarction, angina pectoris, atrial fibrillation, cardiac arrhythmia, left ventricular dysfunction.

It’s important to note that other drugs in the same class as imatinib may also have cardiovascular adverse reactions.

  • Dasatinib: >10%: peripheral edema, cardiac conduction disturbance (7%; including cardiac arrhythmias [tachycardia, ventricular arrhythmia, ventricular tachycardia] and palpitations), cardiac disorder (≤4%; including cardiomyopathy, heart failure, left ventricular dysfunction, ischemic heart disease, reduced ejection fraction), chest pain, edema (1% to 4%), flushing, hypertension, pericardial effusion (1% to 4%), prolonged QT interval on ECG (≤1%) and <1%: Abnormal T waves on ECG, acute coronary syndrome, angina pectoris, cardiomegaly, coronary artery disease, deep vein thrombosis, embolism, hypotension, livedo reticularis, myocarditis, pericarditis, pleuropericarditis, prolongation P-R interval on ECG, pulmonary embolism, syncope, thrombophlebitis, thrombosis, troponin increased in blood specimen.

  • Nilotinib: hypertension (10% to 11%), occlusive arterial disease (9% to 15%; including limb stenosis), peripheral edema (9% to 15%), prolonged QT interval on ECG (children and adolescents: >30 msec from baseline: 28%; adults: >60 msec from baseline: 4%; adults: >500 msec: <1%), angina pectoris, cardiac arrhythmia (including AV block, atrial fibrillation, bradycardia, cardiac flutter, extrasystoles, and tachycardia), cerebral ischemia (1% to 3%), chest discomfort, chest pain, flushing, ischemic heart disease (5% to 9%), palpitations, pericardial effusion (≤2%), peripheral arterial disease (3% to 4%) and <1%: Acute myocardial infarction, arteriosclerosis, cardiac failure, cerebral infarction, coronary artery disease, coronary artery disease, facial edema, heart murmur, hypertensive crisis, intermittent claudication, ischemic stroke, syncope, transient ischemic attacks.

  • Bosutinib: chest pain (8% to 12%), edema (15% to 19%), hypertension (8% to 11%), coronary artery disease (3%), heart failure (2% to 5%), pericardial effusion, prolonged QT interval on ECG and <1%: Pericarditis.

  • Ponatinib: cardiac arrhythmia (17% to 25%; ventricular arrhythmia: 3%), edema (≤41%), heart failure (6% to 16%), hypertension (31% to 53%; severe hypertension: 3% to 13%), occlusive arterial disease (13% to 31%; including carotid, vertebral, and middle cerebral artery and renal artery stenosis), peripheral edema (17%), acute myocardial infarction (2%), atrial fibrillation (8%), bradycardia (≤1%; including leading to pacemaker implantation), cerebral infarction (grade 3/4: 2%), cerebrovascular occlusion (7%), coronary artery disease (grade 3/4: 2%), deep vein thrombosis (2%), pericardial effusion (4%), peripheral arterial disease (occlusive: grades 3/4: 3%), pulmonary embolism (2%), reduced ejection fraction (3%), syncope (2%), venous thromboembolism (4% to 10%) and <1%: atrial flutter, atrial tachycardia, complete atrioventricular block, hypertensive crisis, prolonged QT interval on ECG, retinal thrombosis, sinus bradycardia, sinus node dysfunction, subdural hematoma, superficial thrombophlebitis, supraventricular tachycardia, tachycardia, ventricular tachycardia.

  • Asciminib: hypertension (14%), increased serum creatine kinase (30%), cardiac arrhythmia (<10%), edema (<10%), heart failure (<10%), palpitations (<10%), prolonged QT interval on ECG (<10%)

700529576

230918

[diagnosis] - 2023-03-27 discharge note

  • Malignant neoplasm of extrahepatic bile duct
  • Urinary tract infection, site not specified

[past history]

  • Type 2 DM
  • Hypertension
  • Dyslipidemia

        

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-23 CXR

    • Boderline cardiomegaly
    • Tortuosity of the aorta with atherosclerotic change.
    • Increased lung markings over both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-04-18 SONO - abdomen

    • liver cyst, both lobe
    • post cholestectomy
    • post stenting to bilateral IHD
  • 2023-04-13 CXR

    • Ground glass opacity in bilateral lower lungs.
    • S/P operation with retention of surgical clips.
    • S/P CBD stenting.
  • 2023-04-11 CXR

    • Ground glass opacity in LLL.
  • 2023-03-24, -03-17 CXR

    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2023-03-21 CT - abdomen

    • History and indication: Klatskin tumor (Cancer that forms in the area where the left and right hepatic ducts join just outside the liver and form the common hepatic duct. Bile ducts carry bile from the liver and gallbladder to the small intestine. Klatskin tumor is a type of extrahepatic bile duct cancer. Also called perihilar bile duct cancer and perihilar cholangiocarcinoma. 2023-04-14 https://www.cancer.gov/publications/dictionaries/cancer-terms/def/klatskin-tumor)
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction. With and without-contrast CT of abdomen-pelvis revealed:
      • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
      • Mild enlargement of left thyroid gland. Minimal ascites.
      • Mild bronchiectasis at LLL.
      • R/O right renal cyst (2.5cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Degeneration and spondylosis of L-S spine.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
      • S/P foley catheter indwelling.
    • IMP:
      • S/P CBD stenting. Dilatation of bil. IHD and distention of gallbladder.
      • Mild bronchiectasis at LLL.
  • 2023-03-17 KUB

    • S/P plastic stent implantation in between the IHDs and duodenum
    • S/P Foley’s catheter insertion at the urinary bladder.
    • Fecal material store in the colon.
    • Spondylosis of the L-spine is noted.
  • 2023-03-15, -03-12 CXR

    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Widening of the upper mediastinum is noted, which may be innominate vessel or tumor. Please correlate with standing p-a view or CT.
  • 2023-02-12 ECG

    • Sinus tachycardia
    • Possible Left atrial enlargement
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-09 Nasopharyngoscopy

    • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
  • 2022-12-28 Cholangiography

    • Cholangiography via bil. PTCD catheters administration revealed:
      • Patency of the catheters. Mild migration of right PTCD catheter.
      • Obstruction of left proximal IHD.
      • Partial obstruction of right proximal IHD.
      • S/P operation with retention of surgical clips.
  • 2022-12-28 Endoscopic Retrograde CholangioPancreatography, ERCP

    • diagnosis:
      • Klatskin tumor, post bilateral PTCD, status post bilateral stricture balloon dilation and stenting to right anterior branch and right IHDs
      • Non-visualized GB
    • suggestion:
      • Please keep antibiotics treatment for high post ERCP cholangitis risk
  • 2022-12-26 Percutaneous Transhepatic Cholangio-Drainage, PTCD

  • 2022-12-23 Patho - gallbladder (benign lesion)

    • A: Gallbladder, cholecystectomy — chronic cholecystitis
    • B: Lymph node, group 12a, excision — negative for malignancy (0/1)
    • C: Lymph node, group 12c, excision — negative for malignancy (0/1)
    • F2022-00624 - Lymph node, zone 12 and 8, excision — Negative for malignancy (0/2)
  • 2022-12-12 Percutaneous Transhepatic Cholangio-Drainage, PTCD

  • 2022-12-12 SONO - abdomen

    • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
    • Renal cysts, RK
    • Hepatic cysts, both lobe
  • 2022-12-11, -11-08 CXR

    • Atherosclerosis of the aorta.
    • Enlargement of right hilum.
  • 2022-11-11 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (77.3 - 24.4) / 77.3 = 68.43%
      • M-mode (Teichholz) = 68.4
      • 2D (M-simpson) = 64.4
    • Normal AV with mild AR
    • Normal MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-11-22 Flow volume chart

    • mild obstructive ventilatory impairment
  • 2022-11-21 SONO - abdomen

    • C/W hilar tumor with left IHD and right IHD branch (B6) dilation
    • ERBD in situ (ERBD: Endoscopic Retrograde Biliary Drainage)
    • Renal cysts, RK
  • 2022-11-17 CT - abdomen

    • S/P CBD stenting.
    • Dilatation of bil. IHD and distention of gallbladder.
    • Mild bronchiectasis at LLL.
  • 2022-11-12 MRI - MR Cholangiography, MRCP

    • History and indication: Jaundice
    • IMP: In favor of Klatskin tumor with bil. proximal IHD invasion. Some LNs at hepatic hilar region.
  • 2022-11-11 Patho - liver biopsy needle/wedge

    • Bile duct, tip of cytoplogy brush, ERCP — Negative for malignancy
  • 2022-11-10 Endoscopic Retrograde CholangioPancreatography, ERCP

    • Diagnosis
      • Klastin tumor with obstructive jaundice, suspicious Bismuth-Corlette classification type I, s/p EPBD + brush cytology + ERBD (right IHD)
      • Duodenal ulcer, shallow, bulb
      • Duodenitis, bulb
    • Suggestion
      • On NPO except water tonight
      • f/u Hb, serum AST/ALT, T-bil, lipase on the next morning (11/11)
      • PPI Rx.
  • 2022-11-09 CT - abdomen

    • History and Indication: obstructive jaundice.
      • 20221108 CA199:811 U/mL (<35), CEA and AFP:normal.
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a soft tissue mass in the trifurcation of both lobe IHDs and CHD, measuring 1.5 cm in size, causing IHDs dilatation and this mass directly attached the S4 liver.
        • Klatskin tumor (T2b) is highly suspected.
        • In addition, There are four enlarged nodes in the hepatoduodenal ligament (N2).
      • There are several enlarged nodes in gastrohepatic ligament, para-aortic space and para-cava space that may be non-regional lymph nodes metastases (M1).
      • There is linear calcification in the gallbladder fossa. please correlate with clinical condition.
      • There are several renal cysts on both kidney and the largest one measuring 2.4 cm in size at right upper pole.
      • Others
        • There is no focal abnormality in the pancreas, spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • IMP:
        • Klatskin tumor is highly suspected.
        • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for perihilar CCC: T2b N2 M1, stage:IVB
  • 2021-04-13 Bone densitometry - hip

    • Hip BMD performed by DXA revealed:
    • Hip, BMD is 0.637 gms/cm2, about 1.9 SD below the peak bone mass (75 %) and 0.4 SD above the mean of age-matched people (108%).
    • IMP: osteopenia

[MedRec]

  • 2023-09-07 SOAP Orthopedics Li YiXuan
    • S
      • right hand contusion
      • Herpes zoster of right hand and palm
    • Prescription
      • Toricam (piroxicam) ASORDER TOPI
  • 2023-08-10 SOAP Dermatology Zhou WeiTing
    • S: painful eruption over right upper limb for days.
    • O:
      • Segmental papules, vesicles and crust formation with shooting tenderness over right upper limbs for days.
      • Impression: herpes zoster on the right C10 region.
    • Prescription
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# TID
      • Famvir (famciclovir 250mg) 1# TID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQID
      • Orolisin (chlorpheniramine 5mg, orotic acid 30mg, glycyrrhizic acid 50mg) 1# PRNQID
      • Silverzine (silver sulfadizaine) BID EXT
      • Xyzal (levocetirizine 5mg) 1# HS

[consultation]

  • 2023-01-09 Ear Nose Throat
    • Q
      • For left ear tinnitus
      • This 81 y/o female was a case of Klastin tumor with obstructive jaundice, T2bN2M1, stage:IVB, s/p ERBD on 2022/11/10. This time, she was admitted for further operation. However, TBI showed 15.21 was noted. Abdomen echo was performed which showed C/W hilar tumor with left IHD and right IHD branch (B6) dilation. Right side PTCD insertion was done smoothly on 2022/12/12. Operation was perfomred which revaled CHD tumor with direct bification and right portal vein invasion and severe fatty liver was noted, then no further operation is proceed due to high risk of hepatic failure. Due to persisted of TBI > 6, left side PTCD was inserted on 2022/12/26. In recent, she felt left ear tinnitus for 2 days. No other cold side were noted in recently. We need your help for further assessment for this patient. Thanks for your time!!
    • A
      • S:
        • Left tinnitus for 2 days, high frequency, especially when talking? Autophony?
        • hearing loss-, aural fullness-, dizziness-
        • NO-, Rhinorrhea+, Sneezing+
      • O:
        • Bil TM intact, EAC clean
        • Bil TM atrophic scar
        • Scope:
          • via right nasal cavity: patent right nose, patent right E tube orifice, NPx seemed smooth
          • the patient can’t tolerate the nasopharyngoscopy and refused further exam
        • Hearing exam:
        • Rinne test: Bil AC > BC
        • Weber: no lateralization
      • A:
        • Left tinnitus, cause?
        • DDx: patulous E tube
      • Plan:
        • may try kentamin if no contraindication
        • The patient refused further exam currently (PTA/typanometry or complete nasopharyngoscopy)
        • The patulous E tube may be improved by lying down or lower the head
        • Please arrange ENT OPD f/u
  • 2022-12-23 Radiation Oncology
    • A:
      • A: Klatskin tumor with bil. proximal IHD and portal vein invasion, s/p open cholecystectomy. LN 8,12, dissection.
      • P: Radiotherapy is indicated for this patient with the following indicators: unresectable Klatskin tumor
        • Goal: palliation
        • Treatment target and volume: Klatskin tumor and peripheral involved nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the Klatskin tumor and peripheral involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2023-01-19.

[surgical operation]

  • 2022-12-22
    • Surgery
      • open cholecystectomy
      • LN 8,12, dissection
    • Finding
      • CHD tumor with direct bification and right portal vein invasion
      • regional LN8 and 12 enlarge
      • severe fatty liver

[MedRec]

  • 2023-05-24 SOAP Hemato-Oncology
    • S: supportive treatment with oral UFT
    • Prescription
      • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
  • 2023-05-17 SOAP Hemato-Oncology
    • Plan
      • explain the clinical condition to patient’s daugther
      • suggest oral chemotherapy with UFUR
    • Prescription
      • UFT (tegafur 100mg, uracil 224mg) 1# BID 7D
  • 2023-01-30 SOAP Hemato-Oncology
    • explain to pt & her son about the indication & risk / benefit of palliative CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T

[radiotherapy]

  • 2023-01-19 ~ undergoing - 3960cGy/22 fractions (15 MV photon) of the Klatskin tumor and peripheral involved nodal lesions.

[chemotherapy]

  • 2023-05-17 ~ undergoing - UFT (tegafur 100mg, uracil 224mg) 1# BID

  • 2023-02-06 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-5

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2023-02-02 - fluorouracil 200mg/m2 300mg NS 500mL 24hr D1-2

    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL

[note]

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Biliary Tract Cancers - Version 2.2023 - May 10, 2023 - BIL-C

  • Neoadjuvant Therapy
    • Preferred Regimens
      • None
    • Other Recommended Regimens
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + capecitabine
      • Gemcitabine + cisplatin
      • Durvalumab + gemcitabine + cisplatin
      • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
    • Useful in Certain Circumstances
      • None
  • Adjuvant Therapy
    • Preferred Regimens
      • Capecitabine (category 1)
    • Other Recommended Regimens
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + capecitabine
      • Gemcitabine + cisplatin
      • Capecitabine + cisplatin (category 3)
      • Single agents:
        • 5-fluorouracil
        • Gemcitabine
    • Useful in Certain Circumstances
      • None
  • Agents Used with Concurrent Radiation
    • 5-fluorouracil
    • Capecitabine
  • Primary Treatment for Unresectable and Metastatic Disease
    • Preferred Regimens
      • Durvalumab + gemcitabine + cisplatin (category 1)
    • Other Recommended Regimens
      • Gemcitabine + cisplatin (category 1)
      • FOLFOX
      • Capecitabine + oxaliplatin
      • Gemcitabine + albumin-bound paclitaxel
      • Gemcitabine + capecitabine
      • Gemcitabine + oxaliplatin
      • Gemcitabine + cisplatin + albumin-bound paclitaxel (category 2B)
      • Single agents:
        • 5-fluorouracil
        • Capecitabine
        • Gemcitabine
    • Useful in Certain Circumstances
      • Targeted therapy
        • For NTRK gene fusion-positive tumors:
          • Entrectinib
          • Larotrectinib
        • For MSI-H/dMMR tumors:
          • Pembrolizumab
        • For TMB-H tumors:
          • Nivolumab + ipilimumab (category 2B)
        • For RET gene fusion-positive tumors:
          • Pralsetinib (category 2B)
          • Selpercatinib for CCA (category 2B)
  • Subsequent-Line Therapy for Biliary Tract Cancers if Disease Progression
    • Preferred Regimens
      • FOLFOX
    • Other Recommended Regimens
      • FOLFIRI (category 2B)
      • Regorafenib (category 2B)
      • Liposomal irinotecan + fluorouracil + leucovorin (category 2B)
      • See also: Preferred and Other Recommended Regimens for Unresectable and Metastatic Disease above
    • Useful in Certain Circumstances
      • Nivolumab (category 2B)
      • Lenvatinib + pembrolizumab (category 2B)
      • Targeted therapy
        • For NTRK gene fusion-positive tumors:
          • Entrectinib
          • Larotrectinib
        • For MSI-H/dMMR tumors:
          • Pembrolizumab
          • Dostarlimab-gxly (category 2B)
        • For TMB-H tumors:
          • Nivolumab + ipilimumab
          • Pembrolizumab
        • For BRAF V600E-mutated tumors:
          • Dabrafenib + trametinib
        • For CCA with FGFR2 fusions or rearrangements:
          • Futibatinib
          • Pemigatinib
        • For CCA with IDH1 mutations
          • Ivosidenib (category 1)
        • For HER2-positive tumors:
          • Trastuzumabk + pertuzumab
        • For RET gene fusion-positive tumors:
          • Selpercatinib for CCA
          • Pralsetinib (category 2B)

Principles of Systemic Therapy — NCCN Clinical Practice Guidelines in Oncology - Hepatocellular Carcinoma - Version 1.2023 - March 10, 2023 - HCC-G

  • First-Line Systemic Therapy
    • Preferred Regimens
      • Atezolizumab + bevacizumab (Child-Pugh Class A only) (category 1)
      • Tremelimumab-actl + durvalumab (category 1)
    • Other Recommended Regimens
      • Sorafenib (Child-Pugh Class A [category 1] or B7)
      • Lenvatinib (Child-Pugh Class A only) (category 1)
      • Durvalumab (category 1)
      • Pembrolizumab (category 2B)
    • Useful in Certain Circumstances
      • Nivolumab (Child-Pugh Class B only)
      • Atezolizumab + bevacizumab (Child-Pugh Class B only)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)
  • Subsequent-Line Systemic Therapy if Disease Progression
    • Options
      • Regorafenib (Child-Pugh Class A only) (category 1)
      • Cabozantinib (Child-Pugh Class A only) (category 1)
      • Lenvatinib (Child-Pugh Class A only)
      • Sorafenib (Child-Pugh Class A or B7)
    • Other Recommended Regimens
      • Nivolumab + ipilimumab (Child-Pugh Class A only)
      • Pembrolizumab (Child-Pugh Class A only)
    • Useful in Certain Circumstances
      • Ramucirumab (AFP >=400 ng/mL and Child-Pugh Class A only) (category 1)
      • Nivolumab (Child-Pugh Class B only)
      • For MSI-H/dMMR tumors -Dostarlimab-gxly (category 2B)
      • For RET gene fusion-positive tumors:
        • Selpercatinib (category 2B)
      • For TMB-H tumors:
        • Nivolumab + ipilimumab (category 2B)

==========

2023-09-18

According to the PharmaCloud data, this patient has only sought medical care at our hospital in the past three months. No discrepancies or problems were identified during the medication reconciliation process for this patient.

2023-05-29

  • The patient’s treatment was changed to UFT (a combination of Tegafur and Uracil) on 2023-05-17. There is limited data on the tolerability of UFT in older adults. However, in a study with a control group of 39 patients over 70 years of age who had undergone resection for colorectal cancer and received UFT alone, adverse events were rare and all were grade 2 or less (Reference: Cancer Biother Radiopharm. 2009;24(1):35-40). Given the patient’s advanced age, the chosen drug appears to be appropriate.

  • The drug UFT is approved in Taiwan and other countries, but is not approved by the FDA, Health Canada, or the European Medicines Agency (EMA), and is therefore not recommended by the NCCN guidelines. UFT consists of a 1:4 molar combination of tegafur (a prodrug of 5-FU) and uracil (which competitively inhibits the degradation of 5-FU, resulting in sustained plasma and intratumoral concentrations). As tegafur is a prodrug of 5-FU, which has already been used in this patient in concurrent chemoradiotherapy (CCRT), the efficacy of this approach should be continuously monitored as always.

2023-04-14

  • Amsulber (ampicillin, sulbactam) is used due to 2023-04-13 CRP 2.1mg/dL and CXR showed ground glass opacities in bilateral lower lungs.

  • Baogan (silymarin) is being used for the patient’s elevated AST and ALT.

2023-03-13

  • PharmaCloud database indicates that the medications prescribed within the last 3 months are currently being used properly with no reconciliation issues.

701059574

230918

[MedRec]

  • 2023-07-28 SOAP Gastroenterology Su WeiZhi
    • Prescription x2
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Mopride (mosapride citrate 5mg) 1# TID
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# TID
  • 2023-07-18 SOAP Metabolism and Endocrinology Hu YaHui
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Dyslipidemia ; other and unspecified hyperlipidemia [E78.5]
      • CRI; Unspecified disorder of kidney and ureter [N18.9]
      • Anemia, unspecified [D64.9]
      • Goiter, unspecified [E04.9]
      • Allergic rhinitis [J30.9]
    • Prescription
      • Allegra (fexofenadine 60mg) 1# QD
      • Crestor (rosuvastatin 10mg) 0.5# QW135
      • Ezetrol (ezetimibe 10mg) 1# QD
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Ulstop (famotidine 20mg) 0.5# QD

==========

2023-09-18

Some of the medications prescribed by our gastroenterologist on 2023-07-28 and by our endocrinologist on 2023-07-18 do not appear in the active medication list. Please verify if these omitted medications are still necessary for the patient’s treatment.

701469284

230915

[exam findings]

  • 2023-02-10 MRI - nasopharynx
    • Indication: SCC of right buccal mucosa.
    • Past history: He is an oral cancer patient and has received operations in TSGH in 2011.
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • status post previous surgery with old intraoral flap at the right mandibular gingiva.
      • a large well-enhancing mass (largest diameter about 5.3cm) at right buccal region with direct invasion and destruction of right maxilla and right hard palate, with mass protruding medially into oral cavity. The fat plane between the tumor and inferior portion of medial/lateral pterygoid and temporalis muscles is blurred, with interstitial edema of the masticator space, tumor invasion to masticator space is suspected. T4b disease is favored.
      • slightly enlarged lymph nodes at right retropharyngeal space, bilateral level Ib and II, largest diameter about 1.7cm. N2c disease is suspected.
      • bilateral symmetric pharyngeal mucosa.
      • abnormal high signal change of left mandibular bone marrow with enhancement. However this lesion do not show hot spot in bone scan. Nature is to be determined.
    • Impression:
      • Advanced right buccal cancer, image staging favor AJCC T4bN2c.
      • Bone marrow signal change at left mandible, nature to be determined.
    • Oralcavity
      • Impression (Imaging stage) : T:4b N:2c M:0 STAGE:IVB
  • 2023-02-09, -02-06 CXR
    • Normal heart size. No mediastinal widening. No active lung lesion. Intact bony thorax. S/P Port-A. S/P CVP line from left? Surgical clips at right side of the neck.
  • 2023-02-08 Tc-99m MDP bone scan
    • Hot spots in the right aspect of the maxilla, the nature is to be determined (advanced oral cancer or other nature ?), suggesting PET scan for further evaluation.
    • Suspected benign lesions in some T- and L-spine, right sternoclvicular junction, bilateral shoulders, S-I joints, and knees.
  • 2023-02-07 SONO - abdomen
    • Possible small liver cyst, left lobe
  • 2023-02-06 ECG
    • Sinus bradycardia
    • Voltage criteria for left ventricular hypertrophy
    • ST elevation, consider early repolarization, pericarditis, or injury
  • 2023-01-27 Patho - gingival/oral mucosa biopsy
    • Labeled as “right maxillary gingiva”, biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).

[MedRec]

  • 2023-08-31 SOAP Oral and Maxillofacial Surgery Xia YiRang
    • O: 40% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.
  • 2023-08-28 SOAP Oral and Maxillofacial Surgery He ChengHan
    • O: 20% tumor shrinkage due to radiation therapy is noted. radiation-related painful mucositis is noted.

[consultation]

  • 2023-05-26 Family Medicine
    • Q: This 52-year-old male suffered from an aggressive malignant tumor at his right maxillary gingiva, buccal and palate mucosa with bone destruction since few months ago. His SCC at the right buccal mucosa , maxillary gingiva, and palatal mucosa was classified as cT4bN2cM0, cStage IVB with terminal stage. We need your End-of-life co-care
    • A: 52-year-old male, Squamous cell carcinoma of right maxillary ginvia, buccal mucosa and platal mucosa with bone destruction, cT4bN2cM0, cstage IVB
      • This time suffer from disease progression, in process of induction chemotherapy
      • Consciousness E4V5M6, ECOG 2
      • We will arrange hospice combine care and follow up his condition
      • Indication: upper gum SCC (Major: Malignant neoplasm of upper gum)
      • Plan: Hospice combined care
  • 2023-05-23 Radiation Oncology
    • A: Squamous cell carcinoma of the right upper gingivobuccal mucosa and hard palate, AJCC stage cT4bN2cMo, s/p induction chemotherapy with progression.
    • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4bN2cMo, s/p induction chemotherapy with progression
      • Goal: palliation
      • Treatment target and volume: the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the right upper gingivobuccal mucosa and hard palate tumor, peripheral involved, to bilateral neck, and 7000cGy/35 fractions of the right upper gingivobuccal mucosa and hard palate tumor and involved nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-5-31.
      • Please complete pre-RT dental evaluation and management.
  • 2023-02-10 Gastroenterology
    • Q
      • This 52 year old male suffered from an aggressive malignant tumor of right maxillary and mandibular gingiva, buccal mucosa and palate for a few months. SCC of right buccal mucosa, maxillary gingiva, and palatal mucosa which combined with bone destruction, cT4aN0M0. We will arrange induction chemotherapy with Taxotere, Cisplatin, 5-Fu for him.
      • However, his data showed HbsAg (-), Anti-HBc (-) , Anti-Hbs (+) and Anti-HCV (+). We need your further evaluation and suggestion. Thanks !!
    • A
      • The patient is not in the ward, and has no plans to return to the ward after being contacted. I’ve explained to him over the phone, and he has expressed understanding.
        • Blood Draw: DAA medication pre-examination items (no need to redraw if previously done).
          • ALT, AST, Albumin, BUN, Creatinine, Bil(D), Bil(T), HbsAg, a-Fetoprotein, HCV RNA PCR, CBC, PT
      • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment and echo

[chemotherapy]

  • 2023-09-11 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-09-04 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-08-21 - cisplatin 36mg/m2 60mg NS 300mL 3hr + methotrexate 30mg/m2 50mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-06-13 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-05-24 - docetaxel 36mg/m2 50mg NS 100mL 1hr D1 + cisplatin 36mg/m2 50mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-05-17 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-28 - docetaxel 36mg/m2 60mg NS 100mL 1hr D1 + cisplatin 36mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-21 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-04-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 + methotrexate 30mg/m2 50mg NS 100mL 30min D4 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-13 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-06 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-20 - docetaxel 36mg/m2 55mg NS 100mL 1hr D1 + cisplatin 36mg/m2 55mg NS 300mL 3hr D1 + fluorouracil 900mg/m2 1400mg leucovorin 90mg/m2 140mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-13 - docetaxel 40mg/m2 60mg NS 100mL 1hr D1 + cisplatin 40mg/m2 60mg NS 300mL 3hr D1 + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2 (TPFL = docetaxel + cisplatin + 5-FU + LV, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-28 ~ 2023-04-04 UFT (tegafur 100mg + uracil 224mg) 2# BID

==========

2023-09-15

[oral mucositis]

Since 2023-06-13, the patient has been intermittently receiving radiotherapy. Regarding chemotherapy, after the last TPFL (docetaxel + cisplatin + 5-FU + LV) treatment on 2023-06-13, the patient transitioned to cisplatin + methotrexate starting from 2023-08-21. While oral mucositis could potentially be caused by chemotherapy, it’s important to note that the influence of radiotherapy cannot be entirely ruled out.

According to the recommendations in the article “Management of Cancer Therapy-Associated Oral Mucositis” (https://ascopubs.org/doi/full/10.1200/JOP.19.00652), management options for mucositis severity include bland rinses (normal saline or salt and soda), 2% viscous lidocaine swish and spit, gabapentin, 2% morphine mouthwash swish and spit, doxepin-containing mouthwashes, and systemic opiates, depending on the severity of mucositis.

2023-06-02

  • As the chemotherapy regimen has been ongoing since 2023-02-13, the patient’s WBC level remained within an acceptable range until April. However, a leukopenia event was observed following the most recent treatment cycle which began on 2023-05-24, as evident from the data on 2023-05-29. The patient was discharged on 2023-05-31, and it was noted in the discharge summary that “Filgrastim (G-CSF) 150mcg SC QD (self-paid) was prescribed for the prevention of neutropenia.” Nonetheless, the list of discharge prescriptions - loperamide, metoclopramide, zinc gluconate, and acetaminophen - does not include G-CSF. G-CSF is a reasonable medication in this context.
    • 2023-05-29 WBC 1.58 x10^3/uL
    • 2023-05-24 WBC 2.78 x10^3/uL
    • 2023-05-15 WBC 4.61 x10^3/uL
    • 2023-05-01 WBC 2.54 x10^3/uL
    • 2023-04-26 WBC 3.19 x10^3/uL
    • 2023-04-19 WBC 3.57 x10^3/uL
    • 2023-04-11 WBC 5.17 x10^3/uL
    • 2023-04-06 WBC 5.11 x10^3/uL
    • 2023-03-27 WBC 3.48 x10^3/uL
    • 2023-03-20 WBC 6.35 x10^3/uL
    • 2023-03-15 WBC 4.22 x10^3/uL
    • 2023-03-13 WBC 3.39 x10^3/uL
    • 2023-03-06 WBC 5.74 x10^3/uL
    • 2023-02-24 WBC 3.62 x10^3/uL
    • 2023-02-20 WBC 8.05 x10^3/uL
    • 2023-02-06 WBC 5.55 x10^3/uL
  • For non-hematological malignancy patients who have experienced leukopenia of less than 1000/uL, or an absolute neutrophil count (ANC) less than 500/uL following chemotherapy, national health insurance covers the use of filgrastim and lenograstim. However, the patient’s WBC count does not yet meet this criterion, hence the need for self-payment. Please confirm the prescription status of Filgrastim.

700731896

230912

  • diagnosis - 2022-12-02 admission note
    • Acute kidney failure, unspecified
    • Dyspnea, unspecified
    • Malignant neoplasm of cecum
    • Secondary malignant neoplasm of retroperitoneum and peritoneum
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Essential (primary) hypertension

[lab data]

2022-09-09 Anti-HBc Reactive
2022-09-09 Anti-HBc-Value 2.22 S/CO
2022-09-09 Anti-HBs 81.03 mIU/mL
2022-09-09 HBsAg (quantative) Nonreactive
2022-09-09 HBsAg Value (quantative) 0.00 IU/mL
2022-09-09 Anti-HCV Nonreactive
2022-09-09 Anti-HCV Value 0.11 S/CO

[exam finding]

  • 2023-08-21 CT - abdomen
    • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites.
      • Bil. pleural effusions. Small liver cysts. Mild splenomegaly.
      • Atherosclerosis of aorta, iliac arteries.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P ileostomy. Mild progression of cecal cancer, liver metastases and peritoneal carcinomatosis with ascites. Bil. pleural effusions. Mild splenomegaly
  • 2023-08-17 MRI - brain
    • No brain nodule. No evident acute infarct.
  • 2023-07-25 SONO - abdomen
    • Indication: abdominal pain
    • Findings:
      • At least 4-5 hyperechoic lesions with faint acoustic shadows were noted at right lobe and possible S4. The largest one is about 1cm at S7.
      • Splenomegaly about 13.5cm.
      • Small to moderate amount ascites
      • Tiny echogenic lesions were noted on the peritoneum. (eg. liver surface)
    • Diagnosis:
      • Liver tumors
      • Splenomegaly
      • Ascites
      • c/w carcinomatosis
  • 2023-07-03, -06-20, -05-22, -05-14 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-06-20 KUB
    • Spondylosis of the L-spine is noted.
    • One segmental small bowel in LMQ abdomen shows mild dilatation.
    • Follow up is indicated. Otherwise, Please correlate with CT.
  • 2023-06-19 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
  • 2023-05-25 CT - abdomen
    • History and indication: adenocarcinoma of cecum with total small bowel obstruction and carcinomatosis and liver metastases, stage IVC
    • IMP:
      • S/P ileostomy. Stable condition of cecal cancer, liver metastases and peritoneal carcinomatosis. Minimal ascites.
      • Minimal pleural effusion.
  • 2023-05-11 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2023-04-12 KUB
    • Disk space narrowing with spurs formation at L3-L4, L4-L5, and L5-S1 levels due to spondylosis
    • mild dextroscoliosis of the L-spine
  • 2023-04-12 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch;. dilated ascending aorta
    • skin folds over Lt hemithorax otherwise clean lung fields based on plain image
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Mild dextroscoliosis of the T-spine
  • 2023-04-12 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-02-06 CT - abdomen
    • S/P ileostomy. Mild regression of cecal cancer and liver metastases but mild progression of peritoneal carcinomatosis.
  • 2023-01-12 SONO - nephrology
    • Bilateral chronic change of both kidneys.
  • 2022-12-22 SONO - kidney
    • Normal echogenicity of the bil. kidneys.
    • Normal cortical thickness of the kidneys.
    • No evidence of urolithiasis.
    • No evidence of hydronephrosis.
  • 2022-12-02 CXR
    • Sinus tachycardia
    • T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2022-11-15 CXR
    • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
  • 2022-11-09 CXR
    • enlarged cardiac silhoutte may be prominent cardiophrenic angle mediastinal fat pad/ supine position
    • marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis.
  • 2022-10-24 CXR
    • S/P nasogastric tube insertion
    • Enlargement of cardiac silhouette.
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2022-10-17 CXR
    • appropriately positioned gastric tube
    • Port-A catheter inserted into SVC via left subclavian vein.
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Rt and Lt subpulmonary effusion?
  • 2022-10-14, -10-12, -10-10 CXR
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers and prominent cardiophrenic angle mediastinal fat pad/ supine position
    • Rt and Lt subpulmonary effusion?
    • appropriately positioned gastric tube
  • 2022-10-07 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta
    • enlarged cardiac silhoutte may be due to dilated cardiac chambers (LVD) or LVH and prominent cardiophrenic angle mediastinal fat pad/ supine position?
    • Rt and Lt subpulmonary effusion?
    • appropriately positioned gastric tube
  • 2022-09-07 CT - abdomen, pelvis
    • Inidcation:
      • epigastric pain for one month,
      • abdominal fullness with crampying pain, intermittent
    • Findings:
      • There is ill-defined Eqivocal soft tissue mass-like lesion in the RLQ abdomen, near the cecal base, appendix, and ileocecal valve area, that may be adenocarcinoma. The differential diagnosis include metastasis.
        • In addition, this mass lesion causinig mechanical small bowel obstruction.
      • There is long segmental symmetrical mild wall thickening of the small intestine at the lower abdomen and upper pelvis causing marked dilatation of the proximal small bowel that may be tumor seeding or Crohn disease?
      • There is ascites, soft tissue lesions in the RLQ omentum and the mesentery that may be carcinomatosis. Please correlate with ascites cytology.
      • There is Eqivocal wall thickening of the sigmoid colon that may be primary adenocarcinoma or tumor seeding? Please correlate with colonoscopy.
      • There are three poor enhancing mass measuring 0.8 cm in S8 dome, 0.6 cm in S8, and 1.8 cm in S6 of the liver. Metastases are highly suspected.
      • The pancreas shows small size that is c/w senile atrophy.
      • Abdominal aorta shows atherosclerosis and ectasia 2.7 cm.
      • There is a enlarged node in pre-cava space measuring 2.2 x 1 cm that may be metastatic node.
      • There is no focal abnormality in the gallbladder, biliary system, spleen & both kidney. .
      • The IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Adencoarcinoma of the cecum or appendix causing high grade small bowel obstruction, carcinomatosis, and liver metastases is highly suspected.
      • The differential diagnosis include metastases, origin?
      • Please correlate with colonoscopy.
  • 2022-09-07 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
    • A calcified spot at left pelvic cavity.
  • 2022-09-07 CXR
    • Presence of ileus.
    • Interstitial pattern at bil. lower lungs.

[consultation]

  • 2023-05-18 Infectious Disease
    • Q
      • This 82-year-old man patient is a case of Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA. This time, for Pneumonia, bilateral lung with Antibiotic with Tapimycin 4.5gm iv Q6H from 2023/04/26~. Cytomegaloviral disease with Valcyte F.C 450mg 2# po QD. Chronic obstructive pulmonary disease with Medason 40mg iv BID from 2023/04/27~, Symbicort Rapihaler 2 puff INHL BID and Spiriva Respimat 2 puff INHL QD. Pneumocystosis jirovecii pneumonia (2023/05/02 P.jiroveci DNA-Sp showed Positive) with Antibiotic with Sevatrim 400mg & 80mg 10ml IV Q8H from 2023/05/01~. O2 Mask 5L 31% use, SpO2:95%. Now, for evaluate antibiotic therapy. Thank you.
    • A
      • KP bacteremia on May 14, possible Port-A related.
      • Urine culture disclosed MRSH and Enterococcus faecalis mixed infections, with low colony count.
      • There is complete defervescence since yeterday morning under Brosym and Targocid use.
      • Change of antibiotic regimen should be not necessary.
      • Please keep Targocid for one week, and follow up urine culture 4-5 days later.
      • Port-A blood culture should be rechecekd tomorrow to see if there is sterile blood.
      • Brosym can be replaced by Cipro or Cravit on May 21 as sequential therapy.
  • 2022-10-13 Dermatology
    • Q
      • For skin rash
      • This 68-year-old male has past history of
        • hypertension
        • Adencarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09~09/17.
      • Current problem: Due to skin rash around back, chest, abdomen and inguinal area, so we need your help for evaluation. Thanks!!
    • A
      • The patient had sufferred from diffuse fine reddish papules with minimal pruritus on the trunk, majorly on the compression sweat area.
      • several erythematous annular lesions with active borders over lower legs.
      • Under the impression of milaria over trunk and tinea pedis over foot and lower leg.
      • The following sugeetion:
        • for trunk, keep body position change and avoid too long compression, consider Sinbaby 1 bot topical PRN use for occlusion if pruritus development
        • for lower leg and foot, Exelderm 1 tube topical bid use on the lower leg and foot area.
  • 2022-10-13 Metabolism and Endocrinology
    • Q
      • For abnormal thyroid function (20221012 (nuclear medicine) Free T4: 1.81, TSH: 0.078, T3: 58.119), so we need your help for evaluation. Thanks!
    • A
      • S: For abnormal TFT
      • O:
        • TPR- 37.1/79/12; BP-147/88
        • free T4-1.810, T3-58.119, TSH-0.078
        • HbA1C-6.4
        • No sig. blood flow on bedside thyroid echo
      • A:
        • Favor sick euthyroidism or low T3 syndrome
        • Suspected DM
      • Suggestions:
        • It is unnecessary to medication for thyroid at this timing
        • Just to follow free T4, T3 and TSH after 1 week is fine
        • Any problem, please call me
  • 2022-10-12 Cardiology
    • Q
      • Lab 2022-10-12
        • Mg (Magnesium) 1.5 mg/dL
        • Na (Sodium) 138 mmol/L
        • K(Potassium) 4.0 mmol/L
      • Current problem: For short run VT with pulse around 8 sceonds, so we need your help for evaluation
    • A
      • O
        • BUN: 28
        • Cr: 0.66
        • Hb: 9.4
      • Suggestion:
        • Please add carvedilol (6.25mg) 0.5#bid-1#bid if no contraindication
        • Follow-up on call, Thanks.
  • 2022-10-07 Gastroenterology
    • Q
      • Lab 2022-09-09
        • Anti-HBc Reactive
        • Anti-HBc-Value 2.22 S/CO
        • Anti-HBs 81.03 mIU/mL
        • HBsAg Nonreactive
        • HBsAg Value 0.00 IU/mL
        • Anti-HCV Nonreactive
        • Anti-HCV Value 0.11 S/CO
      • Current problem: Due to chemotherapy will be conducted, we need your help for evaluation of prescription anti-Hepatitis B virus drug.
    • A
      • The patient has Adencoarcinoma of the cecum with total small bowel obstruction and carcinomatosis, liver metastases, stage IVC status post Loop ileostomy on 2022/09/09. This time, he was admitted for respiratory distress, AKI with hyperkalemia, start hemodialysis for oligouria, acidosis during this hospitalization. For planned chemotherapy, and his lab data: HBc(+), we are consulted for HBV therapy.
      • Lab
        • Anti-HBc Reactive
        • HBsAg Nonreactive
      • Impression
        • Resolved HBV infection
        • Acute kidney injury with metabolic acidosis, hyperkalemia, now under hemodialysis
        • Adencarcinoma of the cecum, plan for chemotherapy
      • Suggestion
        • Currently, chemotherapy has not been scheduled, and the NHI only covers HBV insurance covers drugs from one week before chemotherapy to half a year after chemotherapy; and the renal function is not stable, which will affect the dosage of anti-HBV drugs; please call the gastroenterology department to evaluate medicine if the date of chemotherapy has been determined.
  • 2022-10-04 Nephrology
    • A
      • Consult for AKI and renal function impairment
      • Lab data:
        • VBG PH: 7.372, PCo2: 31.5, HCO3: 17.9, BE: -7.6
        • WBC: 16.94, HbL: 17.4, Plt: 314
        • CK :436, CLMB: 37.9, TroponinI: 595.4
        • Na: 115, K: 6.6
        • BUN/ cre: 12/0.47(9/12)-> 139/7.83(9/29)-> 218/15.83(10/4)
        • CEA: 507.17,CA 199: 1052.27
        • U/O: decrease ( no foley)
        • GPT: 281, GOT: 93, T bil :1.52,albumin:5.1
        • BP:70/50mmHg, SOB
      • Impression:
        • Acute kidney injury stage 3 suspect prerenal, septic shock and dehydration
      • Suggestion:
        • Admit ICU
        • Correct metabolic acidosis with sodium bicarbonate 20ml per hr
        • Correct hyperkalemia with D50+ RI, kalimate
        • Correct hyponatremia with 3% NS
        • Suggest IV adequate Hydration
        • Explain family about Emergent CRRT
        • We will arrange RRT if family agree
        • Thank you for your consultation !
  • 2022-09-07 Colorectal Surgery
    • Q
      • epigastric pain for one month
      • panendoscopy at local clinic found DU
      • abdominal fullness with crampying pain, intermittent
      • deny abd op Hx
    • A
      • this patient told me that he got this problem abdout 2-3 months ago and start to feel abdomen distension about one wks ago
      • CT revealed that carcinomatosis was found
      • pt still passage of gas and stool now
      • there’s no need for emergency surgery now
      • thanks for your consultation

[chemoimmunotherapy]

  • 2023-08-23 - bevacizumab 5mg/kg 400mg NS 100mL 90min + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3 + atropine 1mg SC
  • 2023-08-09 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-02 - bevacizumab 5mg/kg 400mg NS 100mL 90min + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 300mg/m2 550mg NS 250mL 2hr + fluorouracil 300mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (Avastin + FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-18 - (Avastin + FOLFOX, Q2W)
  • 2023-03-29 - (Avastin + FOLFOX, Q2W)
  • 2023-03-16 - (Avastin + FOLFOX, Q2W)
  • 2023-02-15 - (FOLFOX, Q2W)
  • 2023-02-02 - (FOLFOX, Q2W)
  • 2023-01-16 - (FOLFOX, Q2W)
  • 2022-12-22 - (FOLFOX, Q2W)
  • 2022-11-25 - oxaliplatin 75mg/m2 135mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-11-07 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-10-24 - oxaliplatin 65mg/m2 120mg 2hr + leucovorin 300mg/m2 550mg 2hr + fluorouracil 300mg/m2 550mg 10min + fluorouracil 2400mg 4400mg 46hr (FOLFOX, Q2W)
  • 2022-10-11 - leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg 4500mg 46hr

==========

2023-07-04

[renal function follow-up]

Given the recent serum Cre and BUN records, it appears that the patient’s AKI status has been resolved for some time. Therefore, this might be marked as an inactive or resolved item in the medical problem list.

  • 2023-06-27 Creatinine 1.10 mg/dL
  • 2023-06-20 Creatinine 1.06 mg/dL
  • 2023-06-19 Creatinine 0.99 mg/dL
  • 2023-06-14 Creatinine 1.62 mg/dL
  • 2023-06-27 BUN 20 mg/dL
  • 2023-06-20 BUN 10 mg/dL
  • 2023-06-19 BUN 11 mg/dL
  • 2023-06-14 BUN 27 mg/dL

2022-12-05

  • On 2022-12-05, both serum creatinine and BUN were lower than on 2022-12-03 (Cre 3.63 -> 1.90 mg/dL; BUN 71 -> 48 mg/dL), which indicates that the patient’s kidney function has improved.
  • The administration of KCl in normal saline is used to treat hypokalemia (2.9 mmol/L 2022-12-05) as well as hyponatremia (127 mmol/L 2022-12-05).
  • In the past three days, the blood pressure has remained approximately 110/60 +- 10 mmHg; in the event that successive data points show BP lower than 100/60, Norvasc (amlodipine) could be held (while Carvedilol is continued for his 90 +-20 heart rate; 2022-10-12 short run VT with pulse around 8 sceonds).

2022-09-08

  • It is suspected that the patient has cecum or colon cancer and is undergoing a workup. There is no issue with the active prescription.

701001983

230912

[diagnosis] - 2023-03-20 admission note

  • Malignant neoplasm of gallbladder
  • Encounter for antineoplastic chemotherapy
  • Insomnia, unspecified
  • Unspecified viral hepatitis B without hepatic coma
  • Constipation, unspecified

[past history]

  • Left multiple lower neck LAP with cystic like change at level III, IV, Vb
  • Left thyroid tumor, small, favor benign.            

[allergy]

  • NKDA             

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-09, -04-10, -04-06 Abdomen - Standing (Diaphragm)
    • S/P plastic stent implantation from right lobe IHD to duodenum.
  • 2023-04-13 Patho - stomach biopsy
    • Stomach, body, biopsy — Non-atrophic chronic gastritis
    • The sections show gastric body mucosal tissue with congestion, edema, mild chronic inflammatory cell infiltration, no neutrophil infiltration, no intestinal metaplasia, no gastric atrophy, and no Helicobacter pylori colonization.
  • 2023-04-13 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Gastric polyp, multiple, body, s/p biopsy
    • Post ERBD
  • 2023-04-12 CT - abdomen
    • History: 20230110 MRI: gallbladder cancer with cystic duct, CHD extension, LNs and liver metastases.
    • Findings:
      • Prior CT identified a mass lesion (3.8x7.5cm) in gallbladder is noted again, marked decreasing in size that is c/w gallbladder cancer S/P C/T with partial response.
      • Prior CT identified several metastatic LNs at hepatic hilar region are noted again, marked decreasing in size that is c/w metastatic LNs S/P C/T with partial response to near complete response.
      • Prior CT identified several metastases in both hepatic lobes are noted again, decreasing in size that is c/w liver metastases S/P C/T with partial response.
      • Prior CT identified a nodule (1.3cm) at right breast is noted again, stationary.
      • There is an ill-defined faint poor enhancing area in S4-8 of the liver, nature? Follow up is indicated.
      • S/P plastic stent implantation in between right lobe IHD and duodenum. However, mild dilatation of IHDs is still noted.
    • Impression:
      • Gallbladder cancer with liver and LNs metastases S/P C/T show partial response.
  • 2023-03-22 CT - brain
    • Indication: Gallbladder cancer with Common bile duct compression and multiple liver metastases, cT3N2M1, stage IV
    • IMP: no evidence of brain tumors.
  • 2023-03-20 CXR
    • Mild Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
  • 2023-03-06 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-01-16 Patho - lymphnode biopsy
    • Labeled as “subclavian lymph node, left”, biopsy — metastatic adenocarcinoma with neuroendocrine feature.
    • Section shows lymph node almost completely replaced by metastatic adenocarcinoma, demonstrating glands and short papillary structure.
    • IHC stains: CK7 (diffuse +), CK20 (-), TTF-1 (focal +), CK19 (diffuse +), PAX-8 (focal +), thyroglobulin (equivocal), Napsin-A (-), CD56 (focal +), synaptophysin (focal +). Extranodal extension is not present.
  • 2023-01-11 SONO - breast
    • A round right breast tumor (#2).
    • Enlarged left axillary lymph nodes, suspect lymphadenopathy.
    • BI-RADS category 4, Suspicious abnormality. Biopsy should be considered.
  • 2023-01-11 Endoscopic Retrograde CholangioPancreatography, ERCP
    • Diagnosis
      • Middle CBD stricture, s/p plastic stent placement (8.5 Fr. 9 cm )
      • Chronic cholangitis
      • Reflux esophagitis, Gr. A
    • Suggestion:
      • f/u amylase & lipase
  • 2023-01-10 MR Cholangiography, MRCP
    • History and indication: Acute cholecystitis
    • IMP: In favor of gallbladder cancer with cystic duct, CHD and CHD extension, LNs and liver metastases. Right breast tumor.
  • 2023-01-09 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Poorly differentiated carcinoma with marked neuroendocrine differentiation
    • The sections show a picture of sheets of poorly differentiated neoplastic cells with marked tumor necrosis, embedded in fibrous stroma. No definite glandular formation can be identified.
    • IHC shows: CK(+), CK7(+), CK20(-), CD56(+), and Synaptophysin(+). Either neuroendocrine carcinoma or mixed carcinoma with marked neuroendocrine differentiation should be considered.
  • 2023-01-08 CT - abdomen
    • Lobulated mass-like lesions within the gallbladder with heterogeneous enhancement. Suspected malignancy.
    • Several hypoperfusion nodular lesions over right hepatic lobe, may be metastatic lesions.
    • Dilated CBD and IHDs.
    • S/P hystorectomy.
    • Suspect confluent lobulated nodes over hepatic hilum.

[MedRec]

  • 2023-09-08 SOAP Ear Nose Throat
    • Prescription
      • Allegra (fexofenadine 60mg) 1# QD
      • Shitan (bromhexine 8mg) 1# BID
      • Anxokast (montelukasf 10mg) 1# HS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD

[consultation]

  • 2023-01-17 Radiation Oncology
    • A
      • A: Poorly differentiated carcinoma with marked neuroendocrine differentiation of the gallbladder, with liver metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: tumor with metastasis and pain
        • Goal: palliation
        • Treatment target and volume: gallbladder tumor, peripheral involved, to metastatic liver tumor
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor
        • The treatment planning of radiotherapy will be started at 0830, 2023-02-06.
  • 2023-01-12 Hemato-Oncology
    • Q
      • for chemotherapy
      • This is a 64 yesr old female patient. Under impressed of gallbladder cancer with liver metastases. We need your professional evaluation for this patient. Thank you so much!!
    • A
      • This 64 year old woman is a case of gall bladder cancer with liver metastasis (liver biopsy: Poorly differentiated carcinoma with marked neuroendocrine differentiation). We are consulted for chemotherapy.
      • Please arrange port A insertion and check HbsAg, Anti Hbc, Anti HCV. We will discuss with patient about further palliative chemotherapy (regimen such as cisplatin + etoposide). Please arrange our OPD after discharge.
  • 2023-01-12 Ophthalmology
    • Q
      • This time she felt headache due to high intraocular pressure at night. We need your help for professional assessment. Thank you so much!!
    • A
      • S
        • Left eyelid twitching and mild fullness
      • O
        • denied bv ou, headache occasionally
        • denied past hx
        • denied oph hx
        • nka
        • VAcNC od 20/70 os 20/70
        • IC 13/14mmHg
        • Pupil 3/3 +/+
        • Conj np ou
        • K clear ou
        • AC shallow / clear ou
        • Lens ns+++
      • A
        • no acute ocular problem at present
      • P
        • Inform the red flags, if worsen vision, come back asap
        • suggest oph opd f/u for prophylatic LI ou
        • opd f/u

[radiotherapy]

  • 2023-02-14 ~ 2023-03-30 - 1800cGy/10 fractions of the gallbladder tumor, peripheral involved, to metastatic liver tumor, and 4500cGy/25 fractions of the gallbladder tumor, peripheral involved area.

[chemotherapy]

  • 2023-07-20 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-02 - etoposide 70mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 70mg/m2 110mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-09 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-20 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 115mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-10 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-16 - etoposide 75mg/m2 110mg NS 500mL D1-3 + NS 500mL 2hr (D1 before cisplatin) + cisplatin 80mg/m2 120mg NS 500mL 4hr D1 + NS 500mL 2hr (D1 after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-21

  • High-grade neuroendocrine carcinomas (NEC) with poor differentiation tend to have a high likelihood of developing distant metastases and a concerning prognosis, even when they appear to be clinically localized. For the treatment of metastatic gastrointestinal and pancreatic NEC, it is often recommended to use a two-drug platinum-based regimen, usually consisting of cisplatin or carboplatin combined with etoposide.

  • The ideal treatment duration remains undetermined. Generally, the goal is to administer 4 to 6 cycles of therapy. However, if a patient continues to respond positively to the treatment and experiences minimal side effects, it may be suitable to extend chemotherapy until the maximum possible response is achieved. ref: UpToDate. https://www.uptodate.com/contents/high-grade-gastroenteropancreatic-neuroendocrine-neoplasms

  • Neuroendocrine tumors, metastatic carcinoma

  • The patient’s current etoposide and cisplatin regimen does not exceed the mentioned dosage, making it suitable and not necessitating any dosage adjustments.

701070729

230912

[MedRec]

  • 2023-07-18 ~ 2023-07-24 POMR Colorectal Surgery Chen ZhuangWei
    • Discharge diagnosis
      • A locally advanced adenocarcinoma at rectosigmoid colon with lumen obstruction, 20cm AAV, cT3N1M1 (liver metastasis), IVa status post Laparoscopic low anterior resection on 2023/07/20
      • ST elevation (STEMI) myocardial infarction involving right coronary artery
      • Hypertensive heart disease
      • Type 2 diabetes mellitus
      • Hyperlipidemia
    • CC
      • Lower abdominal pain, diarrhea and bloody stool noted for 1 month
    • Present illness
      • This 71-year-old male had history of
        • ST elevation myocardial infarction, triple vessels status post balloon angioplasty and drug-eluting stent for right coronary artery proximal segment on 2022/02/07
        • Diabete mellitus, type 2
        • Hyperlipidemia
      • According to his medical record, lab data such as stool occult blood test showed positive on 2022/02/21, however, anti-coagulation could not be stopped due to acute myocardial infaction. This time, he sufferred from lower abdominal pain, diarrhea and bloody stool noted for 1 month. He visited GI OPD for help and sigmoidoscopy on 2023/07/10 revealed rectosigmoid mucosal lesion with lumen obstruction, 20cm AAV. Pathology proved adenocarcinoma. Abdomen CT on 07/11 revealed Rectosigmoid malignancy with regional lymph nodes, poor enhancing liver tumors, suspect liver metastasis, cStage T3N1bM1a. Due to impending obstruction, he was admitted for laparoscopy anterior resection.
    • Course of inpatient treatment
      • After admission, pre-op assessment such as cardiac sonography and lung function test was arranged. Abdomen sonography was arranged for liver nodule suspect metastasis. Laparoscopic low anterior resection was performed smoothly on 2023/07/20. After operation, no specific complain except for mild wound pain was noted. Foley and Drainage was removed on 07/21 and 07/22, respectively. Flatus and stool passage was noted since 07/22 and try semi-liquid diet well. Wound was clean and no ozzing. Under relative stable condition, we arranged his discharge on 2023/07/24 and OPD follow up.
    • Discharge prescription
      • MgO 250mg 2# BID
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID

[surgical operation]

  • 2023-07-20
    • Op Method: Laparoscopic low anterior resection         
    • Finding:
      • A locally advanced tumor is located at rectosigmoid colon and focal tumor lesion grows through the bowel wall was seen. Several small white nodule lesions at colon surface and pelvia floor wall, one was sent for pathology.         - The tumor has caused bowel obstruction with much stool retention and bowel wall edema.         - The procedure of LAR was performed smoothly. Blood loss was about 20ml. Anastomosis was achieved using endo-GIA 60/green1+ 45/green1+ CDH-33+ TISSEEL 4ml. Some seromuscular silk sutures was put on posterior anastomosis site.  Air leak test is ok.         - A drain in pelvis    

[chemotherapy]

  • 2023-08-22 - irinotecan 180mg/m2 288mg D5W 250mL 90min + leucovorin 400mg/m2 640mg NS 250mL 2hr + fluorouracil 2800mg/m2 4488mg NS 1000mL 46hr
    • dexamethasone 8mg + diphenhydramine 30mg + atropine 0.25mg + palonosetron 250ug + NS 250mL

==========

2023-09-12

[diarrhea]

The patient started FOLFIRI treatment on 2023-08-22 and experienced significant diarrhea, with seven or more bowel movements per day.

Irinotecan, a component of FOLFIRI, can lead to both early and late-stage diarrhea. For early-stage diarrhea, which may come with cholinergic symptoms, atropine can be effective. Although a 0.25mg dose of atropine was initially used, increasing the dose to 0.5mg during the next treatment could be considered (can be up to 1mg). Late-stage diarrhea requires immediate attention with loperamide, as it could be life-threatening.

In cases of diarrhea, maintain close monitoring of fluid and electrolyte levels, and provide necessary supplementation. If complications like ileus, fever, or severe neutropenia arise, antibiotics may be needed. In the event of severe diarrhea, consider interrupting the irinotecan treatment and adjusting the dosage for subsequent administrations.

Patients who are homozygous for the UGT1A128 or 6 alleles (28/28, 6/6), or compound heterozygous UGT1A128 and 6 alleles (6/28), may require a dose reduction in the starting irinotecan level. Any future adjustments should be tailored to individual tolerance levels.

For treating diarrhea induced by cancer therapy, the initial oral dose of loperamide is 4 mg, followed by 2 mg every 2 to 4 hours or after each instance of loose stool. If diarrhea continues for more than 24 hours, the dose should be 2 mg every 2 hours, or alternatively, 4 mg every 4 hours. Continue this regimen until 12 hours have elapsed without a loose bowel movement, as per guidelines from Andreyev 2014, Benson 2004, and Sharma 2005. It’s worth noting that daily doses exceeding 16 mg may not offer additional benefit, and alternative treatments should be considered if diarrhea persists for 48 hours or more.

[leukopenia]

Around the third week following the patient’s initial FOLFIRI treatment, leukopenia was detected. However, after administering a dose of G-CSF (filgrastim 150ug) on 2023-09-11, no further instances of leukopenia have been observed as of now.

2023-09-12 WBC 4.70 x10^3/uL
2023-09-11 WBC 1.58 x10^3/uL
2023-09-08 WBC 1.81 x10^3/uL
2023-09-05 WBC 1.95 x10^3/uL
2023-08-22 WBC 4.85 x10^3/uL

701192853

230912

[exam findings]

  • 2023-08-16 CXR
    • Linear densities at LLL.
  • 2023-07-27, -05-08 CXR
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-07-04 CT - abdomen
    • Stable condition of rectal cancer.
    • Bronchiectasis at bilateral basal lungs.
    • Grade 5 fatty liver.
    • Hyperplasia of left adrenal gland.
    • Renal cysts (up to 1.1cm).
    • Gallbladder stones (up to 1.2cm).
  • 2023-07-04 Sigmoidoscopy
    • rectal cancer s/p TNT, with total regression
  • 2023-06-27 MRI - pelvis
    • History and indication: Rectal cancer, cT3N2a M0, stage IIIB
    • IMP:
      • Stable condition of rectal cancer as compared with previous CT study (2023-04-13).
      • Bronchiectasis at bilateral basal lungs.
  • 2023-04-13 CT - abdomen
    • Much regression of rectal cancer.
    • Bronchiectasis at bilateral basal lungs.
    • Grade 5 fatty liver. Some calcifications at pancreas.
    • Hyperplasia of left adrenal gland.
    • Renal cysts (up to 1.1cm).
    • Gallbladder stones (up to 1.2cm).
  • 2023-03-28 Sigmoidoscopy
    • tumor shrinkage to smaller
    • 5cm above AV, TATAME if need OP
  • 2023-03-24 SONO - abdomen
    • Diagnosis:
      • Fatty liver, moderate
      • Suspected GB stones with cholecystopathy
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion:
      • GS OPD f/u
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-03-21 CXR
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-01-19 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric erosion, antrum
    • R/O gastric intestinal metaplasia with suspicious ulcer scar, prepyloric antrum, PW site
    • Duodenal ulcer, bulb
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (125 - 30) / 125 = 76.00%
      • M-mode (Teichholz) = 76
    • Conclusion:
      • Concentric LV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; mild MR; mild TR.
  • 2022-12-07 CT - abdomen
    • CC: intermittent bloody stool for times,
      • Constipation with excessive straining (-)
      • 20221206 colonoscopy: middle rectal cancer
    • Indication: CT staging
    • Findings:
      • There is asymmetrical wall thickening at right lateral aspect of the middle rectum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are five enlarged node in the perirectal space (N2a).
      • There is mild fatty liver, grade 3.
      • There are stones (< 1.6 cm) and sludge in the gallbladder.
      • There is a homogeneous enhancing lesion measuring 1.6 cm in the pancreatic head that may be neuro-endocrine tumor. Please correlate with CA199, MRI, and EUS.
      • Bronchiectasis in RLL and LLL of the lung are suspected.
      • There are few small ovoid-shaped lymph nodes in paratracheal space that may be benign reactive nodes. Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2022-12-07 Patho - colon biopsy (Y1)
    • DIAGNOSIS: Intestine, large, middle rectum, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.

[MedRec]

  • 2023-07-07 Colorectal Surgery Lv ZongRu
    • A. rectal adenocarcinoma, cT3N2M0
    • P. rectal cancer s/p TNT with total regression.
      • after discuss with patient, patient want follow sigmoidioscopy + CT ever 3 months and LAR if recurrence, refuse TAMIS first. (TAMIS: Transanal Minimally Invasive Surgery)

[chemotherapy]

  • 2023-09-11 FOLFOX

  • 2023-08-16 FOLFOX

  • 2023-07-28 FOLFOX

  • 2023-07-12 FOLFOX

  • 2023-06-26 FOLFOX

  • 2023-06-05 FOLFOX

  • 2023-05-08 FOLFOX

  • 2023-04-10 FOLFOX

  • 2023-03-21 FOLFOX

  • 2023-03-03 FOLFOX

  • 2023-02-16 FOLFOX

  • 2023-01-16 5-FU

  • 2023-01-09 5-FU

  • 2022-12-30 5-FU

  • 2022-12-28 5-FU

==========

2023-09-12

The medications in the repeat prescription provided by VGHTPE on 2023-08-09 were replenished on 2023-09-04 and are currently in use. No issues with medication reconciliation have been identified.

2023-08-17

This patient obtained a 28-day refill of aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine, and atorvastatin from VGHTPE on 2023-08-09. All these medications are actively being used, and there are no discrepancies identified.

2023-07-13

This patient refilled a prescription on 2023-07-03 that was issued by VGHTPE on 2023-05-10 for aspirin, bisoprolol, fenofibrate, ezetimibe, amlodipine and atorvastatin. These drugs are now on the active formulary with no reconciliation issues identified.

700021224

230906

[exam findings]

  • 2023-06-24 CT - abdomen
    • Indication: Combined hepatocellular and cholangiocarcinoma of the liver, s/p S2/3 hepatectomy (2021-08-18, NTUH), with left subhepatic region and retroperitoneum recurrence and lung metastasis, stage IV
    • With and without contrast enhancement CT of abdomen shows:
      • s/p left lobe hepatectomy. A cyst, 0.8cm, in S7 of liver.
      • Mild regression of nodules along celiac axis.
      • Regression of LUL nodule.
    • Impression
      • Hepatocellular and cholangiocarcinoma of liver, s/p operation
      • Lung metastsis, in regression
      • Retroperitoneal recurrence, mild in regression
  • 2023-03-01 CT - chest
    • Indication: HCC with lung mets
    • Comparison was made with previous CT dated on 2022/11/05
      • Lungs: significant regression of a subsegmwental opacity at lingula as compared with previous CT. no nodule and minimal dependent atelectasis at LLL.
      • Pleura: minimal Lt-sided effusion.
      • Visible abdominal-pelvic contents:
        • mild dilatation of CHD and CBD
        • regression of presumbed metastatic LAP at retroperitoneum, around the pancreatic head.
        • wall thickening at antral part of stomach?.
        • Lt renal cyst measuring 1.5cm. unremarkable of both adrenal glands. diffuse wall thickening of the U-bladder.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Lingular nodule, significant in regression.
      • retroperitoneal LAP, in regression. chronic cystitis.
  • 2022-12-26 KUB
    • Spondylosis with scoliosis of the T-and L-spine with convex to right side.
    • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical symptom and history.
    • S/P clips projecting at right lobe liver?
  • 2022-11-10 CXR
    • A nodular opacity projecting in the left middle lung is noted that may be metastasis suspected. Please correlate with CT.
    • Wedge deformity at left lateral aspect of T12 vertebral body is noted. Please correlate with clinical condition.
  • 2022-11-10 Patho - peritoneum biopsy
    • Lung, LUL, Ct-guide biopsy — poorly differentiated carcinoma, suggestive of metastatic hepatocellular carcinoma
    • Sections show sheets of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK(focal +), CK7(focal +), CK20(-), a-fetoprotein(focal +), Hepatocyte(-), Arginase(-), TTF-1(-), p40(-), and CD56(-). The resitulin special stain reveals trabecular growth pattern. The results are suggestive of metastatic hepatocellular carcinoma. Please correlate with the clinical presentation.
  • 2022-11-07 PET
    • Glucose hypermetabolic lesions in the gastrohepatic space, left subhepatic region, and right subhepatic region, highly suspected recurrent tumor with celiac chain lymph nodes metastases, suggesting biopsy for further investigation.
    • Glucose hypermetabolic lesions in the left upper lung with pleura involvement, highly suspected another primary or secondary lung cancer. Please correlate with the findings of pathological examination.
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal regions, the nature is to be determined (cancer with regional or distant lymph nodes mets, reactive nodes or other nature ?), suggesting biopsy for investigation.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Malignant neoplasm of liver s/p treatment with tumor recurrence in the gastrohepatic space, left subhepatic and right subhepatic regions; another primary or secondary lung cancer in the left upper lung, by this F-18-FDG PET/CT scan.
  • 2022-11-05 CT - chest
    • History and indication: Malignant neoplasm of liver
    • With and without-contrast CT of chest revealed:
      • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum. Right liver cyst (1.0cm).
      • A soft tissue nodule (2.3cm) at LUQ r/o accessory spleen.
      • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
      • R/O left renal cyst (1.5cm).
    • IMP:
      • S/P liver and spleen operation. Soft tissue tumors (up to 4.4cm) at left subhepatic region and retroperitoneum.
      • A patchy density (2.7cm) at LUL. A tiny nodule (1.8cm) at LLL.
  • 2021-03-25 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 81 dB HL; L’t 91 dB HL
      • R’t moderately severe to profound mixed type HL.
      • L’t severe to profound mixed type HL.
      • (masking dilemma)
    • Tymp: R’t type A; L’t type C.
    • ART: Bil ipsi absent. (contra line malfunctioned, test not done)
    • Functional gain
      • RE: 10-35 dB.
      • LE: 20-45 dB.

[MedRec]

  • 2023-03-20 SOAP Hemato-Oncology
    • Owing to Leukopenia (WBC: 4890, seg:20, ANC:987) was notd and hold C/T on 3/20 23 .
  • 2022-11-24 ~ 2022-11-27 POMR Hemato-Oncology
    • Discharge diagnosis
      • Liver cell carcinoma
      • hepatocellular carcinoma, stage IVB
      • viral hepatitis B of anti-Hbc positive
    • Prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • Promeran (metoclopramide 3.84mg) 1# TIDAC 7D
  • 2022-11-21 SOAP Hemato-Oncology
    • S
      • explain to pt & his brother & sister about the indication & risk / benefit of palliative C/T wt FOLFOX4 plus Pembrolizumab (self paid) or Atezolizumab / Avastin ( self-paid).
      • Pt cannot afford expensive Atezo / Avastin, but accepted FOLFOX4 plus pembrolizumab (11/21 22).
      • will give FOLFOX4 plus Pembrolizumab IV Q2W x 4 then do chest CT for response evaluation (11/21 22).
      • Adm on 11/21 22 for #1 FOLFOX4 plus Pembrolizumab ( self-paid ) IV Q2W x 4.
  • 2022-11-08 SOAP Hemato-Oncology
    • A
      • combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, was noted to have recurrence in retroperitoneal lesion & lung mets.

[consultation]

  • 2023-05-30 Dermatology
    • Q
      • for skin itchy, small bubble noted for one week.
      • This 69-year-old female, a pt of combined hepatocellular & cholangiocarcinoma s/p Op x 2 in 2018 & 2021 at NTUH, recurrence at lung mets & retroperitoneal LNs mets Dx in Nov 2022.
      • Today, he was admitted for #8 FOLFOX4 plus Pembrolizumab (self-paid) IV Q2W x 4 on 5/30 23. 
      • He complaints skin itchy, small bubble noted for one week, so we need your help for evaluation, thanks a lot!!
    • A
      • The patient had sufferred from dry scaling texture witherythematous papules on the trunk.
      • Under the impression of xerotic dermatitis. r/o follculitis development.
      • The following sugeetion:
        • First, use lotion broadly, then Mycomb cream 1 tube topical bid use for crust and itchy erythematous lesions.
        • consdier add Topysm cream 1 tube topical bid PRN use over residual itchy papules.

[chemoimmunotherapy]

  • 2023-09-05 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-08-01 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-13 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-21 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 310mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 620mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 935mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-30 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 315mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 630mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 945mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-27 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa hereafter)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-08 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-05 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-15 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 85mg/m2 130mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-24 - pembrolizumab 100mg NS 100mL 30min + oxaliplatin 70mg/m2 100mg D5W 250mL 4hr + leucovorin 200mg/m2 300mg NS 250mL 2hr D1-2 + fluorouracil 400mg/m2 600mg NS 100mL 10min D1-2 + fluorouracil 600mg/m2 900mg NS 500mL 22hr D1-2 (Keytruda + FOLFOX4; reduced Oxa)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-09-06

According to PharmaCloud, this patient has no records of visiting other healthcare facilities in the past three months. The repeat prescriptions for Baraclude (entecavir) and Harnalidge (tamsulosin), issued on 2023-08-10 by our hospital OPD, are currently on the active medication list and no reconciliation issues have been identified.

2023-05-31

  • Pembrolizumab is associated with a variety of dermatologic toxicities. These can include immune-mediated rashes, severe conditions like Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN; some cases can be fatal), exfoliative dermatitis, and bullous pemphigoid. Among the spectrum of immune-related adverse events (irAEs) linked to pembrolizumab, skin-related effects like skin rash, pruritus, and vitiligo are the most common and typically occur earliest. However, rarer rashes such as lichenoid eruption (e.g., lichenoid dermatitis), psoriasis flare (e.g., plaque), and bullous disorders including bullous pemphigoid, SJS, and TEN warrant special attention due to their severity and potential life-threatening consequences.
  • The exact mechanism underlying these skin-related side effects is not well-understood. It is thought to possibly involve the blockade of a common antigen present both on tumor cells and the dermo-epidermal junction, or other layers of the skin.
  • The onset of these dermatologic toxicities can vary, but they often appear within the first 3 to 4 weeks of therapy and may affect patients with any type of tumor. They have also been reported to occur later in the course of treatment. The median time to onset for Sjogren syndrome-like symptoms is 70 days. For most patients, dermatologic toxicity is the first irAE experienced.
  • Considering the first administration of pembrolizumab was on 2022-11-01, approximately six months ago, it would be worth considering whether the skin symptoms might have developed earlier in the treatment course. According to recent outpatient records, there have been no reports of skin-related adverse events. This might warrant further investigation.

[bedside visit]

  • I visited the patient around 14:00 on 2023-05-31, the patient was with his wife by his side. It is confirmed that the skin symptoms appeared about a week ago, limited to the back near the waist, with a few scattered spots of broken skin due to scratching, which showed signs of subsiding after the use of dermatological medication. The patient believes it is caused by rubbing too hard during a bath, while his wife suspects it was caused by contact with moldy wood shavings when he was sawing wood. It was suggested that the skin symptom had little to do with pembrolizumab.
  • In addition, a rash occurred during the 7th chemotherapy administration (started on 2023-04-24). It was treated with a reliever and by reducing the infusion rate. During this (8th) chemotherapy session, the infusion rate was reduced as soon as the patient felt itchy. No adverse skin reactions were observed during the visit, and the management was appropriate.

701170059

230906

[exam findings]

  • 2023-08-12 KUB and lateral views of lumbar spine:
    • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
    • No loosening of TPs
    • S/P decompressive laminectomy of L2-L5
  • 2023-08-08 SONO - nephrology
    • Bilateral chronic change of both kidneys.
    • Bilateral renal cysts.
    • Thickened bladder wall with irregular border, cause?.
  • 2023-08-07 CT - abdomen
    • Patchy consolidation over LLL. Increased infiltration over both lower lungs. May be active infection.
    • Left pleural effusion.
    • Markedly distended urinary bladder. Mild bilateral hydroureteronephrosis.
    • Bilateral perirenal fatty strandings.
    • S/P posterior instrumentation of L2-S1 vertebrae.
  • 2023-08-07 CT - brain
    • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Old lacuna infarct over left internal capsule. There is no intracranial hemorrhage seen.
    • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
    • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • 2023-08-07 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Widening of the mediastinum.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Left pleural effusion.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-07-03, -06-29 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and pleura effusions are seen. Acute pulmonary edema is highly suspected.
  • 2023-06-24 ECG
    • Sinus rhythm with Premature atrial complexes
    • T wave abnormality, consider anterior ischemia
  • 2023-06-23 SONO - abdomen
    • Fatty liver, moderate
    • Parenchymal liver disease
    • cholecystopahty: improved.
    • Renal cyst, right
    • Renal stone, right
    • Ascites, moderate
  • 2023-06-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 44.1) / 113 = 60.97%
      • M-mode (Teichholz) = 61.0
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Moderate MR, mild AR and TR
      • Dilated LA, IVC and aortic root; thick IVS and LVPW
      • Moderate pulmonary hypertension
      • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
  • 2023-06-16 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-06-16 SONO - abdomen
    • Diagnosis:
      • Fatty liver, moderate
      • suspicious, acute cholecystitis
      • Ascites, mild
      • Parenchymal renal disease, bilateral
      • Renal cyst, right
      • r/o, Renal stone, left
      • pancreatic tail masked by gas.
    • Suggestion:
      • consult GS surgeon.
  • 2020-03-20 MRI - L-spine
    • History
      • 20200318 Residual pain over sacrum.
      • 20200219 Numbness for 2 days. Residual pain.
      • 20200204 For SIJ RF
      • 20191218 Bilateral SIJ pain, VAS 7.
      • 20190403 SIJ pain improved 50%, acceptable. Still right L5 radicular pain and numbness.
      • 20190319 For IPM
      • 20190313 Pain relieved for one day. VAS 10.
      • 20190227 L-spine s/p PD + PI + PF x 4 time, last op one month ago. Bilateral buttock pain, VAS 9. CAD s/p stent. Plvix use. Numbness over right lateral leg.
    • Non-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness in sagitta images and 4 mm thickness in the other images) reveals:
      • Scoliosis of L-spine.
      • S/P posterior decompression and TPSs at L2-3-4-5-S1.
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3-4-5-S1, esp right side at L2-3 (with midl retrolisthesis).
      • No intramedullary lesion.
      • Diffuse infiltrative T2-hyperintensity in the atrophic muscles of lower back, indicating myositis.
      • Several T2-hyperintence cysts in both kidneys, with the largest one about 15 mm.
  • 2019-03-13 KUB + L-spine Lat.
    • KUB and lateral views of lumbar spine show:
      • S/P posterior instrumental fixation with TPS-rod fixation and posterolateral fusion and anterior fusion with cage at L2-S1 levels
      • No loosening of TPs
      • S/P decompressive laminectomy of L2-L5

[MedRec]

  • 2023-07-06 MultiTeam - Oncology Psychology
    • Referral Date: 2023-06-28
    • Reason for Referral: Disease stress event: Psychophysiological stress reactions caused by physical illness or decisions about what kind of treatment to accept. Emotional distress: anxiety, fear, depression, anger; shyness, shock, etc. Social/interpersonal/communication difficulties: Conflicts or communication difficulties with family, colleagues, friends, medical staff, other patients.
    • Conclusion:
      • S
        • Visited on 2023/07/04, cared for by a caregiver, the patient was sleeping deeply. The patient’s wife mentioned that her husband would cough at night, couldn’t sleep well, had deep phlegm that couldn’t be suctioned out. The caregiver encouraged the patient to try coughing it out himself. The patient’s wife said that tying up his hands at night makes him even more unable to sleep. Once he falls asleep, it’s fine. The pain originally was only in the stomach, now it’s in the back and all over the body. When changing patches, he needs an extra half a shot for pain relief. Moreover, when he feels pain, it’s acute, very painful, not a gradual pain. If it’s a little pain, he wouldn’t say he needs an injection. When he was first admitted to the hospital, it was too painful, he even cursed himself and his daughter, because it was too painful and he was confused.
        • Now he’s more lucid, even jokes around with everyone, unlike the initial confusion. (Speaking softly) “Sometimes he says he’s in so much pain, it would be better to die”, now the doctor helps him relieve the pain, prescribed four kidney medications, thanks for the concern.
      • O
        • Prostate cancer (bone metastasis), colon cancer (post-surgery 2022-07) treated in another hospital, 2023/06/01-15 melena, discovered gastritis, internal hemorrhoids, abnormal liver function, thickened gallbladder wall at Taipei Mackay Hospital, transferred to our hospital for further treatment on 2023/06/16, 2023/06/28 confused consciousness, aggressive behavior, emotional and communication issues were referred by the NP, 2023/06/30 family meeting, 2023/07/03 occupational safety room, social worker concern.
      • I
        • Caring for the family’s care expectations.
      • AP
        • After care from multiple parties, the family expressed apology. They still have relatively strong opinions on care (suctioning, restraint, pain relief, etc.). It is recommended to communicate in a coordinate way and enhance prognostic awareness. Counselor Psychologist Huang XiaoFang
    • Reply by: Huang XiaoFang
    • Reply date: 2023-07-05 18:34
  • 2023-07-04 MultiTeam - Social Services
    • Referral Date: 2023-06-30
    • Reason for Referral: The patient and family members have emotional distress issues during hospitalization
    • Case Status: Not Open
    • Reason for not opening the case : 2023-07-03 Consultation with the patient’s wife:
    • Family situation:
      • The patient is 70 years old, married with three daughters.
      • The patient usually lives with his wife in Shulin District.
      • The eldest daughter is married and lives in Taipei, and sometimes can work remotely due to her job nature; the second daughter is unmarried, lives in Linkou District, runs her own business, and has flexible working hours; the youngest daughter is unmarried and lives in Neihu District.
    • Assessment and Treatment:
      • During the patient’s hospitalization, the caregiver and the patient’s wife were by his side to care for him. Due to the patient’s weakness, a conversation was held with his wife. Concerned about the patient’s condition during hospitalization, his wife expressed that the patient was in discomfort and sometimes confused when he was first admitted. The wife mentioned that last week, the patient had difficulty coughing up phlegm, the primary nurse suggested suctioning, but the patient didn’t want to be suctioned. The primary nurse then said, “If you don’t get the phlegm suctioned, (coughing like this) is expected.” The patient was displeased when he heard this, and his wife was also somewhat dissatisfied.
        • The wife stated that she asked the primary nurse whether it was the doctor’s recommendation to suction, but the primary nurse did not give a straightforward answer, which led to an argument that day. However, the team was informed and intervened, the wife said that it was mainly due to a misunderstanding in communication, and the patient was cursing people randomly due to his confusion at the time. The family has since apologized to the nursing staff, the wife stated that there were no issues with the care provided by the nursing staff afterwards, the patient is now more lucid, and there have been no more incidents of cursing people randomly. Therefore, there have been no issues with the care in recent days.
      • It was also understood during the consultation that there is a nurse caring for the patient during the hospitalization period. The patient’s wife, eldest daughter, and second daughter also take turns coming to the hospital to accompany him. Considering that the patient has out-of-pocket and other derivative expenses, the social worker was concerned about the family’s financial burden. The wife indicated that the family is financially secure and able to cover the additional expenses during hospitalization. The main issue currently is the patient’s back pain and other multiple sites of pain, sometimes the pain relief is not very effective, so the team is asked to pay attention to the patient’s pain.
      • The head nurse was informed of the above matters, and it was also learned from the head nurse and the primary nurse that the patient and his family’s attitudes have been more amicable recently, and there are currently no derivative issues with the care.
      • This referral provides the above treatment, and it is understood from the consultation that the patient and his family members currently have no derivative emotional distress issues, and the main concern is the patient’s pain, asking the team to pay attention. If there are further needs for social worker assistance in the future, they can be informed again, thank you.
    • Reply by: Luo Yuquan
    • Reply date: 2023-07-03

[consultation]

  • 2023-06-29 Dermatology
    • Q
      • This is a 70-year-old man with past history of:
        • Transverse colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH
        • Prostate cancer with multiple osseous metastases
        • CAD s/p PCI DES x2 at RP, under clopidogrel/Nicorandil
        • HFDEF (2022/04 LVEF:58%)
        • Adrenal insufficiency Hypoaldosteronism Hypotonic hyponatremia, r/o Al
        • Normocytic anemia, related to colon cancer
        • Hypertension Benign prostate hyperplasia.
      • Patient bedridden.
      • For skin itchy, we need your further evaluation and management.
    • A
      • The patient had sufferred from generalized itchy skin over trunk and limbs.
      • Under the impression of xerotic dermattiis
      • The following sugeetion:
        • CB strong 3 tube mix-up with Sinphraderm 1 tube. After evenly mixing with baby oil or lotion, apply it to the dry areas of the body.
        • consider Xyzal 1# HS po use and Orolsin 1#PRNTID po use for itchy control.
  • 2023-06-24 Rehabilitation
    • Q
      • For general weakness, rehabilitation plan, we need your further evaluation and management.
    • A
      • Due to deconditioning, we were consulted for bedside PT rehabilitation programs.
      • Assessment
        • Malignant neoplasm of prostate
      • Plan
        • His wife and the patient declined rehab training currently
  • 2023-06-23 Gastroenterology
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • For cholecystitis, liver function raised, we need your further evaluation and management.
    • A
      • 70M.
        • The clinical history and medical records were reviewed.
        • He was hospitalized 2023/6/1-6/16 with admission diagnosis of GI bleeding.
        • The definite etiology of bleeding was uncertain, but may be colon ulcer according to the endoscopy.
        • He received a protracted antibiotic treatment course in the hospitalization, including Flumarin plus metronidazole (6/5-6/10), ertapenem (6/10-6/14) and fluconazole (6/3-6/15).
        • He developed RUQ pain and tenderness with an acute cholestatic hepatitis in days before his transfer to our hospital.
      • S+O:
        • Drinking alcohol (-)
        • Raw food consumption (-)
        • Nausea (-), Vomiting (-)
        • Diarrhea (-)
        • Taking other medications not from this hospital (-)
      • PE: mild tenderness over RUQ region
      • Lab:
        • in MMH
          • 2023/06/02 AST 18 ALT 16 TBI 0.5
          • 2023/06/13 AST 405 ALT 391 ALP 451 GGT 1494 Lipae 33 TBI 2.0 DBI 1.7
          • 2023/06/15 AST 654 ALT 672 TBI 3.8 DBI 2.6
        • in TTCH
          • 2023/06/16 AST 237 ALT 441 ALP 430 GGT 1489 TBI 2.97 DBI 1.74; WBC 9.65 Seg 94.8% CRP 1.2 PCT 0.36

          • 2023/06/23 AST 68 ALT 127 ALP 239 GGT 993 TBI 5.64 DBI 3.43 PT 11.5 NH3 51

          • 2023/06/17 HBsAg-/AntiHBs+/AntiHCV-

          • 2023/06/23 TSH 0.053 (low), T3 0.67 (low) FT4 1.27; cortisol 17.74

        • in MMH
          • 2023/06/15 CT scan: marked edematous change of GB, but no evident gallstone or CBD stone, no biliary tract dilatation
        • in TTCH
          • 2023/06/16 Abd echo: moderate fatty liver, marked GB wall thickening with non-disteded GB, no biliary tract dilatation, mild ascites
          • 2023/06/23 Abd echo: moderate fatty liver, improved GB wall thickening, no biliary tract dilatation, moderate ascites
      • Impression:
        • Cholecystopathy or cholecystitis (non-calculous)
        • Acute cholestatic hepatitis or cholangitis, more likely to be intrahepatic cholestasis, but extrahepatic cause (such as microlithiasis of CBD) could not be ruled out
          • possible etiology of intrahepatic cholestas is included: atypical viral hepatitis, DILI (e.g. fluconazole or other antibiotic), sepsis, TPN, autoimmune liver disease (less likely)
        • Abnormal thryoid function, r/o sick euthyroid syndrome
      • Suggestion:
        • Treat acute disease per your expertise
        • No indication of biliary drainage since there was NO sign of biliary obstruction
        • Watch out for the hepatic decompensation for the progression of ascites and jaundice
        • May try empirical treament of Urso in dose of 1-2# TID
        • Consider EUS or MRCP to rule out microlithiasis of CBD
        • Screen viral hepatitis, such as HAV, EBV, CMV. May survey HEV (by CDC) if the other viral infeciton is excluded
        • Consider diagnostic paracentesis for the ascites
        • Avoid hepatic toxic agent and simplify medication if possible
        • Regularly follow up liver and biliary enzymes, bilirubin, PT
        • If the diagnosis remains inconclusive after these studies, consider to survey autoimmune profile, including: ANA. SMA, AMA, IgG4
        • Monitor liver function. If the above examinations and treatments do not yield results or improvements, please contact us.
  • 2023-06-23 Cardiology
    • Q
      • For HF history, liver function raised, R/O HF related, we need your further evaluation and management.
    • A1
      • 70 year-old male had the history of HF, CAD s/p stent(?), DM, T-colon cancer s/p left hemicolectomy at other hospital.
        • CXR 20230616 cardiomegaly
        • ECG 20230616 sinus tachycardia
      • O
        • LAB
          • 20230623 TSH 0.053, FT4 1.27 T3 0.67 cortisol 17.7 A1c6.3% chol 147 TG182 LDL99
          • Hb13.3 WBC8800 PLT112k ALT 441–201-127 Cre0.63 K2.8 albumin3.7 CRP4.8
        • Echocardiogram 20230623
          • Findings
            • AO(mm) = 38
            • LA(mm) = 47
            • IVS(mm) = 14.8-14.3
            • LVPW(mm) = 13.9-14.8
            • LVEDD(mm) = 49.1
            • LVESD(mm) = 33.0
            • TAPSE(mm) = 18.5
            • LVEF(%) =M-mode(Teichholz) = 61.0
            • TR: mild ; Max pressure gradient = 49 mmHg
            • Mitral E/A = 124 / 81.4 cm/s (E/A ratio = 1.52) ;
            • IVC size 21.4 mm with inspiratory collapse < 50%
          • Conclusion:
            • Adequate LV systolic function with no regional wall motion abnormality at resting state
            • Moderate MR, mild AR and TR
            • Dilated LA, IVC and aortic root; thick IVS and LVPW
            • Moderate pulmonary hypertension
            • Premature beats and suspected short-run atrial arrhythmia during the exam, HR 79-117bpm
      • liver echo-20230616
        • Fatty liver, moderate
        • suspicious, acute cholecystitis
        • Ascites, mild
        • Parenchymal renal disease, bilateral
        • Renal cyst, right
        • r/o, Renal stone, left
        • pancreatic tail masked by gas.
      • Impression
        • Moderate MR
        • suspected arrhythmia
        • abnormal liver biochemistry, related to fatty liver? congestive liver?
      • Suggestion
        • Holter ECG for atrial arrhythmia evaluation
        • resume medications as bisoprolol, valsartan, antiplatelet, OADs, furosemide and spironolactone
        • Monitor fluid status and titrate diiuretic dose, monitor potassium level
    • A2 2023-06-23 20:36:51
      • 6/23 NTproBNP 22334 A1c6.3%
      • Heart failure with preserved EF
    • A3 2023-07-11 14:22:49
      • lowest body weight on 7/1
      • more clear lung field by CXR of 7/3 than 6/29 and 7/10
      • Suggestion
        • may increase concor dose for HR control
        • may add digoxin 0.5# qd for HF
  • 2023-06-23 Infectious Disease
    • A
      • Consultation of Mepem antibiotic
        • There is no medical record about underlying disease and indication of Mepem antibiotic
        • Normal white count, negative serum PCT level, CRP level 4.9 on 2023-06-19, 4 days ago.
        • Patient has received one-week Flumarin for possible cholecystitis since 2023-06-16, the day of admission.
        • Higher bilirubin level noted today, that Flumarin is replaced by Mepem today.
        • Mepem seems not absolutely necessary at the present time.
      • Suggestion:
        • Recheck serum CRP level.
        • Use Brosym to replace Mepem.
  • 2023-06-21 Metabolism and Endocrinology
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • For Adrenal insufficiency history, we need your further evaluation and management.
    • A
      • This 70-year-old male, with past history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent x2, Adrenal insufficiency, was admitted due to bloody stool. We were consulted for adrenal insufficiency.
      • O:
        • Lab
          • 2023-06-19 S-GOT/AST 32 U/L
          • 2023-06-19 S-GPT/ALT 201 U/L
          • 2023-06-19 BUN 31 mg/dL
          • 2023-06-19 Creatinine 0.74 mg/dL
          • 2023-06-16 Na (Sodium) 141 mmol/L
          • 2023-06-16 K(Potassium) 3.8 mmol/L
        • SBP: 122-163
        • HR: 77-111
        • F/S: 377/239/284
      • A:
        • Adrenal insufficiency history
        • DM
      • Suggestions:
        • Keep Cortisone 1# BID at present
        • If vital signs unstable, IV hydrocortisone is indicate
        • Check ACTH/cortisol 8am, HbA1C, Cho, TG and LDL
        • After new data available, call me to interpret
  • 2023-06-17 Gastroenterology & General Surgery
    • Q
      • The patient is an 70-year-old male with a history of CHF, suspect IAI, T-colon cancer s/p laparoscopic left hemicolectomy on 2022/07/09 at MMH, Prostate cancer with multiple osseous metastases, CAD s/p stent*2, Adrenal insufficiency. He presented with intermittent bloody stool for 4 days sent to MMH.
      • 2023/06/10 CT showed
        • Compared with last CT on 2022/07/08, no CT evidence of local recurrence at previous operation region at colon loop & mild shrinkage of prostate gland and bilateral seminal vesicles
        • Neurogenic bladder
        • Suspicious for congestive heart failure; Please correlate with cardiac sonography findings.
      • 2023/06/16 Abdominal echo showed
        • Fatty liver, moderate
        • suspicious, acute cholecystitis
        • Ascites, mild
        • Parenchymal renal disease, bilateral
        • Renal cyst, right
        • r/o, Renal stone, left
        • pancreatic tail masked by gas.
      • above all, we need your further evaluation and management.
    • A
      • we were consulted for suspect cholecystitis and abnormal liver function test
      • lab data:
        • jaundice and AST/ALT improved (comparing the data on 6/15 and 6/16)
      • impression
        • abnormal LFT, suspect passing tiny CBD stones with cholangitis related
        • cholecystitis
      • suggest
        • keep flumarin use
        • try water today, may try clear liquid diet tomorrow
        • f/u lab data next w1

[treatment]

  • 2023-07-07 ~ undergoing - Xtandi (enzalutamide 40mg) 4# QDAC

  • 2023-07-10 - Zoladex Depot (goserelin 3.6mg) SC ST

  • 2023-05-09 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

  • 2023-04-11 - Firmagon (degarelix 80mg) at Taipei Mackey Hospital

  • 2023-05-09 - Xgeva (denosumab)

  • 2023-04-11 - Xgeva (denosumab)

==========

2023-09-06

[hyperbilirubinemia]

This patient’s blood bilirubin level has increased significantly since late August.

2023-09-04 Bilirubin total 25.09 mg/dL 2023-08-31 Bilirubin total 19.49 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-29 Bilirubin total 19.02 mg/dL 2023-08-28 Bilirubin total 18.30 mg/dL 2023-08-24 Bilirubin total 13.31 mg/dL 2023-08-21 Bilirubin total 10.81 mg/dL 2023-08-17 Bilirubin total 6.25 mg/dL 2023-08-14 Bilirubin total 3.61 mg/dL 2023-08-10 Bilirubin total 1.49 mg/dL 2023-08-08 Bilirubin total 1.03 mg/dL 2023-08-07 Bilirubin total 1.19 mg/dL

2023-09-04 Bilirubin direct 14.35 mg/dL 2023-08-31 Bilirubin direct 12.67 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-29 Bilirubin direct 12.16 mg/dL 2023-08-28 Bilirubin direct 9.94 mg/dL 2023-08-24 Bilirubin direct 7.89 mg/dL 2023-08-21 Bilirubin direct 6.44 mg/dL 2023-08-17 Bilirubin direct 3.58 mg/dL 2023-08-14 Bilirubin direct 2.11 mg/dL 2023-08-10 Bilirubin direct 0.74 mg/dL 2023-08-08 Bilirubin direct 0.37 mg/dL

Upon reviewing all drugs on the active medication list, 3 drugs are found to be associated with liver-related adverse reactions:

  • Furosemide (frequency unspecified): Can cause hepatic encephalopathy, elevated liver enzymes, and intrahepatic cholestatic jaundice.
  • Fentanyl (occurring in 1% or more of patients): Associated with ascites, elevated serum alkaline phosphatase, increased serum aspartate aminotransferase, and jaundice.
  • Ceftriaxone (<= 6%): increased serum alanine aminotransferase, increased serum alkaline phosphatase, increased serum aspartate aminotransferase, increased serum bilirubin.

2023-08-08

[Brosym 1000mg Q12H for patients with CrCl < 15mL/min]

Patient: Male, 70 years old, weighing 52kg, with a creatinine level of 3.58mg/dL, resulting in a creatinine clearance (CrCl) of 14mL/min.

According to the Sanford Guide, the recommended maximum dose of sulbactam for patients with a CrCl < 15mL/min is 500mg every 12 hours. Therefore, the appropriate dose for this patient would be Brosym 1000mg every 12 hours.

2023-07-12

[to increase the dose of long-acting insulin]

Considering that fasting blood glucose levels from 2023-07-10 to 2023-07-12 are still on the high side, ranging around 200mg/dL to 300mg/dL, even with the current insulin regimen of Apidra (insulin glulisine) 3 units TIDAC and Tresiba (insulin degludec) 6 units HS for days, it is recommended to increase the dosage of Tresiba from 6 units to 7 units and continue monitoring blood glucose levels to determine if further adjustments are necessary.

[bilirubin level follow-up]

The patient’s bilirubin levels have remained stable over the past two weeks.

  • 2023-07-10 Bilirubin total 1.62 mg/dL
  • 2023-07-07 Bilirubin total 1.59 mg/dL
  • 2023-07-03 Bilirubin total 1.84 mg/dL
  • 2023-06-29 Bilirubin total 1.71 mg/dL
  • 2023-07-10 Bilirubin direct 0.53 mg/dL
  • 2023-07-07 Bilirubin direct 0.75 mg/dL
  • 2023-07-03 Bilirubin direct 0.67 mg/dL
  • 2023-06-29 Bilirubin direct 0.78 mg/dL

Upon reviewing the drugs in the patient’s active medication list, there is no clear evidence suggesting a need to adjust the dosages based on the current state of the patient’s liver function.

2023-07-10

[bedside visit]

I visited the patient around 09:15 on 2023-07-10. He was lying in bed with his eyes closed, and his wife and a caregiver were present in the room. The patient didn’t respond when I conversed with his wife and the caregiver.

The patient’s caregiver mentioned that the patient’s feet were cold, so she placed a warm water bag near his feet to try to provide warmth. The patient’s wife reported that the patient had begun to sweat profusely on his head the previous night (without night sweats from the body), had not slept all night, and had a poor appetite, eating only a small amount.

Upon asking about the patient’s pain, bowel movements, and breathing, the caregiver indicated that the patient’s stools were regular, but his urine output was reduced due to concerns about pulmonary edema and fluid retention leading to reduced fluid intake. The patient continues to experience occasional shortness of breath and expresses discomfort, but there has been no significant increase in the intensity or duration of pain.

[Zoladex (goserelin)]

There is no dosage adjustment necessary for Zoladex (goserelin) in kidney impairement and/or hepatic impairment patients.

NHI provides coverage for the use of Gn-RH analogs, such as goserelin, exclusively for conditions like prostate cancer, central precocious puberty, endometriosis, and breast cancer in pre-menopausal (or peri-menopausal) cases. This patient should meet the criteria for coverage.

2023-07-06

[bedside visit: breathing smoother]

I visited the patient on 2023-07-06 at approximately 10:30. The patient was in bed, using an oxygen mask with his eyes closed, and his wife and daughter were in the room with him. I noticed that the patient’s breathing did not seem rapid. I asked his wife and daughter about the patient’s condition, and his daughter replied that the patient’s breathing seemed smoother than it had been in the past few days and that there were no specific problems at the moment. When I asked if they had any questions about the medication or wanted to understand more, they indicated that they did not have any at this time.

[patient education: enzalutamide]

The patient agreed to use Xtandi (enzalutamide). I prepared an information sheet about enzalutamide, highlighting points the patient should be aware of, as well as potential side effects of the medication. At approximately 14:10 on 2023-07-06, I visited the patient, who was resting in the room with his daughter and caregiver. I gently woke the patient’s daughter and gave her the highlighted sheet. I also gave her the contact information for the pharmacy window and encouraged her to call if she had any questions about the medication.

2023-06-30

[Minutes of the Multidisciplinary Team Meeting and Patient Family Meeting]

Today, on 2023-06-30 at around 11:45, Dr. Hsia gathered the patient’s daughter and the patient’s wife’s brother, and explained the current status of the patient’s condition using medical images. Then, from 12:15 to 13:15, a multidisciplinary team meeting and family meeting was held in the ward conference room. The meeting was chaired by Dr. Hsia and included members such as the nurse practitioner, the head nurse of the ward, the charge nurse, the social worker, and myself as the pharmacist. The the patient’s family representatives included the patient’s daughter and the patient’s wife’s brother. Dr. Hsia first clarified several key observations and considerations about the patient’s current condition. I presented the rationale behind the selection of anti-androgen agents, taking into account the expected changes in liver function. In addition, each of the nursing professionals also expressed their own perspectives.

Going forward, the pharmacy will continue to collaborate with the entire team in the management of this patient.

[bedside visit]

I visited the patient around 13:15 on 2023-06-30. The patient was using an oxygen mask, and his wife was standing by his bed. I asked about the patient’s current condition, and his wife indicated that he still had difficulty breathing, but he no longer coughed up blood. Upon checking the patient’s feet, I did not find any signs of lower limb edema.

2023-06-29

[Rationale for the Selection of Anti-Androgen Agents in Patients with Potential Hepatic Impairment]

We currently have three anti-androgen medications in stock: Casodex (bicalutamide 50mg), Xtandi (enzalutamide 40mg), and Nubeqa (darolutamide 300mg), with the last one is a temporary purchase item and thus limited its use for certain patients.

Considering the patient’s normal AST and ALT levels along with elevated bilirubin (direct 0.78mg/dL, total 1.71mg/dL) as of 2023-05-29, the patient’s liver function should be taken into account when prescribing these drugs.

  • Bicalutamide:
    • For hepatic impairment at treatment initiation: No dosage adjustment is necessary for mild, moderate, or severe impairment. However, caution is advised for patients with moderate to severe impairment as clearance may be delayed in severe impairment (based on a limited number of patients).
    • For hepatic impairment during treatment: If ALT rises above twice the upper limit of normal or jaundice develops, the treatment should be discontinued immediately.
  • Enzalutamide:
    • For mild, moderate, or severe impairment (Child-Pugh class A, B, or C): No dosage adjustment necessary. Nevertheless, an increased drug half-life has been observed in patients with severe hepatic impairment.
  • Darolutamide:
    • For mild impairment (Child-Pugh class A): No dosage adjustment necessary.
    • For moderate impairment (Child-Pugh class B): The dose should be reduced to 300 mg twice daily.
    • For severe impairment (Child-Pugh class C): There are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).

In conclusion, enzalutamide appears to be least affected by liver function and could be a reasonable choice if the patient’s liver function is not expected to recover in the short term.

2023-06-19

  • The PharmaCloud database does not disclose any data for this patient, which could be due to the patient not having granting access.

  • In the past 3 years, there have been no records of outpatient or inpatient services for this patient at our hospital prior to this hospitalization. Consequently, no medication reconciliation issues have been detected.

  • Since the patient’s admission, fasting blood glucose levels have consistently ranged between 200 and 300 mg/dL, even with the administration of regular insulin 2 units PRNQ6H. To better manage these elevated blood sugar levels, it is advisable to increase the insulin dose to 3 units just before each meal. This approach trys to prevent blood glucose levels from exceeding 200 mg/dL. Continue to monitor blood glucose readings to assess the effectiveness of this adjustment and determine if further changes are needed.

  • The fasting serum glucose levels since this hospitalization were between 200 and 300 mg/dL even under regular insulin 2 units PRNQ6H. It is recommended to increase the dose to 3 unit right before each prandial to keep the blood sugar level at least not exceed 200mg/dL and keep monitoring the readings to decide if furthur adjustment necessary.

700208930

230905

[exam findings]

  • 2023-09-02 Ocular fundus color photography
    • BDR, Background Diabetic Retinopathy
  • 2023-08-05 MRI - pelvis
    • Indication: Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage, pT2N0, cM0, stage II / FIGO stage II
    • Pelvic MRI with and without IV contrast enhancement shows:
      • s/p ATH and BSO
      • Cystic change at bilatral iliac fossa measuring 1.33cm at right side and 1.5cm at left side. Lymphocele is favored. In comparison with MRI dated on 2023-04-15, the lesion is stationary.
    • Imp:
      • s/p ATH and BSO.
      • Cystic change at bilatearal iliac fossa, stationary in size.
      • r/o lymphocele.
  • 2023-07-03 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-04-15 MRI - pelvis
    • Clinical history: 44 y/o female patient with EM cancer.
    • Without contrast enhancement MRI: Pelvis
      • S/P hystercctomy.
      • Presence of gallbladder stones.
      • Mild ascites.
      • Disc space narrowing at L5-S1.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T: T0_(T_value) N:N0_(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • Impression:
      • Clinical endometrial malignancy.
      • S/P hysterectomy.
      • GB stones.
  • 2023-04-13 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, frozen + LSC staging surgery — Endometrioid carcinoma, grade 2
      • Myometrium, uterus, ditto — Tumor invasion, less than half thickness
      • Cervix, uterus, ditto — Stromal invasion
      • Ovary, left, ditto — Free of tumor invasion, cystic follicles
        • Fallopian tube, left, ditto — Free of tumor invasion, paratubal cyst
      • Ovary, right, ditto — Free of tumor invasion
        • Fallopian tube, right, ditto — Free of tumor invasion
      • Lymph nodes
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/7)
        • Lymph node, left oburator, ditto — Free of tumor metastasis (0/5)
        • Lymph node, right iliac, ditto — Free of tumor metastasis (0/6)
        • Lymph node, right oburator, ditto — Free of tumor metastasis (0/4)
      • Parametrium, bilateral — Free of tumor invasion
      • AJCC Pathologic stage — pT1aN0, if cM0, stage IA / FIGO stage IA
      • Revised diagnosis: 8. AJCC Pathologic stage — pT2N0, if cM0, stage II / FIGO stage II
        • Reason for revision: cervical stromal invasion
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: frozen section + LSC staging surgery (TAH, BSO and BPLND)
      • Specimens include: uterus, bilateral ovaries and fallopian tubes and pelvic LNs
      • Specimen size:
        • uterus: 7.8 x 5.2 x 3.5 cm, 98 gm
        • right ovary: 3.5 x 2.1 x 1.6 cm
        • left ovary: 3.7 x 2.3 x 2.2 cm
        • right fallopian tube: 4.8 cm in length; 0.5 cm in diameter
        • left fallopian tube: 5.1 cm in length; 0.6 cm in diameter with one paratubal cyst 2.6 x 1.7 cm
      • Tumor site: endometrium
      • Tumor size: 4.8 x 4.1 cm, solid mass with many detached tumor fragments
      • The myometrium: up to 1.7 cm in thickness
      • The cervix : mucoid cysts
      • Adnexa (bilateral): left ovary and bilateral tubes are not invaded by tumor
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as follows: A: left iliac LNs; B: left obturator LNs; C: right iliac LNs; D: right obturator LNs, E1: R’t fallopian tube, E2: R’t ovary, E3: L’t fallopian tube, E4: L’t paratubal cyst, E5-E6: L’t ovary, E7: R’t parametrium, E8: L’t parametrium, E9-E13: mass, E14: cervix and E15: detached tumor fragments [Reference: F2023-00161 blood and some white tumor fragments measured up to 0.7 x 0.5 x 0.3 cm. All embedded as FSA1-FSA2]
    • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: less than half thickness of myometrium
      • Lymphovascular invasion: absent
      • The cervical stroma involvement: involved
      • Resection margins of the cervix: Free, 1.4 cm away from tumor
      • Additional pathologic findings: focal tumor necrosis
      • Lymph nodes: Free of tumor metastasis (0/22) in total number
      • Immunohistochemistry: P53(wild type), ER(+), PAX-8(+), P16(-) and vimentin(+) for tumor
      • Ascites cytology: negative
  • 2023-03-27 Gynecologic ultrasonography
    • R/O Mass ? Cx, 36 x 32 mm, RI: 0.44
  • 2023-03-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 23) / 79 = 70.89%
      • M-mode (Teichholz) = 70.4
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild MR, PR

[MedRec]

  • 2023-08-26 SOAP Metabolism and Endocrinology Laio YuHuang
    • Prescription
      • Linicor (niacin 500mg, lovastatin 20mg) 1# QD
      • Forxiga (dapagliflozin 10mg) 1# QD
      • Uformin (metformin 500mg) 1# QLCC
      • Glimet (glimepiride 2mg, metformin 500mg) 2# BIDCC
      • Lipanthyl (fenofibrate 160mg) 1# QD
      • Tresiba FlexTouch (insulin degludec) 10 unit HS SC
  • 2018-05-05 SOAP Metabolism and Endocrinology Laio YuHuang
    • Diagnosis
      • Type 2 diabetes mellitus without complications [E11.9]
      • Hyperlipidemia, unspecified [E78.5]
    • Prescription x3
      • Grumed (glimepiride 2mg) 0.5# QDCC
      • Uformin (metformin 500mg) 1# QLCC
      • Uformin (metformin 500mg) 2# BIDCC
      • Robestar (rosuvastatin 10mg) 1# QD
      • Januvia (sitagliptin phosphate 100mg) 1# QDCC
      • Lipanthyl (fenofibrate 160mg) 1# QD

[radiotherapy]

[chemotherapy]

  • 2023-09-05 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-08-05 - paclitaxel 165mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (lower paclitaxel)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-14 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-19 - paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-19 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-10 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL

==========

2023-09-05

After reviewing the PharmaCloud and HIS5 records, no issues with medication reconciliation were identified. However, a blood glucose level of 263mg/dL recorded at 06:21 on 2023-09-05 suggests that glucose control may be suboptimal despite the use of multiple antidiabetic medications. Continuous monitoring of blood sugar levels is recommended to identify any developing trends.

[hypertriglyceridemia > 1000mg/dL]

During the months of June and July, there was a significant increase in triglyceride levels, leading to severe hypertriglyceridemia (exceeding 1000 mg/dL). Elevated triglycerides could interfere with an initial stage of the insulin signaling pathway, or conversely, insulin resistance might be contributing to the hypertriglyceridemia.

2023-08-26 Triglyceride (TG) 2209 mg/dL
2023-08-19 Triglyceride (TG) 1581 mg/dL
2023-08-05 Triglyceride (TG) 1183 mg/dL
2023-07-29 Triglyceride (TG) 2254 mg/dL
2023-07-22 Triglyceride (TG) 1814 mg/dL
2023-07-13 Triglyceride (TG) 2383 mg/dL
2023-07-08 Triglyceride (TG) 1802 mg/dL
2023-06-03 Triglyceride (TG) 597 mg/dL
2023-05-06 Triglyceride (TG) 491 mg/dL
2023-04-08 Triglyceride (TG) 495 mg/dL
2023-03-11 Triglyceride (TG) 409 mg/dL
2023-02-11 Triglyceride (TG) 318 mg/dL
2023-01-14 Triglyceride (TG) 309 mg/dL

Hypothyroidism is most often associated with hypercholesterolemia (2023-07-08 cholestrol total 355 mg/dL), but association with hypertriglyceridemia has also been described. Ref: Thyroid function and prevalent and incident metabolic syndrome in older adults: the Health, Ageing and Body Composition Study. Clin Endocrinol (Oxf). 2012;76(6):911-918. doi:10.1111/j.1365-2265.2011.04328.x

When the TG level is >1000 mg/dL, drugs used to lower TG have limited effectiveness. These agents work primarily by reducing hepatic TG synthesis and secretion as VLDL-TG and thus are relatively ineffective when TG level is severely elevated.

2023-06-20

  • Based on the PharmaCloud records, all recent medications have been prescribed by our hospital. This patient last visited our metabolism OPD on 2023-06-03 for her type 2 diabetes mellitus and hyperlipidemia. Our endocrinologist provided prescriptions for Linicor (niacin 500mg, lovastatin 20mg) 1# QD, Forxiga (dapagliflozin 10mg) 1# QD, Uformin (metformin 500mg) 1# QLCC, Glimet (glimepiride 2mg, metformin 500mg) BIDCC, Lipanthyl (fenofibrate 160mg) 1# QD and Tresiba Flex Touch (insulin degludec) 10 units HS. All these medications have been successfully incorporated into the active medication list, without any reconciliation issues identified.

[patient education]

  • At around 15:15 on 2023-06-20, I visited the patient, who was resting with her eyes closed. Her sister, who was sitting in a chair next to the bed, woke her up. I brought the patient information leaflets for paclitaxel and carboplatin, explaining the potential side effects of each drug one by one. I asked her to inform the medical team as soon as possible if any suspicious symptoms occur. The patient reported that she had previously told Dr. Wan about numbness in her fingertips after chemotherapy, and stated that this condition still persists at the time of this visit.

  • Although carboplatin has been linked to peripheral neuropathy in 4% to 6% of cases, the association is even stronger with paclitaxel, which is linked to peripheral neuropathy in 42% to 70% of cases (grades 3/4 <= 7%). Therefore, it’s more probable that the numbness in the patient’s fingertips is primarily due to paclitaxel.

  • The 2020 ASCO guidelines suggest that clinicians may consider offering duloxetine to patients with chemotherapy-induced peripheral neuropathy. Additionally, the 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for the treatment of neuropathic pain in this context. Reference: “Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325”.

  • We currently have Cymbalta (duloxetine 30mg/cap) in stock. For chemotherapy-induced peripheral neuropathy, the oral initial dose is 30 mg once daily for 1 week, then increased to 60 mg once daily. (ref: UpToDate)

701196950

230905

[exam findings]

  • 2023-09-04 CXR (erect)
    • Increased infiltration in both lungs
    • Bilateral pleural effusion
    • Borderline enlarged cardiac sihoutte

[consultation]

  • 2023-09-04 Urology
    • Q
      • RECENT DIAGNOSED LUNG AND RENAL TUMORS at TaoYuan Hospital
      • PH; EV bleeding + Hx
      • alcohol cirrhosis
    • A
      • Left RCC with right lung metastasis is impressed on 2023/08/10 film
      • He underwent renal tumor biopsy twice at TaoYuan Hospital (first time only found necrosis, second biopsy report may be shown on 2023/09/05)
      • Now ascites, pleural and pericardial effusion had rapid progress on 2023/08/21 film
      • He used to drink one bottle of sorghum liquor (GaoLiang Jiu) with severe liver cirrhosis
      • He was brought to ER for leg edema and dyspnea
      • I had limited experince on liver cirrhosis with pain control
      • His elder sister and daughter had understand the difficulty of treatment and multiple complication for severe liver cirrhosis

==========

2023-09-05

The patient monthly refills for his repeat prescription medications, which include famotidine, silymarin, vitamin B complex, and propranolol, with the last refill occurring on 2023-08-06. Please confirm whether these medications are no longer required for the patient’s current medical status.

700905127

230904

[MedRec]

  • 2023-05-02 ~ 2023-05-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • LUL lung adenocarcinoma, cT3N3M1a stage IVA, with lung to lung and malignancy pleural effusion s/p TKI with Erlotinib from 2022/11/10~, progression
      • Anemia due to antineoplastic chemotherapy
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Hypothyroidism, unspecified
      • Hyperlipidemia, unspecified
      • Cachexia
      • Insomnia, unspecified
      • Chronic kidney disease, stage 4 (severe)
    • CC
      • For bronchoscopy with biopsy.
    • Present illness
      • This 82-year-old woman is a case of LUL lung adenocarcinoma, cT3N3M1a stage IVA, with lung to lung and malignancy pleural effusion in 2022/09 (but no tissue prove of malignancy yet, pleural effusion smears suggeted metastatic pulmonary adenocarcinoma with immunohistochemical stain, but further biopsy results will need to be comfirmed).
      • Progressive dyspnea in 2022/10. Left pleural effusion with chest tapping on 2022/11/01 (1000c.c for drainage). (Drainage suspended on 11/4 due to excessive volune loss related to her morning dizziness suspected).
      • Chest echo on 2022/11/03 showed left massave pleural effusion with left pigtail tube drainge.
      • Brain MRI on 2022/11/03 showed mild general brain atrophy, cerebral small vessel disease and intracranial artherosclerosis.
      • Abdominal echo on 2022/11/04 showed suspected GB polyp, suspected fatty infiltration of pancreas, propable chronic renal paremchymal disorders, bil, suspected renal cysts,bil and suboptimal examination of liver due to poor echo window.
      • Pleural effusion cell block on 2022/11/04 and 2022/11/08 showed neutrophils, lymphocytes and reactive mesothelial cells. No aerobic culture or TB found in pleural effussion.
      • Chest/Abdominal CT on 2022/11/09 revealed ground-glass opacity 1.2 cm at RUL of the lung that may be primary lung cancer.
      • Due to highly lung cancer suspected, the self-paid TKI with Erlotinib (Tarceva) 150mg 1# QD from 2022/11/10.
      • Chest CT on 2023/03/27 showed LUL cancer stage IVA in progression. Dyspnea in 2023/04. Now, she was admitted to ward for bronchoscopy with biopsy.
    • Course of inpatient treatment
      • After admitted, Self pay TKI with Erlotinib(Tarceva) 150mg 1# QD.
      • Bronchoscopy with biopsy 2023/05/05.
      • Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# po TID.
      • Famotidine 0.5# po QD for GERD.
      • Type 2 diabetes mellitus with Check finger sugar and diet control.
      • Cancer cachexia with Megest 10ml po QD.
      • Insomnia with Xanax 1# po HS.
      • Anemia(Hb:8.6g/dL) with P-RBC 2u on 2023/05/02.
      • Patient tolerated the bronchoscopy with biopsy without dyspnea.
      • With the stable condition, she was discharged on 2023/05/05 and OPD followed up later.        
  • 2023-04-19 SOAP Hemato-Oncology
    • A/P: On 2023-04-19, already mention that admission for tissue biopsy (bronchoscopy), otherwise self pay osimertinib directly, or IV or oral C/T.
  • 2023-02-01 SOAP Hemato-Oncology
    • O
      • AE: Gr 1 Anorexia
      • AE: Gr 2 Anemia
  • 2022-12-28 SOAP Hemato-Oncology
    • A/P: Due to more amount of left pleural effusion on 2022-12-28, increase erlotinib from 1# QOD to 1# QD since 2022-12-28.
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Tarceva (erlotinib 150mg) 1# QD for QODAC use
      • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
  • 2022-11-30 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, meeting date 20221108
        • NSCLC, stage IVA
        • TKI.
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# TID
      • Tarceva (erlotinib 150mg) 1# QOD for QODAC use
      • Alpraline (alprazolam 0.5mg) 1# HS if insomnia
  • 2022-11-01 ~ 2022-11-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of upper lobe, left bronchus or lung
      • Pleural effusion in other conditions classified elsewhere
      • Secondary malignant neoplasm of right lung
      • Hyperlipidemia, unspecified
      • Hypothyroidism, unspecified
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
    • CC: Dyspnea noted during activity

==========

2023-09-04

On 2023-08-05, the patient received a 30-day prescription for pioglitazone, linagliptin, pentoxifylline, amlodipine, irbesartan, and atorvastatin. Not all of these medications are currently on the list of active medications. Please check to see if any of these medications are no longer needed.

700588033

230901

[exam findings]

  • 2023-08-24 PET scan
    • Glucose hypermetabolism in a left supraclavicular lymph node, multiple bilateral paraaortic lymph nodes, bilateral common iliac lymph nodes and a left internal iliac lymph node, suggesting metastatic lymph nodes.
    • Mild glucose hypermetabolism in some focal areas in the right anterior lower pelvic cavity and right inguinal region. Metastatic lesions suhc as metastatic lymph nodes can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in the left anterior upper abdomen. The nature is to be determined (physiological FDG accumulation in the colon? other nature?). Please correlate with other imaging modalities for further evaluation.
  • 2023-08-18 CT - abdomen
    • Findings:
      • There are lobulated soft tissue lesions in right inguinal area and right common iliac chain, causing encasement of the adjacent artery and vein.
        • Metastatic nodes are highly suspected.
        • In addition, there are several newly developed enlarged nodes in para-aortic space and para-cava space that also c/w metastatic nodes.
      • There are multiple soft tissue lesions in the omentum at LUQ abdomen and left upper pelvis that are c/w tumor seeding (metastases).
      • S/P hysterectomy
    • IMP:
      • Metastatic nodes in right inguinal area, right common iliac chain, para-aortic space and para-cava space.
      • Multiple metastases in the omentum.
      • Detailed findings, please see description.
  • 2023-08-21, -03-16 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-05-13 CT - abdomen
    • Indication: Right side ovarian (high-grade serous carcinoma), pT3cN1a, stage IIIC s/p debulking surgery, s/p chemotherapy with carboplatin + paclitaxel + Avastin
    • Imp: s/p ATH and BSO. No evidence of recurrent/residual tumor in the sudy.
  • 2023-04-06 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
    • Suggestion:
      • Symptomatic treatment
  • 2023-01-16 CT - abdomen
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • s/p ATH.
      • The soft tissue mass at left pelvic sidewall is not visualized in the study. However,
      • Increased intestinal gas is found.
      • No evidence of free air is noted at the subphrenic region.
      • Non-specific bowel gas at abdominal cavity is found.
      • The liver, spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Visible chest
      • Normal heart size.
      • The lung fields are clear.
      • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp:
      • s/p ATH.
      • Dirty appearance of the pelvis mesetery is found. Suspected residual tumor activity.
  • 2023-01-06, 2022-12-09 CXR
    • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
  • 2023-01-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (88 - 32) / 88 = 63.64%
      • M-mode (Teichholz) = 63
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
  • 2022-11-09 Patho - soft tissue tumor, extensive resection
    • DIAGNOSIS:
      • A. Labeled as “01 left pelvic tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • B. Labeled as “02 omentum tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • C. Labeled as “03 para-rectal tumor (in CDS)”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • D. Labeled as “04 right peritoneal tumor”, debulking surgery/ excision — high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • B. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • C. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
      • D. Section shows high grade serous carcinoma. IHC stains: CK highlights irregular glands. P53 (aberrant type 0%).
  • 2022-11-09 Body fluid cytology
    • 35 cc brown turbid ascites
    • The smears show many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-10-18 CT - abdomen
    • Clinical history: 45 y/o female patient with right side Ovarian (high-grade serous carcinoma) , pT3cN1a, stage IIIC s/p debulking surgery, s/p chemotherapy with Carboplatin + paclitaxel + Avastin (2021/10/01~2022/01/14 6 cycles).
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy.
      • Left obturator region hypodense lesion, 1.3cm, stationary.
      • Soft tissue lesion, 1.8cm in left pelvic cavity, anterior to left psoas muscle.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Subpleural nodule in right lower lung, nature?
    • Impression:
      • S/P hysterectomy.
      • Stationary left pelvic cavity tumors.
      • Right lower lung subpleural nodule, nature?
  • 2022-10-17 Gynecologic ultrasonography
    • ATH + BSO
  • 2022-09-01 CT - abdomen
    • History and indication:
      • ROV cancer, stage IIIC s/p debulking surgeryeating and self voiding, defecation
    • IMP:
      • S/P hysterectomy.
      • A cystic lesion (1.1cm) at left pelvic cavity.
      • Grade 4 fatty liver.
  • 2022-08-12 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA grade A
    • Superficial gastritis
    • Gastric erosions, antrum
  • 2022-06-09 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2022-04-19 CXR
    • A nodular opacity projecting in the right middle lung is suspected. Please correlate with CT.
  • 2022-03-11 CT - abdomen
    • History:
      • 20210821 G-I OPD refer. SONO: pelvic mass and Ascites, BW LOSS 7 KG/2-3 MO,
      • 20210821 ERCT: suspected ovarian cancer with massove ascites
      • 20210827 debulking surgery:ROV cancer, pT3cN1a, pstage IIIC
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • S/P hysterectomy
      • There is a cystic lesion measuring 3 cm in left pelvic sidewall that may be lymphocele? please correlate with clinical condition.
      • Others
        • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • S/P hysterectomy.
      • Lynmphocele 3 cm in left pelvic sidewall is suspected. please correlate with clinical condition.
  • 2022-03-08 CT - chest
    • stationary of a well-defined RLL-S6 solid nodule (8 mm) as compared with previous CT study on 2021/12/06
  • 2021-12-16 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2021-12-06 CT - chest
    • stationary of a well-defined RLL-S6 solid nodule (8 mm) and regression lobular/centriolobular ground-glass opacities in RUL-S2 as compared with previous CT study on 2021/09/25.
  • 2021-09-25 CT - chest
    • Right lower lobe nodule. In regression. Meta is not likely.
    • Right upper lobe ground glass nodules with bronchial distribution. suspected recent inflammation. Suggest closely follow up.
  • 2021-08-30 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, R’t, frozen + debulking surgery — High-grade serous carcinoma
      • Fallopian tube, R’t, ditto — Tumor present
      • Endometrium, uterus, debulking surgery — Free from tumor, proliferative phase
      • Myometrium, uterus, ditto — Tumor invasion and leiomyomas
      • Endoervix, uterus, ditto — Tumor present at serosa with myometrial invasion
      • Cervix, uterus, ditto — Free from tumor
      • Ovary. L’t, ditto — Tumor present
      • Fallopian tube, L’t, ditto — Tumor present at serosa area
      • Omentum ttissue, excision — Tumor present
      • Pelvic (in Douglous) mass, excision — Tumor present
      • R’t peritoneal mass, excision — Tumor present
      • Lymph node, R’t iliac, dissection — Tumor metastasis (1/6) without extracapsular extension (0/1)
      • Lymph node, R’t obturator, ditto — Free from tumor metastasis (0/3)
      • Lymph node, L’t iliac, ditto — Tumor metastasis (1/8) without extracapsular extension (0/1)
      • Lymph node, L’t obturator, ditto — Tumor metastasis (2/2) without extracapsular extension (0/2)
      • AJCC Pathologic staging: pT3cN1a, if cM0; stage IIIC
    • MICROSCOPIC EXAMINATION
      • Histologic type: high-grade serous carcinoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary involvement: present
      • Right tube involvement: present
      • Left tube involvement: present at serosal layer
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Uterine serosa involvement: present
      • Omentum involvement: present
      • Uterine Cervix involvement: absent
      • Endocervix: tumor involved serosal and myometrial area, without endocervical glands invasion
      • Endometrium involvement: absent
      • Myometrium involvement: present at post endocervical region
      • Lymph nodes metastasis: tumor metastasis (4/19) without extracapsular extension (0/4) in total number
      • Immunohistochemistry: CK (+), WT-1 (+), PAX-8 (+), P53 (aberrant expression) and Napsin-A (-) for tumor
      • Ascites cytology: negative
  • 2021-08-21 CT - abdomen
    • suspected ovarian cancer with massove ascites
  • 2021-08-21 Gynecologic ultrasonography
    • Pelvic mass, suspected bilateral ovarian tumor, malignancy was highly suspected
  • 2021-08-21 SONO - abdomen
    • Diagnosis
      • Pelvic cystic tumor, huge
      • massive Ascites
    • Suggestion
      • GYN OPD visit

[consultation]

  • 2021-08-21 Obstetrics and Gynecology
    • A
      • S
        • This 44 y/o female suffered from abodminal fullness and poor appetite for one mth. She visited our GI OPD and was noted to have pelvic mass and ascites and was referred to ER.
        • BW LOSS 7 KG/2-3 MO,NO BLOODY STOOL
        • PH: NIL NKDA
      • O
        • P1, C/Sx1
        • LMP: 07/20+
        • MC: regular
        • PV: Discharge: mucoid, whitish, mild amount
        • VP: smooth, no motion tender
        • Adx and ut: unclear due to distend abdomen
        • Echo: pelvic mass, bil, malignancy was highly suspected
      • Imp
        • Ascites, cause to be determined
        • Pelvic mass, suspected ovarian cancer, origin to be determined
      • P
        • Please keep w/u other cause of ascites and origin of pelvic mass, eg. GI origin
        • Please contact us if other GYN lesion noted in the following study
        • Please also check CA 15-3 and gyneco-oncological OPD f/u for further management

[surgical operation]

  • 2022-11-08
    • Surgery: debulking surgery (left pelvic tumor + omentum tumor + pararectal tumor + right pelvic tumor excision) + enterolysis
  • 2021-08-27
    • Surgery: debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND + peritoneal tumor excision) + enterolysis

[chemoimmunotherapy]

  • 2023-08-31 - bevacizumab 800mg NS 250mL 1.5hr + topotecan 1.5mg/m2 2.5mg NS 80mL 30min D1-4
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg D1-4 + NS 250mL
  • 2023-08-01
  • 2023-07-05
  • 2023-06-06
  • 2023-05-12
  • 2023-04-07
  • 2023-03-06 - bevacizumab 800mg NS 250mL 1.5hr + liposome doxorubicin 30mg/m2 55mg D5W 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06
  • 2023-01-06
  • 2022-12-09
  • 2022-10-17 - bevacizumab 15mg/kg 1200mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-09-20
  • 2022-08-30
  • 2022-08-11
  • 2022-07-21
  • 2022-06-27
  • 2022-06-07
  • 2022-05-12 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-04-20
  • 2022-03-25
  • 2022-03-07
  • 2022-02-11
  • 2022-01-14 - bevacizumab 15mg/kg 900mg NS 250mL 1.5hr + paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 6 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2021-12-24
  • 2021-12-03
  • 2021-11-12
  • 2021-10-22
  • 2021-10-01 - no bevacizumab

==========

700021591

230831

[exam findings]

  • 2023-06-28 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some C-, T- and L-spine, right sternoclavicular junction, bilateral shoulders, elbows, and knees.
  • 2023-06-27 MRI - larynx
    • Impression (Imaging stage): T: T3(T_value) N: N1(N_value) M: M0(M_value) STAGE: ____(Stage_value)
  • 2023-06-27 SONO - abdomen
    • Liver cyst, right lobe
    • Gall stone
  • 2023-06-27 EGD
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Heterotopic gastric mucosa, upper esophagus
    • Superficial gastritis, s/p CLO test
    • Dudenal ulcer and ulcer scar, bulb
  • 2023-06-08 Patho - tonsil and/or adenoid
    • Labeled as “left tonsillar tumor”, excisional biopsy — poorly differentied squamous cell carcinoma.
    • Section shows poorly differentied squamous cell carcinoma. Margin (+).
    • IHC stains: EBER (-), p16 (+), HPV (-).
  • 2023-06-03 Nasopharyngoscopy
    • Finding: left odynophagia for months
    • Conclusion: left tonsillar tumor+, airway patent
  • 2023-02-01 Neurosonography
    • Mild atheromatous lesions in R CCA bifurcation and ICA.
    • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows except elevated flow velocity in R M1 (PS/ED= 124/42 cm/s)

[MedRec]

  • 2023-07-04 SOAP Hemato-Oncology He JingLiang
    • P: Tx: Bio-RT (erbitux weekly)
  • 2023-07-04 SOAP Ear Nose Throat Huang YunCheng
    • O: staging cT3N1M0, p16+, stage II suggest CCRT
  • 2023-07-04 SOAP Radiation Oncology Chang YouKang
    • A: IMP: Left tonsillar caner, PD SqCC, with left level II LAP metastasis, cT3N1M0, p16+, stage II.
    • Plan: CCRT to left ORX tumor and level II LAP for 7140cGy/34 fx is suggested for locoregional control. CT simulation on 7/04; possible treatment toxicity is told; diet education is given.
      • Refer to Medical Oncology for Bio-RT (weekly cetuximab).
  • 2023-07-01 SOAP Oral and Maxillofacial Surgery He ChengHan
    • Problem:
      • Squamous cell carcinoma of left tonsil
      • retained root of tooth 38 and 48
    • Plan:
      • explain the risk/benefit of dental extraction prior to radiotherapy
      • sign the informed consent
      • block anesthesia of bilateral mandible
      • complicated extraction of tooth 38 and 48
      • medication
      • teach him how to do home care
    • Prescription
      • Acetal (acetaminophen 500mg) 1# PRNTID
      • amoxicillin 250mg 2# Q8H
  • 2023-06-26 ~ 2023-06-28 POMR Ear Nose Throat Huang YunCheng
    • Discharge diagnosis
      • Malignant neoplasm of tonsil, unspecified
    • CC
      • left odynophagia noted for months
    • Present illness
      • This is a 79-year-old man with past history of prostate cancer status post operation
      • He had been suffered from left odynophagia for months. No dysphagia or hemoptysis was noticed. He was then brought to our OPD for help. Scope showed smooth nasopharynx with left tonsillar tumor. Excision of the tumor was done, and the pathology report prooved malignancy. Admission for further examination was suggested, and the patient agreed after thorough consideration. Therefore, under the impression of left tonsillar cancer, the patient was admitted for cancer work-up.        
    • Course of inpatient treatment
      • After admission, serial tests were arranged for tumor staging work up. Abdominal sonography showed right hepatic cyst. Upper GI pandescopy revealed no evidence of metastatic lesion. Consulted OS for dental evaluation was done, and tooth extraction will be arranged on this W6. Under relative stable condition, the patient was dishcarged with OPD follow up
    • Discharge prescription
      • cephalexin 500mg 1# Q6H
      • Acetal (acetaminophen 500mg) 1# Q6H
  • 2023-06-03 SOAP Ear Nose Throat Huang YunCheng
    • S: left odynophagia for months
    • O: NP scope: left tonsillar tumor, Np was smooth
    • Prescription
      • Comfflam Spray (benzydamine) 3 puff TID MOSP
  • 2021-01-11 SOAP Ear Nose Throat Huang YunCheng
    • S
      • lump in throat for long time, patient has strong gap reflex, hard to assess NP and larynx by mirror
      • cough and sorethroat for few days with purulent NR
    • O
      • Nasopharyngoscope findings: Smooth NP, Laryngx: mild edematous change of laryngeal mucosa
    • Prescription
      • Nasonex Aqueous Nasal Spray (mometasone) 2 puff QD
      • Actein Effervescent (acetylcysteine 600mg) 1# BID

[surgical operation]

[radiotherapy]

[immunochemotherapy]

  • 2023-07-21 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO
  • 2023-07-14 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO
  • 2023-07-07 - cetuximab 400mg/m2 400mg 2hr (CCRT)
    • acetaminophen 500mg PO

==========

2023-08-31

[vancomycin dosing for adults with normal kidney function]

Loading dose (for patients with known or suspected severe Staphylococcus aureus infection) 20 to 35 mg/kg (based on actual body weight, rounded to the nearest 250 mg increment; not to exceed 3000 mg). Within this range, we use a higher dose for critically ill patients; we use a lower dose for patients who are obese and/or are receiving vancomycin via continuous infusion. The patient’s weight is approximately 50 kg, which suggests a loading dose range of 1000mg to 1750mg. The administered dose of 1000mg on 2023-08-28 at 10:49 falls on the lower end of this range.

Initial maintenance dose and interval typically 15 to 20 mg/kg every 8 to 12 hours for most patients (based on actual body weight, rounded to the nearest 250 mg increment). The dosage of 20mg/kg every 12 hours is then being administered to this date currently.

Given the lower initial loading dose and the recently observed elevated trough level of 16.5 mg/L (2023-08-31 morning), a 20% reduction in the current dosage is recommended, which equates to administering 800mg Q12H.

700348601

230831

[lab data]

2023-07-27 LDH 150 U/L
2023-07-20 B2-Microglobulin 2197 ng/mL
2023-07-18 BM chromosome analysis - cytogenetics laboratory report

  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 400
    • Chromosome Counts: 45-()、46-(20)、47-()、Other-() Total-(20)
    • Karyotype: 46,XY[20]
  • Interpretation:
    • Analysis of this bone marrow sample shows a male having 46,XY[20] karyotype. No chromosomal abnormality was detected.

2023-07-13 B2-Microglobulin 2254 ng/mL
2023-07-12 LDH 142 U/L

2023-06-21 Anti-HBc Reactive
2023-06-21 Anti-HBc-Value 4.63 S/CO
2023-06-21 Anti-HBs 297.01 mIU/mL
2023-06-21 HBsAg Nonreactive
2023-06-21 HBsAg (Value) 0.35 S/CO

[exam findings]

  • 2023-06-28 CXR
    • Spondylosis of the T-spine
    • Enlargement of cardiac silhouette.
  • 2023-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 17.3) / 81.3 = 78.72%
      • M-mode (Teichholz) = 78.7
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2023-06-26 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Sections show 30-35 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-10/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
    • The immunohistochemical stains of CD3 and CD20 show mixed lymphoid cells, and no aggregation of lymphoid cells.
  • 2023-06-26 Whole body PET scan
    • Increased FDG uptake in the stomach, compatible with the primary B-cell lymphoma of stomach.
    • Increased FDG uptake in the left axillary lymph nodes, probably reactive nodes.
    • Increased FDG accumulation in the left ureter and colon, probably physiological uptake of FDG.
    • B-cell lymphoma of stomach, stage I, by this F-18 FDG PET scan.
  • 2023-06-23 Patho - stomach biopsy
    • Stomach, low body to proximal antrum, biopsy — Diffuse large B cell lymphoma
    • Histology type: diffuse large B cell lymphoma characterized by dense lymphoid infiltration consists of large atypical lymphocytes
    • Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor
  • 2023-06-23 CT - chest
    • Indication: B-cell lymphoma
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • The lung fields are clear.
        • Non-specific lymph nodes are found at paratracheal region is found.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Diffuse wall thickening at gastric body is found. Gastric lymphoma is compatible.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp: Compatible with gastric lymphoma without chest nor mediastinal involvement.
  • 2023-06-23 EGD
    • Gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy
    • Superficial gastritis
  • 2023-05-31 CT - abdomen gastric filling with water
    • Findings:
      • There is segmental wall thickening at the greater curvature side of the gastric body, measuring 2.2 cm in wall thickness.
        • Malignant lymphoma is highly suspected.
        • Please correlate with gastroscopy.
      • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
      • There is no evidence of ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Malignant lymphoma in the gastric body is highly suspected.
        • Please correlate with gastroscopy.

[MedRec]

  • 2023-07-19 SOAP Hemato-Oncology
    • P: Arrange admission for R-CHOP on 2023-07-19
  • 2023-07-07 SOAP Metabolism and Endocrinology
    • A/P
      • Educate complications: poor wound healing, hyperlipidemia, CAD/Stroke/DKD/retinopathy..
      • Diet and exercise control
      • Encourage SMBG
      • F/u OPH. QY and dentist Q6M
      • Check
        • TG/LDL/TCHO Q6M (2023/)
        • H1c, AC Q3M (2023/)
      • Medication:
        • metformin 2000, amayl BID -> metformin BID, amaryl BID, trajenta QD, 1M one touch
      • Educate hypoglycemia (in the event of hypoglycemia (below 70 mg/dL), drink a bottle of Yakult or YiMei’s small BaiJi fruit juice. Each serving contains approximately 10~15 grams of sugar. After 15~20 minutes, measure the blood sugar again, or consider having your main meal earlier.)
      • Goal:
        • SMBG: <65y/o/mutliple underlying - A1c 7.5-8.0%;AC 100-130mg/dl; PC 180mg/dl
        • BP <140/90mmHg, DKD < 130/80mmHg
        • Lipid: TCHO<160mg/dl, non-HDL<130mg/dl, HDL > 40(male), 50(female), TG< 150mg/dl
      • Side effects education
        • metformin: GI discomfort, renal function, Vit B12 deficiency
        • statin: hepatic dysfunction, myopathy, renal dose.
        • fibrate: gallstone, myopathy, GI upset, rash, pruritis
    • Prescription
      • Uformin (metformin 500mg) 2# BID
      • Trajenta (linagliptin 5mg) 1# QD
      • Amepiride (glimepiride 2mg) 1# BIDAC
  • 2023-06-21 ~ 2023-07-04 POMR Hemato-Oncology
    • Discharge diagnosis
      • Diffuse large B-cell lymphoma of gastric, stage I, Bcl-6(+), Bcl-2(-), C-MYC (+, >30%) and Ki-67(>90%) s/p chemotherapy with R-COP from 2023/06/27
      • Type 2 diabetes mellitus without complications
      • Essential (primary) hypertension
      • Chronic viral hepatitis B without delta-agent
      • Anemia due to antineoplastic chemotherapy
      • Constipation, unspecified
    • CC
      • For examine and prepare chemotherapy.
    • Present illness
      • This 72-year-old man patient suffered from epigastric pain in 2023/02. No body weight loss, night sweat and fever. PES on 2023/05/13 at LMD showed middle body huge ulcer s/p biopsya and GRED, grad A, R/O advanced gastric cancer. Gastric pathology showed malignant B-cell lymphoma, Immunostains for CK(AE1/AE3), CD20 and CD3 are also performed. Abdominal CT on 2023/05/31 showed malignant lymphoma in the gastric body is highly suspected. Now, he was admitted for further treatment and prepare chemotherapy.
    • Course of inpatient treatment
      • After admitted, Check PES on 2023/06/23 showed gastric tumor, Borrmann type III, low body to proximal antrum, s/p biopsy and superficial gastritis. Stomach, low body to proximal antrum, biopsy showed diffuse large B cell lymphoma, Immunohistochemistry: CD20(+, diffuse), CD3(-), CD10(-), CK(-), Bcl-6(+), Bcl-2(-), C-MYC (+, >30%), Cyclin-D1(-) and Ki-67(>90%) for tumor.
      • Chest CT on 2023/06/23 showed compatible with gastric lymphoma without chest nor mediastinal involvement.
      • Bone marrow study on 2023/06/28 and pathology showed negative for malignancy.
      • Whole body PET scan on 2023/06/28 showed primary B-cell lymphoma of stomach with left axillary lymph nodes metastasis, B-cell lymphoma of stomach, stage.
      • Check 2D echo on 2023/06/27 showed M-mode (Teichholz) = 78.7, 1. Normal AV with no AR 2. Normal MV with mild MR 3. Concentric LVH 4. Preserved LV and RV systolic function 5. Mild PR, mild TR, normal IVC size.
      • Consilt GS on 2023/06/26 for Port-A catheter insertion on 2023/06/28.
      • Chemotherapy with COP (Cyclophosphamide 750mg/m2, Vincristine 1.4mg/m2, Prednisolone 60mg/m2)(C1) on 2023/06/29~2023/07/03. NS 1000ml IVF hydration. Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting.
      • Major Illness applied on 2023/07/03. Type 2 diabetes mellitus without complications with Diet control and check finger sugar, Glimepine 2mg 1# po BIDAC and Metformin 500mg 2# po BID. Essential (primary) hypertension with Norvasc 1# po QD and Aspirin 1# po QD. Chronic viral hepatitis B without delta-agent(2023/06/21 Anti-HBc showed Reactive) with Vemlidy 1# po QD. Anemia(Hb:7.5g/dL) with BT P-RBC 2u on 2023/07/03, 2023/07/04. Constipation with MgO 2# po TID, Sennoside 2# po HS and Bisadyl supp 1# RECT PRNQD. Patient tolerated the chemotherapy without nausea and vomiting. With the stable condition, he was discharged on 2023/07/04 and OPD followed up later.
    • Discharge prescription
      • MgO 250mg 2# TID
      • Through (sennoside 12mg) 2# HS
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
  • 2023-06-06 SOAP Hemato-Oncology
    • O
      • 2023/05/31 CT: Abdomen gastric filling with water: Malignant lymphoma in the gastric body is highly suspected
    • P
      • Admission for EGD, Chest CT, PET-CT, bone marrow, lab HBV/HCV, LDH, UA. Port-A insertion.
  • 2023-05-30 SOAP General Surgery
    • S
      • epigastric pain for 3 months
      • BW: 75 kg
      • DM+ with 10 yrs
      • H/T with TX 10 yrs
    • O
      • UGI scope: middle body huge ulcer
      • path: malignant B cell lymphoma
      • arrange CT scan

[immunochemotherapy]

  • 2023-08-14 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-21 - rituximab 375mg/m2 680mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + doxorubicin 50mg/m2 75mg + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 50mg BID PO D1-5 (R-CHOP Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-29 - cyclophosphamide 750mg/m2 1300mg NS 250mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 100mg QD PO D1-3 (COP Q3W)
    • dexamethasone 4mg + + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-09-01

[Dipeptiven dosage and administration]

(Dipeptiven ref: https://www.fresenius-kabi.com/nz/documents/Dipeptiven_Datasheet.pdf)

Solution for infusion after mixture with a compatible infusion solution. Solutions of mixtures with an osmolarity above 800 mosmol/L should be infused by the central venous route.

Dipeptiven is administered parallel with parenteral nutrition or enteral nutrition or a combination of both. Dosage depends on the severity of the catabolic state and on amino acids/protein requirement.

A maximum daily dosage of 2 g amino acids/or protein per kg bodyweight should not be exceeded in parenteral/enteral nutrition. The supply of alanine and glutamine via Dipeptiven should be taken into consideration in the calculation. The proportion of the amino acids supplied through Dipeptiven should not exceed approx. 30% of the total amino acids/protein supply.

  • Patients with total parenteral nutrition
    • The rate of infusion depends on that of the carrier solution and should not exceed 0.1 g amino acids/kg body weight per hour.
    • Dipeptiven should be mixed with a compatible amino acid carrier solution or an amino acid containing infusion regimen prior to administration.
  • Patients with total enteral nutrition
    • Dipeptiven is continuously infused over 20-24 hours per day. For peripheral venous infusion, dilute Dipeptiven to an osmolarity ≤ 800 mosmol/L (e.g. 100 mL Dipeptiven +100 ml saline).
  • Patients with combined enteral and parenteral nutrition
    • The full daily dosage of Dipeptiven should be administered with the parenteral nutrition, i.e. mixed with a compatible amino acid solution or an amino acid contained in infusion regimen prior to administration.

2023-08-31

[Selection of antiviral drugs for Hepatitis B]

This patient is undergoing dialysis, and the current administration methods for Hepatitis B medication available in our hospital for dialysis patients are:

  • Baraclude (entecavir 0.5mg)
    • Hemodialysis, intermittent (thrice weekly): Not significantly dialyzed (13%): Administer 10% of usual indication-specific dose daily. Alternatively, administer usual indication-specific dose every 7 days. When scheduled dose falls on a dialysis day, administer after hemodialysis.
    • Hepatic Impairment: No dosage adjustment necessary.
  • Vemlidy (tenofovir alafenamide 25mg)
    • Hemodialysis, intermittent (thrice weekly): No dosage adjustment necessary; when scheduled dose falls on a dialysis day, administer after dialysis.
    • Hepatic Impairment: Decompensated cirrhosis (Child-Pugh class B or C): Use is not recommended.
  • Viread (tenofovir disoproxil fumarate 300mg)
    • Hemodialysis, intermittent (thrice weekly): Tenofovir disoproxil fumarate: 300 mg following dialysis every 7 days; use with caution and close monitoring.
    • Hepatic Impairment: No dosage adjustment necessary.

Considering the patient’s bilirubin levels on 2023-08-30, with total bilirubin at 2.32mg/dL and direct bilirubin at 1.78mg/dL, the use of Baraclude 0.5mg QWAC may be an option.

2023-08-15

The patient renewed his prescription on 2023-08-03 for metformin, aspirin, bisoprolol, amlodipine, and atorvastatin. Comparing with the active medication list, statins are not listed. Lab results from 2023-08-04 indicated no hyperlipidemia. Thus, there are no identified issues with medication reconciliation.

2023-08-04 Cholesterol total 148 mg/dL
2023-08-04 Triglyceride (TG) 95 mg/dL
2023-08-04 LDL-C 95 mg/dL
2023-08-04 HDL-C 43 mg/dL

701181620

230831

[exam findings]

  • 2023-07-25 ECG
    • Sinus bradycardia
  • 2023-07-25 CXR
    • Atherosclerotic change of aortic arch
  • 2023-07-11 CT - abdomen
    • Clinical history: 64 y/o female patient with postoperative radiotherapy due to endometrium carcinoma.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy and oophorectomy.
      • Cystic lesions, 2.9cm in left and 2.1cm in right pelvic cavity, r/o lymphocele.
    • Impression:
      • S/P hysterectomy and oophorectomy. Suggest follow up.
      • R/O lymphocele in the pelvic cavity.
  • 2023-06-05 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: No obvious uterine or ovarian lesion
  • 2023-02-27 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Endometrium, uterus, 3D laparoscopic staging surgery — Endometrioid carcinoma, grade 2
      • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
      • Cervix, uterus, ditto — Free of tumor invasion
      • Ovary, left, ditto — Free of tumor invasion
      • Fallopian tube, left, ditto — Free of tumor invasion, paratubal cysts
      • Ovary, right, ditto — Free of tumor invasion
      • Fallopian tube, right, ditto — Free of tumor invasion, paratubal cysts
      • Lymph node, L’t iliac, dissection — Free of tumor metastasis (0/3)
      • Lymph node, L’t oburator, ditto — Free of tumor metastasis (0/9)
      • Lymph node, R’t iliac, ditto — Free of tumor metastasis (0/2)
      • Lymph node, R’t oburator, ditto — Tumor metastasis (2/5)
      • Parametria, bilateral — Free of tumor invasion
      • Omentum, partial omentectomy — Free of tumor invasion
      • AJCC Pathologic stage — pT1bN1a, if cM0, stage IIIC1 (FIGO stage IIIC1)
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: 3D laparoscopic GYN cancer staging surgery
      • Specimens include: uterus, bilateral adnexa, partial omentum and pelvic lymph nodes
      • Specimen size:
        • uterus: 7.3 x 5.2 x 3.7 cm in size, 79 gm in weight
        • right ovary: 1.9 x 0.7 x 0.4 cm
        • left ovary: 2.3 x 1.0 x 0.7 cm
        • right fallopian tube: 5.7 cm in length, 0.5 cm in diameter
        • left fallopian tube: 4.5 cm in length, 0.5 cm in diameter
      • Tumor site: endometrium
      • Tumor size: 3.7 x 2.6 cm
      • The myometrium: tumor invasion more than half thicknes
      • The cervix: no remarkable change
      • Adnexa (bilateral): no remarkable change, bilateral paratubal cysts (L’t: 0.2 cm, R’t: 0.2 cm)
      • Omentum: two pieces, up to 7.8 x 4.8 x 1.7 cm, no remarkable change
      • Lymph nodes: left iliac LNs; left obturator LNs; right iliac LNs and right obturator LNs
      • Representative sections as A1: R’t F-tube, A2: R’t ovary, A3: L’t F-tube, A4-A10: tumor, A11-A12: cervix, A13: detached tumor fragments, X1: L’t ovary, X2: R’t parametrium, X3: L’t parametrium, B: omentum, C: L’t iliac LNs, D: L’t obturator LNs, E: R’t iliac LNs and F: R’t obturator LNs
    • MICROSCOPIC EXAMINATION
      • Histology type: Endometrioid carcinoma
      • Histology grade: Grade 2
      • Depth of invasion: More than half thickness of myometrium
      • Lymphovascular invasion: Present
      • The cervical stroma involvement: Absent
      • Resection margins of the cervix: Free, 2 cm away from tumor
      • Additional pathologic findings: secretory metaplasia, focal clear cell change, microabscesses
      • Lymph nodes: tumor metastasis (2/19) in total number without extracapsular extension (0/2)
      • Vaginal stump: free of tumor invasion
      • Perineural invasion: Present
      • Ascites: negative for malignancy
      • Immunohistochemistry: Napsin-A(+, scatter), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for tumor
  • 2023-02-15 MRI - pelvis
    • With and without contrast enhancement MRI: Pelvis
      • Diffuse soft tissue tumors in the uterine cavity, r/o endometrial malignancy, involvement of more than half myometrium.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Incresed density in superior anterior aspect of urinary bladder.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE: IB_(Stage_value)
    • Impression:
      • Diffuse soft tissue tumor in the uterine cavity, r/o endometrial malignancy, if proven endometrial malignancy cstage T1bN0M0.
      • Incresed density in superior anterior aspect of urinary bladder, nature?
  • 2023-02-13 Patho - endocervix curretage/biopsy Y1
    • Uterus, endocervical, ECC — adenocarcinoma, favor endometrial origin
    • Microscopically, section shows adenocarcinoma with complex atypical hyperplasia of atypical neoplastic glands with increased glandular complexity and glandular crowding with clear cytoplasm and nuclear enlargement, loss of polarity and prominent nuleoli with mitoses.
    • IHC stain — vimentin (+), p16(-)
  • 2023-02-13 Patho - endometrium curretage/biopsy Y1
    • Uterus, endometrium, EM sampling — endometrioid carcinoma, with clear cell carcinoma component
    • Microscopically, sections A and B show endometrioid carcinoma composed of proliferation of atypical neoplastic glands with papillary pattern and focal cribriform architecture. The tumor shows orund to oval hyperchromatic nuclei, increased N/C ratio, pleomorphsim, focal clear cytoplasm and mitoses.
    • IHC stain — p53: wild-type, ER: positive (moderate, 40%), Napsin A: posiitve
  • 2023-02-10 Gynecologic ultrasonography
    • EM: 25.3mm

[MedRec]

  • 2023-03-29 ~ 2023-03-31 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Endometrioid carcinoma, with clear cell carcinoma component, of the uterine endometrium, stage pT1bN1a,cM0, stage IIIC1 (FIGO stage IIIC1), s/p 3D laparoscopic GYN cancer staging surgery (on 2023-02-24).
    • CC
      • for chemotherapy
    • Present illness
      • Pathology showed endometrioid carcinoma,grade2. Port-A insertion on 2023/03/20.
      • Planning radiotherapy with 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.
      • This time, she was admitted for chemotherapy
    • Course of inpatient treatment
      • After admission, pre medication with Dexamethasone 20mg at 23:00 2023/03/29 and 05:00 2023/03/30. chemotherapy with C1 Taxol plus Carboplatin was administered on 2023/3/30.
      • Patient tolerated the chemotherapy.With the relatively stable condition, she was discharged on 2023/03/31 and will OPD follow up later
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Meitifen (diclofenac Na 75mg) 1# PRNQD
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC
  • 2023-02-22 ~ 2023-02-28 POMR Obstetrics and Gynecology Chen GuoHu
    • Discharge diagnosis
      • Endometrial cancer (endometrioid carcinoma, with clear cell carcinoma component), clinical stage Ib) C54.1
      • Female pelvic peritoneal adhesions
      • Laparoscopic staging on 2023-02-24
    • CC
      • Postmenopausal bleeding after COVID-19 vaccine (for 1 year)
    • Present illness
      • This 64 y/o woman, G1P1, NSD*1, menopaused at 48 y/o, menstral cycle irregular with a duration/interval of 5-7/28-30 days, had dysmenorrhea before.
      • She had no other underlying disease and denied any food or drug allergy, denied anticoagulants or hormone use. Mild postmenopausal bleeding was noted by THE patient HERSELF for one year and THE BLEEDING became severe in recent months. She had to wear the night sanitary pad in the morning and period panties at night. The blood clots could be found sometimes, with fresh red color.
      • There were mild abdominal pain with tenderness. HOWEVER, she denied nausea or vomiting, AND HAD no tarry/bloody stoool, no constipation, no unintention NOR body weight loss. She turned to our GYN OPD for help, and some examinationS were done. The pelvic examination showed smooth cervix and active bleeding after brush, VD watery old bloody.
      • The transvaginal sono on 2023.02.10 revealed EM 25.3mm, SO ECC + EM sampling were done and revealed endometrioid ADENOcarcinoma with clear cell component.
      • PELVIC MRI was also done and revealed diffuse soft tissue tumorS in the uterine cavity, r/o endometrial malignancy, if proven endometrial malignancy cstage T1bN0M0.
      • THE Tumor markerS WERE examinated and showd CA125 LEVEL WAS 108.5, CEA LEVEL WAS 1.76, AND SCC LEVEL WAS 0.4.
      • Under the impression of endometrioid ADENOcarcinoma, CLINICAL STAGE Ib, she was admitted on 2023.02.22 for further evaulation and THE sugery of laparoscopic gynecologic oncology staging surgery (LAVH + BSO + BPLND + partial omentectomy) and possible adhesiolysis will be performed on 2023.02.24.
    • Course of inpatient treatment
      • The patient was admitted on 2023-02-22 due to endometrial cancer (endometrioid carcinoma, with clear cell carcinoma component). GI panendoscopy was done on 2023-02-23. She underwent laparoscopic staging surgery (Laparoscope-assisted Vaginal Hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymph node dissection + partial omentectomy + washing cytology) and LSC dhesiolysis on 2023-02-24. The pathology was pending. Her postoperative course was uneventful. After flatus, her self voiding, eating and defecation were smooth. She was discharged on 2023-02-28. Her follow up appointment is scheduled on 2023-03-06.
    • Discharge prescription
      • MgO 250mg 1# QID
      • Actein (acetylcysteine 200mg) 1# TID
      • Sodicon (dextromethorphan 15mg) 1# TID
      • cephalexin 500mg 1# QID
      • Acetal (acetaminophen 500mg) 1# QID

[surgical operation]

  • 2023-02-24
    • Surgery
      • 3D laparoscopic GYN cancer staging surgery (laparoscopic hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic lymphonode dissection + partial omentectomy) + laparoscopic adhesiolysis
    • Finding
      • Uterus: 9x5x3 cm
      • endometrium: s/p D & C, lots of eroded tissues, due to residual EM cancer?
      • myomectrium - seemed involved by cancer cells ( > 1/2)
      • prev pathology report of endometrium (D & C): endometrioid adenocarcinoma
      • cervix - eroded, seemed involved by cancer cells
      • bil adnexa: normal-looking
      • bowels, omentum - seemed free of cancer invasion
      • Bilateral pelvic iliac and obturator LNs was removed
      • CDS: no ascites (washing cytology was sent) but pelvic adhesion was noted between ant peritoneum, pelic walls, and bowels s/p lysis
      • A 7mm JP drain was placed in CDS

[radiotherapy]

  • 2023-03-30 ~ 2023-05-18 - 4500cGy/25 fractions of the pelvic, and another 1200cGy/3 fractions via IVRT to vaginal cuff mucosa surface.

[chemotherapy]

  • 2023-07-26 - paclitaxel 175mg/m2 245mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-06-29 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-05-31 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-03-30 - paclitaxel 175mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 465mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

==========

2023-08-31

Based on PharmaCloud records, this patient has only received medical care at our hospital in the last three months, with no medication reconciliation issues identified.

從 PharmaCloud 紀錄來看,該名患者最近三個月只在本院就診,沒有發現 medication reconciliation issue.

700382066

230830

[lab data]

2023-08-14 CMV viral load assay Target not detecetedIU/mL

2023-08-09 CD45+Total leukocyte 329085 /uL
2023-08-09 %CD34+ 0.41 %
2023-08-09 CD34+ Count 1350 /uL

2023-08-09 CD45+Total leukocyte 25806 /uL
2023-08-09 %CD34+ 0.10 %
2023-08-09 CD34+ Count 26 /uL

2023-08-09 HPC Ratio 0.41 %
2023-08-09 HPC# 0.1050 10^3/ul

2023-08-08 CD45+Total leukocyte 367310 /uL
2023-08-08 %CD34+ 0.31 %
2023-08-08 CD34+ Count 1140.0 /uL

2023-08-08 RPR/VDRL Nonreactive
2023-08-08 HIV Ab-EIA Nonreactive
2023-08-08 Anti-HIV Value 0.07 S/CO

2023-08-08 Anti-HCV Nonreactive
2023-08-08 Anti-HCV Value 0.09 S/CO

2023-08-08 HBsAg Nonreactive
2023-08-08 HBsAg (Value) 0.27 S/CO

2023-08-08 CD45+Total leukocyte 22719 /uL
2023-08-08 %CD34+ 0.10 %
2023-08-08 CD34+ Count 24.0 /uL

2023-08-08 HPC Ratio 0.34 %
2023-08-08 HPC# 0.0820 10^3/ul

2023-07-18 IgG (blood) 732 mg/dL

2023-06-06 Free Light Chain κ/λ, (blood) ratio
2023-06-06 FKLC 9.6 mg/L
2023-06-06 FLLC 86.8 mg/L
2023-06-06 FK/FL ratio 0.11 ratio

2023-06-01 B2-Microglobulin 1862 ng/mL

2023-05-31 IgG (blood) 867 mg/dL

2023-05-23 CD45+Total leukocyte 216525 /uL
2023-05-23 %CD34+ 0.13 %
2023-05-23 CD34+ Count 285 /uL

2023-05-23 CD45+Total leukocyte 36136 /uL
2023-05-23 %CD34+ 0.02 %
2023-05-23 CD34+ Count 6 /uL

2023-05-23 HPC Ratio 0.04 %
2023-05-23 HPC# 0.018 10^3/ul

2023-05-22 CD45+Total leukocyte 243730 /uL
2023-05-22 %CD34+ 0.31 %
2023-05-22 CD34+ Count 760 /uL

2023-05-22 HPC Ratio 0.18 %
2023-05-22 HPC# 0.094 10^3/ul

2023-05-03 Free Light Chain κ/λ; (blood) ratio
2023-05-03 FKLC 11.2 mg/L
2023-05-03 FLLC 53.5 mg/L
2023-05-03 FK/FL ratio 0.21 ratio

2023-04-27 B2-Microglobulin 1275 ng/mL

2023-04-26 IgG (blood) 782 mg/dL

2023-04-11 CD45+Total leukocyte 246285 /uL
2023-04-11 %CD34+ 0.08 %
2023-04-11 CD34+ Count 200 /uL

2023-04-11 CD45+Total leukocyte 24252 /uL
2023-04-11 %CD34+ 0.01 %
2023-04-11 CD34+ Count 2 /uL

2023-04-11 HPC Ratio 0.15 %
2023-04-11 HPC# 0.036 10^3/ul

2023-04-10 CD45+Total leukocyte 191835 /uL
2023-04-10 %CD34+ 0.11 %
2023-04-10 CD34+ Count 205 /uL

2023-04-10 CD45+Total leukocyte 30658 /uL
2023-04-10 %CD34+ 0.02 %
2023-04-10 CD34+ Count 6 /uL

2023-04-10 HPC Ratio 0.21 %
2023-04-10 HPC# 0.062 10^3/ul

2023-03-31 Free Light Chain κ/λ; (blood) ratio
2023-03-31 FKLC 9.4 mg/L
2023-03-31 FLLC 55.1 mg/L
2023-03-31 FK/FL ratio 0.17 ratio

2023-03-25 B2-Microglobulin 1833 ng/mL

2023-03-24 IgG (blood) 621 mg/dL

2023-03-13 Free Light Chain κ/λ; (blood) ratio
2023-03-13 FKLC 9.6 mg/L
2023-03-13 FLLC 87.3 mg/L
2023-03-13 FK/FL ratio 0.11 ratio

2023-03-04 B2-Microglobulin 1701 ng/mL
2023-03-03 IgG (blood) 880 mg/dL

2023-02-23 Influenza A Ag Negative
2023-02-23 Influenza B Ag Negative

2023-02-08 Free Light Chain κ/λ; (blood) ratio
2023-02-08 FKLC 15.1 mg/L
2023-02-08 FLLC 231.25 mg/L
2023-02-08 FK/FL ratio 0.07 ratio

2023-02-04 B2-Microglobulin 2002 ng/mL

2023-02-03 IgG (blood) 757 mg/dL

2022-12-22 Free Light Chain κ/λ; (blood) ratio
2022-12-22 FKLC 13.4 mg/L
2022-12-22 FLLC 287.5 mg/L
2022-12-22 FK/FL ratio 0.05 ratio

2022-12-17 B2-Microglobulin 2642 ng/mL

2022-12-16 IgG (blood) 1463 mg/dL

2022-11-29 HBsAg Nonreactive
2022-11-29 HBsAg (Value) 0.41 S/CO
2022-11-29 Anti-HCV Nonreactive
2022-11-29 Anti-HCV Value 0.24 S/CO
2022-11-29 Anti-HBc Reactive
2022-11-29 Anti-HBc-Value 6.61 S/CO
2022-11-29 Anti-HBc IgM Nonreactive
2022-11-29 Anti-HBc IgM Value 0.09 S/CO
2022-11-29 Anti-HBs 9.54 mIU/mL

2022-11-24 CD2 NA
2022-11-24 CD3 61.7
2022-11-24 CD4 19.9
2022-11-24 CD5 75.6
2022-11-24 CD7 82.3
2022-11-24 CD8 52.2
2022-11-24 CD10 12.5
2022-11-24 CD11b NA
2022-11-24 CD13 NA
2022-11-24 CD14 3.9
2022-11-24 CD15 NA
2022-11-24 CD16 NA
2022-11-24 CD19 19.5
2022-11-24 CD19/kappa 7.27
2022-11-24 CD19/Lambda 9.4
2022-11-24 CD20 25.7
2022-11-24 CD23 18.9
2022-11-24 CD25 16.5
2022-11-24 CD33 NA
2022-11-24 CD34 6.9
2022-11-24 CD38 85.2
2022-11-24 CD56 29.1
2022-11-24 CD103 NA
2022-11-24 CD117 NA
2022-11-24 CD138 16.2
2022-11-24 FMC7 19.3
2022-11-24 HLA-DR NA
2022-11-24 MPO NA
2022-11-24 TdT NA
2022-11-23 BM chromosome analyz see attachment

  • Chromosome Analysis:
    • Tissue Examined: Bone marrow
    • Staining Method: G-Banding
    • Colony number: NA
    • Bands level: 350
    • Chromosome Counts: 45-(1)、46-(11)、47-()、Other-() Total-(12)
    • Karyotype: 46,XY[11]
    • Interpretation: Analysis of this bone marrow sample shows a male having 46,XY[11] karyotype. There was no significant clonal chromosomal abnormality detected. However, from 12 cells analyzed, one cell with 45,X,-Y was observed. No clinical significance can be ascribed to this single finding at the present time. Only 12 cells were available for chromosomal analysis due to low mitotic index.

2022-11-10 Free Light Chain κ/λ; (urine)
2022-11-10 Total Volume(24hr) 4500 mL
2022-11-10 FKLC 28.8 mg/L
2022-11-10 FLLC 6875 mg/L
2022-11-10 FK/FL ratio 0.004189

2022-11-08 IgD; <46.7 U/mL

2022-11-08 Free Light Chain κ/λ; (blood) ratio
2022-11-08 FKLC 14.0 mg/L
2022-11-08 FLLC 2725 mg/L
2022-11-08 FK/FL ratio 0.01 ratio

2022-11-07 Protein EP; (urine)
2022-11-07 Protein (Urine) 334 mg/dL
2022-11-07 Albumin(Urine) 4.8 %
2022-11-07 Alpha-1 0.9 %
2022-11-07 Alpha-2 1.1 %
2022-11-07 Beta 2.8 %
2022-11-07 Gamma 90.4 %
2022-11-07 A/G Ratio (Urine) 0.1

2022-11-05 Protein EP;
2022-11-05 Protein, total 8.8 g/dL
2022-11-05 Albumin 35.0 %
2022-11-05 Alpha-1 1.8 %
2022-11-05 Alpha-2 9.7 %
2022-11-05 Beta 8.6 %
2022-11-05 Gamma 44.9 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50

2022-11-05 Protein, total 9.0 g/dL
2022-11-05 Albumin 35.3 %
2022-11-05 Alpha-1 2.4 %
2022-11-05 Alpha-2 9.5 %
2022-11-05 Beta 8.5 %
2022-11-05 Gamma 44.3 %
2022-11-05 M-peak Positive
2022-11-05 A/G Ratio 0.50
2022-11-05 IgG/A/M Kappa/Lambda IgG + Lambda chain
2022-11-05 IgE 13.4 IU/mL

2022-11-04 B2-Microglobulin 2800 ng/mL

2022-11-03 IgG (blood) 4374 mg/dL
2022-11-03 IgA 95 mg/dL
2022-11-03 IgM 34.0 mg/dL
2022-11-03 Total protein 9.4 g/dL

[MedRec]

  • 2023-08-23 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Zulitor (pitavastatin 4mg) 1# QOD
      • Uformin (metformin 500mg) 1# TID
      • Canaglu (canagliflozin 100mg) 1# QDAC
  • 2023-07-30 ~ 2023-08-10 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma, immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+). S/P autologous stem cells collection on 4/10-4/11 23 & C1 C/T with Endoxan
      • Type 2 diabetes mellitus without complications
    • CC
      • for collect stem cells
    • Present illness
      • This 63-year-old man, a patient of multiple myeloma, IgG lambda type s/p posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07, suffered from bilateral flank pain for 6 days and he visited to our hema OPD for evaluation and survey.
      • Image study with abdominal CT (10/30 22) showed Osteolytic change of T10 r/o metastases. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions. EGD (10/31 22) revealed duodenal ulcers. Chest CT (11/2 23) revealed old lung TB with tiny granulomas. no lung or medistinal tumor.favor metastatic lesion in spine and left ilium, origin?, d/d multiple myeloma and T-spine MRI (11/4 22) showed Multiple spinal metasases as described, esp T10 with paraspinal and intraspinal involvement and T10-spine, frozen section (11/7 22) proved no evidence of metastatic carcinoma. Bone marrow, site unspecified, biopsy (11/7 22) revealed Plasma cell myeloma,immunohistochemical stain profiles: CD138(+, > 60%), lambda light chain(+), kappa light chain(-), CD20 (focal+, < 3%), CD34(-), MPO(focal+), CD71(focal+), CD117(focal+).
      • Soft tissue, T10-spine, tumor excision (11/10 22) proved hematoma with lymphocytes, leukoyctes and plasma cells, Immunohistochemical stain reveals CD138(+ at plasma cells).
      • The laboratory showed tatal protine : 9.4g/dl, IgG: 4373mg/dl, B2-Microglobulin:2800ng/ml on 11/4 22 -> 2642ng/ml on 12/17 22 -> 2002ng/ml on 2/4 23 -> 1701 ng/ml on 3/4 23 -> 1833ng/ml on 3/25 23. IgG/A/K/M kappa/Lambda: Protein, total: 9.0 g/dL Albumin L 35.3 %, Alpha-1 2.4 %, Alpha-2 9.5 %, Beta L 8.5 %, Gamma H 44.3 %. The FKLL:15.1mg/L, FLLC: 231.25mg/L on 2/8 23, FKLL:9.6mg/L, FLLC: 87.3mg/L on 3/13 23.
      • He received posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 on 2022/11/07. He also received VTD C1W1 (20221128), C1W2 (20221205), C2W1 (20221216), C2W2 (20221223), C3W1 (20230106), C3W2 (20230113), C4W1 (20230203), C4W2 (20230210), C5W1 (20230303) and Xgeva (20230303).
      • Autologous stem cells collection after GCSF mobolization on account of multiple myeloma after VTD threatment with VGPR on 4/9 23. The HPC#: 0.062 10^3/ul, HPC Ratio: 0.21%, CD34+count: 6/ul, %CD34+: 6/ul, CD45+ total leukocyte: 30658/ul on 4/10 23 & HPC#: 0.036 10^3/ul, HPC Ratio: 0.15%, CD34+count: 2/ul, %CD34+: 0.01/ul, CD45+ total leukocyte: 24252/ul on 4/11 23.
      • Last time, he received chemotherapy with Endoxan 2000mg/m2 was given on 5/11 23.
      • Collect stem cell was done on 5/22-5/23 23.
      • CD34+ count: 760/UL, CD34+: 0.31%, CD45+ total leukocyte: 243730/uL on 5/22 23 CD34+ count: 285/UL, CD34+: 0.13%, CD45+total leukocyte: 216525/uL on 5/23 23. Double lumen was removed on 5/24 23.
      • This time, he was admitted for collect stem cell under Mozobil on 2023/07/30.
    • Course of inpatient treatment
      • After admission, echocardiography was done for prepare BMT later. D/L insetion was done, but failure. Portable was done, showed tracheal deviation to left side, but no pneumothorax. Re-on D/L over left inguinal area on 8/7. GCSF 750mcg sc qdac on 8/5-8/8. Mozobil 24mg at 10pm on 8/7-8/8. Collection stem cell at 9am on 8/8-8/9. Removed D/L smooth and no hematoma. Under the stable condition, he can be discharged on 2023/08/10.
      • PBSC:
        • CD34: 4.18kg x10^6
        • Total CD34: 311.05 x10^6
  • 2022-10-31 POMR Hemato-Oncology Wan XiangLin
    • Discharge diagnosis
      • Multiple myeloma, IgG lambda type
      • Suspect multiple myeloma with bone metastasis
      • Gastrointestinal hemorrhage, unspecified
      • Anemia, unspecified
      • Pleural effusion, not elsewhere classified
      • Type 2 diabetes mellitus without complications
      • Hyperlipidemia, unspecified
      • Constipation, unspecified
      • Hypermagnesemia
      • Enlarged prostate with lower urinary tract symptoms
    • CC
      • Due to bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently.
    • Present illness
      • This is a 63 y/o male with underlying diseae of DM and dyslipidemia. This time, he was admitted due to Bilateral flank pain for 6 days.
      • According to the patient, he had bilateral flank pain since May, progression in July, and worse weakness unable to sit up and when changing position pain recently. He had went to ER and neuro OPD and pain killer was given. However, the patient said no improvement. And the pain was progressed and radiated to epigastric region. He also stated tarry stool for one week. He denied fever, cough, rhinorrhea, dyspnea, chest pain, dysuria, incontinence. Due to above symptoms, he came to ER for help.
      • At ER, BP: 143/77; HR: 76; Temp: 36.5; RR: 16; Con’s: E4V5M6, SpO2: 97%. PE showed pale conjunctiva, epigastric tenderness. Lab showed Hb:7, CRP 8.57. Blood transfusion and PPI were given.
      • CT showed 1. Osteolytic change of T10 r/o metastases. 2. A patchy density (2.6cm) at left lingual lung. Bil. minimal pleural effusions.
      • Upper GI showed 1. Reflux esophagitis LA Classification grade A 2. Superficial gastritis, s/p CLO test 3. Duodenal shallow ulcers, bulb 4. Duodenal polyps, bulb.
      • Under impression of Upper GI bleeding with anemia, he was admitted to our ward for further treatment.
    • Course of inpatient treatment
      • After admission, Rivotril 0.5mg HS, Mefno 200mg TID for lower back pain, Tramacet 37.5 & 325mg/tab 1# PO Q6H, and Limadol 100mg/amp 1amp IVD PRNQ6H for pain control were prescribed. The patient tolerated soft diet since 2022/11/01, and oral PPI was prescribed.
      • We followed tumor markers on 2022/11/02, and CEA, CA199, SCC, PSA, CA125, AFP were within normal range. Chest CT on 2022/11/02 showed old lung TB and metastatic lesion in spine and left ilium, r/o multiple myeloma.
      • Lab data on 2022/11/02 revealed (Hb:9.9), (serum Ca: 2.2), (Serum IgG: 4374), (Serum IgA: 95), (Urine protein: 334mg/dl).
      • Skull PA on 2022/11/02 revealed multiple punch out lesions.
      • Pelvis AP view on 2022/11/02 revealed bony metastases in bilateral ilium and pubic bone.
      • Long Bones series performed on 2022/11/02 revealed osteolytic lesions in bilateral humerus.
      • Pathology report of bone marrow biopsy on 2022/11/03 revealed plasma cell myeloma.
      • Spine MRI on 2022/11/04 revealed multiple spinal metasases T6, T10-T12, L1-5, S1-3 verteral bodies, esp T10 with paraspinal and intraspinal involvement.
      • On 2022/11/07, posterior spinal fusion with instrumentation lumbar discectomy over thoracic 9-11 were performed, and he tolerated the surgery well. However, he suffered from dysuria after operation, so foley tube was re-inserted on 2022/11/09.
      • On 2022/11/10, we consult urology department for the dysuria, and they suggested UFR/PVR + TRUS and Urief 1# po QD.
      • On 2022/11/15, we had well explained further management plan including target therapy and stem cell implantaion to patient and his family 11/15.
      • We also consulted Radiation Oncology Department for T10 radiotherapy. The radiotherapy started on 2022-11-16.
      • Due to improving status, chemotherapy with Velcade 1.3 mg/m2 at D1, 4, 8, 11 and thalidomide 1# HS D1-21, dexamethasone 20mg BID started on 11/28, the patient tolerated the chemotherapy well.
      • Severe anemia with Hb:6.3 was noted, so we transfused LPRBC 2 units on 2022/11/28 and 2022/11/29 respectively. Foley was removed on 2022/11/30 and he had no urinary difficulty. Surgical staples were also removed after radiotherapy on 2022/12/01.
      • Under stable condition, he discharged on 2022/12/01 outpatient follow up and further treatment were also arranged.
    • Discharge prescription
      • Thado (thalidomide 50mg) 1# HS (2022-11-28 ~ 2022-12-18 D1-21)
      • Canaglu (canagliflozin 100mg) 1# QDAC
      • Mefno (mephenoxalone 200mg) 1# TID
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Uformin (metformin 500mg) 1# TID
      • Urief (silodosin 8mg) 1# QD
      • Zulitor (pitavastatin 4mg) 1# QN
      • Wecoli (bethanechol 25mg) 1# TIDAC
      • Ulstop (famotidine 20mg) 1# BID
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Lactul (lactulose 666mg/mL) 20mL PRNTID
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Limeson (dexamethasone 4mg) 5# BID (2022-12-01 18:00)
      • Through (sennoside 12mg) 2# HS
      • bisacodyl supp 10mg 2# PRNQD RECT
  • 2017-01-10 SOAP Metabolism and Endocrinology Guo XiWen
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3 Uformin (metformin 500mg) 1# TID

==========

2023-08-30

[family meeting minutes prior to ASCT]

On 2023-08-30 at 10:15 in the ward conference room, Dr. Gao chaired a family meeting with the patient and his relatives. Attendees included the patient himself, his wife, and his daughter, while his son joined via phone. Dr. Gao explained the treatment plan, the importance and potential risks of autologous stem cell transplantation as a treatment method, and allowed family members to ask questions freely during the meeting.

Overall, the family seemed supportive, and the patient indicated that he would be willing to use a nasogastric tube if necessary during the transplantation treatment. His daughter asked if mouthwash could alleviate symptoms of oral mucositis, to which Dr. Gao responded that mouthwash could help maintain oral cleanliness but couldn’t completely prevent or mitigate the condition, which is mainly caused by conditioning agents.

After the meeting, some casual conversation with the family revealed that the patient was a chef and had run his own business in the past. After retiring, he assisted with religious services in several temples. He is also a vegetarian and has no objections to the hospital’s food offerings.

[Evomela (melphalan) as conditioning regimen prior to HSCT for multiple myeloma]

The recommended dosing schedule is IV 100 mg/m2 daily for 2 days on day -3 and day -2 prior to autologous stem cell transplantation on day 0. Ref: Hari P, Aljitawi OS, Arce-Lara C, et al. A Phase IIb, Multicenter, Open-Label, Safety, and Efficacy Study of High-Dose, Propylene Glycol-Free Melphalan Hydrochloride for Injection (EVOMELA) for Myeloablative Conditioning in Multiple Myeloma Patients Undergoing Autologous Transplantation. Biol Blood Marrow Transplant. 2015;21(12):2100-2105. doi:10.1016/j.bbmt.2015.08.026

700557074

230830

[MedRec]

  • 2023-08-24 SOAP Hemato-Oncology He JingLiang
    • A:
      • Squamous cell carcinoma, moderately differentiated, of the urinary bladder, stage pT3aN0(cM0), stage IIIA, s/p Robotic-assisted pelvic organ preserving radical cystectomy with neobladder reconstruction.
      • Squamous cell carcinoma of the right kidney, stage pT4(cN1M0), stage IV, with para-aortic LNs metastases, s/p LPS right radical nephroureterectomy, and s/p radiotherapy.
    • Prescription
      • Through (sennoside 12mg) 1# HS
      • codeine phosphate 15mg 1# PRNQ12H
      • Roumin (prochlorperazine maleate 5mg) 1# TID
      • Limadol (tramadol 100mg) ST IM
      • OxyNorm (oxycodone 5mg) 1# PRNQ4H
      • Decan (dexamethasone 4mg) ST IM
      • Axcel Cream (acyclovir) TID TOPI
      • Limeson (dexamethasone 4mg) 1# QD
  • 2023-08-04 SOAP Cardiology
    • Diagnosis
      • Hypertensive heart disease without heart failure [I11.9]
      • Anxiety state,unspecified [F41.9]
      • Other insomnia [G47.00]
      • Mixed hyperlipidemia [E78.2]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription
      • Uformin (metformin 500mg) 0.5# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Pravafen (pravastatin 40mg, fenofibrate 160mg) 1# QD
      • Doxaben XL (doxazosin 4mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD
  • 2022-02-20 ~ 2022-03-08 POMR Urology
    • Discharge diagnosis
      • Malignant neoplasm of bladder, status post robotic-assisted radical cystectomy with neobladder reconstruction, pT3N0M0
      • Bladder cancer, stage IIIA
    • CC
      • Pain after voiding. Hematuria.
    • Present illness
      • This is a 62-year-old female with underlying disease:
        • Type II Diabetes Mellitus under medication control for 7 years
        • Hypertension under medication control for 8 years
        • Hyperlipidemia under medication control for 7 years
      • She had Bladder cancer, SqCC and urinary tract infection. She felt pain after voiding and had hematuria. She came to OPD for help. At OPD hydronephrosis and urinary tract infection was diagnosed on 2021/12/09. Therefore, transurethral resection of bladder tumor was done on 2021/12/12. SqCC of bladder was diagnosed after biopsy. Therefore, admitted to Urology ward for Robot-Assisted Radical Cystectomy with neobladder on 2022/02/23.
  • 2021-12-12 ~ 2022-12-15 POMR Urology
    • Discharge diagnosis
      • Benign neoplasm of bladder status post transurethral resection of bladder tumor on 2021/12/13
      • Right hydronephrosis status post right  uretetroscopy on 2021/12/13
      • Urinary tract infection with Pseudomonas aeruginosa
    • CC
      • freqency, gross hematuria, lower abdominal pain for days.
    • Present illness
      • The 59-year-old woman had history of 1) Hypertension under medication control for years; 2) Right patellar lateral sublaxation s/p arthroascopic lateral release on 2009/06/10; 3) Right back mass excision on 2011/11.
      • According for this patient statement, freqency, gross hematuria, lower abdominal pain for days. She visited our urologic clinic for help where urinalysis showed WBC=50-59/HPF, RBC=20-29/HPF, OB=3+. Renal sonography revealed severe right hydronephrosis. Under the impression of right hydronephrosis, we advised the patient to receive right URS exam. After well explaining, the patient agreed. This time, she was admitted for further evaluation and management.
    • Course of inpatient treatment
      • After admission, transurethral resection of bladder tumor and right URS exam was performed on 2021/12/13. A large papillary tumor with hypervascularity was noted in right lateral wall of bladder with right ureteral orifice invasion was noted. Post-operatively, continuous irrigation of bladder with normal saline was given. Intravesical chemotherapy with Mitomycin was done. Slight urine color was noted and removed Foley tube done smoothly. With fair urination and stable condition, she was discharged today and follow up at urologic clinic.
  • 2017-03-10 SOAP Cardiology
    • Diagnosis
      • Hypertensive heart disease without heart failure [I11.9]
      • Anxiety state,unspecified [F41.9]
      • Other insomnia [G47.00]
      • Mixed hyperlipidemia [E78.2]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
    • Prescription
      • Norvasc (amlodipine besylate 5mg) 1# QD
      • Eurodin (estazolam 2mg) 1# HS
      • Vytorin (ezetimibe 10mg, simvastatin 20mg) 0.5# HS
      • Concor (bisoprolol 5mg) 1# QD

[chemotherapy]

  • 2023-08-10 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-28 - gemcitabine 400mg/m2 600mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-07-14 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-16 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-06-02 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-24 - gemcitabine 400mg/m2 400mg NS 100mL 30min + cisplatin 25mg/m2 40mg NS 500mL 3hr (low Gemzar)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-12-14 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-08-30

In the last three months, all medical records on PharmaCloud are from this hospital. Currently, no medication reconciliation issues have been identified.

700178859

230822

(not completed)

[MedRec]

  • 2023-05-08 ~ 2023-05-11 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Suspicious of right papillary thyroid carcinoma status post bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection on 2023/05/09
      • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b, Stage IVB, status post Port-A implantation on 2023/05/09
    • CC
      • Glucose hypermetabolism at thyroid gland at whole body PET scan during evaluation of colon cancer was noted about 2 months ago
    • Present illness
      • This 59-year-old female had history of Adenocarcinoma of D-colon with multiple liver and lung metastases, pT4aN0cM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13.
      • After discharge from CRS ward, she was regular follow up at our GS and CRS OPD. According our multidisciplinary cancer conferrence, after colon surgery, she will receieve thyroid surgery, adjuvent chemotherapy and staged lung surgery. She denied any symptoms such as hoarseness, difficulty swallowing or pain at neck. Physical examination revealed some small firm nodules at right neck. Recently thyroid sonography on 2023/03/28 revealed 1. Heterogeneous right thyroid nodule, with calcifications, 1.6x1.2cm. 2. Tiny right thyroid nodules, 0.18x0.17cm, 0.24x0.17cm. 3. Left thyroid cyst, 0.83x0.49cm, Biopsy of right thyroid nodule revealed suspicious for papillary carcinoma. After discussion with patient, she will bilateral total thyroidectomy.
    • Course of inpatient treatment
      • After admission, pre-op preparation and anesthesia assessment was done. bilateral thyroidectomy, parathyroidectomy, right neck lymph node dissection and port-A implanatation were done smmothly on 2023/05/09. After operation, no specific complain except for mild wound pain was done. Follow up lab data revealed mild decreased serum calcium, so calcium supplement was given. Little ammount discharge from J-P drainage was noted. Under relative stable condition, we arranged her discharge on 2023/05/11 and OPD follow up.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# QID
      • Antica syrup (orciprenaline, bromhexine, doxylamine) 10mL TID
      • calcium carbonate 500mg 4# QID
      • Strocain (oxethazaine polymigel 5mg) 1# TIDAC
      • U-Ca (calcitriol 0.25ug) 1# TIDAC
  • 2023-04-11 ~ 2023-04-20 POMR Colorectal Surgery
    • Discharge diagnosis
      • Adenocarcinoma of D-colon with multiple liver and lung metastases, cT4aN1bM1b, stage IVB status post Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy on 2023/04/13, pT4aN0M1b(0/20), G2, LVI(+), PNI(-), CRM(-), Stage IVB
      • Hypertension
      • Hyperlipidemia
      • Highly suspect right thyroid cancer
    • CC
      • diarrhea and bowel habit change since last year.
    • Present illness
      • This 59 y/o female patient with 1. D-colon cancer with liver and lung metastases 2. suspicious papillary carcinoma 3. Htn was quite well until she suffered from diarrhea and bowel habit change since last year. She visited our OPD for help and colonoscopy was done.
      • Colonoscopy showed a large circumferential tumor with near lumen obstruction was noted at sigmoid colon, s/p biopsy8. A 2cm advanced pedunculated polyp was noted at sigmoid colon (7-8cm below the tumor), s/p biopsy3. Pathology findings showed Adenocarcinoma, moderately differentiated in S-colon and villous adenoma 7 cm below the tumor.
      • Abdominal CT showed a segmental circumferential asymmetrical wall thickening at the sigmoid colon with irregular contour, measuring 6.5 cm in size(T4a). In addition, there are two enlarged nodes in the adjacent mesocolon (N1b). There is a poor enhancing mass 2.2 cm in S5 of the liver. Metastasis (M1a) is highly suspected.
      • In addition, there is a soft tissue nodule 1.1 cm in RML or RUL of the lung that may be lung metastasis (M1b).
      • This time, she admitted to our ward for preoperative preparation and surgical treatment. 
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of Laparoscopic left hemicolectomy with partial hepatectomy and cholecystectomy under general anesthesia were performed on 112/04/13. NPO and adequate IV fluid supplement. Chewing cookies, toast, rice with gum was started at op day. Early activity is encouraged. The wound healing well and no erythema change. She had flatus passage and abdominal wound pain subsided. She started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. His abdominal wound pain had got much better. Drain is clear ascites and removal of JP drain. In stable condition, he was discharged on 112/04/20 and will receive OPD follow up next week.
    • Discharge prescription
      • Meitifen (diclofenac 75mg) 1# BID
      • Urosin (atenolol 100mg) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • MgO 250mg 2# BID
      • Through (sennoside 12mg) 1# HS
  • 2023-03-31 SOAP Colorectal Surgery
    • S
      • Vomiting and diarrhea during Chinese New Year >> relieved by fasting and rest
      • 2023-02-11: LLQ intermittent pain, soft loose stool; anemia was noted at LMD
      • 2023-03-13: referred from GI Dr for newly found a tumor of S-colon with impending obstruction, bloody stool and change in bowel habit for 1+ years
      • 2023-03-18: CT showed distal D-colon cancer with possible liver and lung metastases, arrange PET or more infomration
      • 2023-03-24: for PET report (Liver, lung metastases, and R/O thyroid tumor), can pass loose and liquid stool, no abdomen pain
      • 2023-03-31: Thyroid sono-biopsy showed suspicious papillary carcinoma, refer to GS, favor combined colon and hepatic surgery first followed by chemotherapy therapy + target therapy and lung and thyroid surgery
    • O
      • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-03-28
      • Referring to the General Surgery (GS) and Cardiothoracic Surgery (CS) Outpatient Department (OPD), the General Surgery team has scheduled a thyroid ultrasound with a possible biopsy. Depending on the results, a staged surgery plan is anticipated, which may also include chemotherapy.
    • A
      • D-colon cancer with liver and lung metastases
      • suspicious papillary carcinoma
    • P
      • admission (2023/04/11), albumin use, prepare colon, ERAS? inform GS, colectomy + partial hepatectomy (2023/04/13)

[immunochemotherapy]

  • 2023-08-22 - Avastin + FOLFIRI
  • 2023-08-02 - Avastin + FOLFIRI
  • 2023-07-04 - Avastin + FOLFIRI
  • 2023-05-31 - Avastin
  • 2023-05-29 - FOLFIRI

==========

2023-08-04

On 2023-07-09, the patient refilled her repeat prescription for atenolol and valsartan to manage her primary hypertension. This prescription was originally issued by JingMei Hospital on 2023-06-15. Both medications have been added to the active medication list, and there are no reconciliation issues detected.

700558953

230821

[MedRec]

  • 2021-02-08 SOAP Radiation Oncology Chang YouKang
    • A/P
      • PE, 2021-02-08: Op scar(+) over UOQ. No palpable LAPs over axilla or SCF.
      • Imp: Right breast cancer, Mucinous carcinoma, pT2N0(sn) cM0 s/p BCT & SNB on 2021/01/29.
      • Endocrine therapy: Femara since 2021/02/08.
      • Plan: Adjuvant R/T to Rt breast & scar for 5000cGy/25 fx & 6000cGy/30 fx is suggested. Possible toxicity (radiation dermatitis and pneumonitis) is told. CT simulation on 2021/03/02. Psychosocial support. Diet education.
  • 2021-01-21 SOAP General and Gastroenterological Surgery
    • S: s/p CNB (2021-1-13): mucinous carcinoma ==> advise adm for BCT + SLND
    • O:
      • 2021/01/14 PATHO - breast biopsy (no need margin)
        • Breast, right, sono-guided biopsy — Mucinous carcinoma, hypercellular type
        • IHC shows following features:
          • ER (Ab): Positive (> 95%, strong intensity)
          • PR (Ab): Positive (> 95%, strong intensity)
          • HER-2/Neu (Ab): Negative (score= 1)
          • Ki-67: 10%
      • A 3x2.5 cm sl firm mass in rt breast
        • Rt breast ca
        • cT2N0M0 stage 2A
  • 2021-01-12 SOAP General and Gastroenterological Surgery
    • S: breast sono: right breast tumor, r/o carcinoma, cT2N0 - BI-RADS 5
      • Chief complaint: A breast lump was noted recently with mastalgia
    • P: CNB

[surgical operation]

  • 2023-04-03
    • Operation
      • Excision of intraabdominal malignant tumor: omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Tenckhoff tube: over RLQ
  • 2023-04-03
    • Surgery
      • Diagnosis: Right ovarian cancer
      • Surgery: Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Adnexa:
        • LOV: grossly normal
        • ROV: 8cm tumor
        • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: ascites (+), adhesion (+)
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal
      • Estimated blood loss: 150 mL
      • Blood transfusion: nil
      • Complication: nil
  • 2021-01-29
    • Surgery
      • Partial mastectomy and sentinel node(s) biopsy        
    • Finding
      • a 3x2.5x1.5 cm sl firm mass in rt breast    
      • SLN 0/2    
  • 2021-01-13
    • Operation
      • Breast tumor biopsy (63010C)
      • Intraoperative sonography (19002B)
    • Finding
      • IOUS: a breast tumor in right side, 8 o’clock / 4 cm location

[chemotherapy]

  • 2023-07-31 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-07-06 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 500mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 45mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-12 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-22 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 290mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-28 - bevacizumab 7.5mg/kg 500mg NS 100mL 1.5hr + paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 45mg + cisplatin 30mg/m2 50mg + gentamicin 45mg + sodium bicarbonate 2800mg + NS 800mL] IP 1hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL

701158972

230821

[immunochemotherapy]

  • 2023-08-07 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-07-19 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-07-05 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-28 - trastuzumab 6mg/kg 330mg NS 250mL 90min (Chang YaoRen)

  • 2023-06-21 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-14 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-07 - cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 1hr (after cisplatin) (CDDP QW CCRT) (He JingLiang)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-07 - trastuzumab 6mg/kg 350mg NS 250mL 90min (Chang YaoRen)

  • 2023-02-10 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-01-27 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2023-01-12 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO
  • 2022-12-29 - trastuzumab deruxtecan 100mg D5W 100mL 90min (light-proofed and filtered) (Enhertu) (Chang YaoRen)

    • betamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-07 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-11-16 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-10-26 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-10-05 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-09-14 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-08-24 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-08-03 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-07-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-06-22 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-05-25 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2022-05-04 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2023-04-13 - trastuzumab 6mg/kg 390mg NS 250mL 90min

  • 2023-03-23 - trastuzumab 6mg/kg 375mg NS 250mL 90min

  • 2022-03-02 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2022-02-09 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2022-01-19 - trastuzumab 6mg/kg 360mg NS 250mL 90min

  • 2021-12-29

  • 2021-12-08

  • 2021-11-17

  • 2021-10-27

  • 2021-10-06

  • 2021-09-15

  • 2021-08-25

  • 2021-08-04

  • 2021-07-14

  • 2021-06-23

  • 2021-06-02

  • 2021-05-05

  • 2021-04-14

  • 2021-03-24

  • 2021-03-03 - trastuzumab emtansine 230mg NS 250mL 1.5hr

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2021-02-10 - trastuzumab emtansine 230mg NS 250mL 1.5hr

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2021-01-11

  • 2020-12-21

  • 2020-11-30

  • 2020-11-09

  • 2020-10-19

  • 2020-09-28

  • 2020-09-07

  • 2020-08-17

  • 2020-07-27

  • 2020-07-06

  • 2020-06-22

  • 2020-06-15

  • 2020-06-03

  • 2020-05-27

  • 2020-05-13

  • 2020-05-06

  • 2020-04-22

  • 2020-04-15

  • 2020-04-01 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 20mL
  • 2020-03-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + NS 250mL
  • 2020-03-11 - eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 20mL
  • 2020-03-04 - trastuzumab 600mg SC 5min + pertuzumab 840mg NS 250mL 1hr + eribulin 1.4mg/m2 2.4mg NS 50mL 10min

    • betamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2020-02-10 - trastuzumab 600mg SC 5min

  • 2020-01-20 - trastuzumab 600mg SC 5min

==========

2023-08-21

[cachexia]

The patient has lost 10 kg in three months, from 63.2 kg on 2023-05-25 to 52.5 kg on 2023-08-11. To combat this significant weight loss, it’s important to improve the patient’s nutritional intake. In the absence of dysphagia, megestrol can be introduced as an appetite stimulant at a suggested dosage of 200 to 600 mg/day to counteract anorexia.

[oral mucotitis]

For oral mucotitis, the introduction of Nincort Oral Gel (triamcinolone) is recommended to relieve discomfort.

701493999

230821

[MedRec]

  • 2023-08-15 SOAP Family Medicine Ye JiaZe
    • S: previosu tx at CGMH, elevated Bil
    • P: arrange hospice ward
  • 2023-08-15 SOAP Hemato-Oncology He JingLiang
    • S: adenocarcinoma of pancreatic tail with liver mets
    • O: jaundice, T Bili 8.22
    • P: refer to hospice admission

==========

2023-08-21

The patient renewed a repeat prescription for insulin degludec, linagliptin, clopidogrel, doxazosin, bisoprolol, pitavastatin, levothyroxine, and ginkgo biloba extract on 2023-08-04. Some of these medications are not listed in the active medication list. Please verify if the unlisted medications are no longer required.

701494892

230821

[exam findings]

  • 2023-07-10 CT
    • PHx: left RCC S/P operation.
    • Findings: CT of chest, abdomen, and pelvis without and with IV contrast enhancement show - Comparison: CT on 2023-04-08.
      • Chest
        • No identified residual pulmonary embolism.
        • Multiple newly-developed nodules up to 0.8cm in bilateral lungs, in favor of lung metastasis
        • A fatty mass with calcified spot about 11.4x9.2x3.7cm at left upper back, in favor of lipoma.
        • Otherwise, the mediastinum is centered and of normal width. There is no lymphadenopathy and there are no perihilar masses. The heart has a normal configuration. Major intrathoracic vessels are unremarkable. No evidence of osteolytic or osteoblastic change of thoracic cage.
      • Abdomen
        • S/P left nephrectomy for RCC; no evidence of local tumor recurrence nor visible regional lymphadenopathy.
        • A newly-developed hypodense lesion with heterogeneous enhancement about 3.4x2.2cm at left adrenal gland, in favor of adrenal metastasis.
        • Faint hypodense lesions up to 2.2x1.8cm in bilateral liver lobes, in favor of liver metastasis.
        • Osteolytic lesion at left pubic inferior ramus, R/O bone metastasis.
        • Compression fracture of L2 vertebra.
        • Small right renal cysts.
        • Right inguinal hernia without bowel loop in the hernia sac.
        • Otherwise, the GB, spleen, pancreas are normal in size and position. The urinary system is not obstructed. The pelvic inlet appears normal, with normal configuration of the iliac wings and iliopsoas muscles.
    • IMPRESSION:
      • S/P left nephrectomy without local tumor recurrence nor visible regional lymphadenopathy.
      • Newly-developed left adrenal, liver, and bilateral lung metastasis as described above.
      • R/O bone metastasis at left pubic inferior ramus.
      • No identified residual pulmonary embolism.
      • A lipoma about 11.4x9.2x3.7cm at left upper back.

[MedRec]

  • 2023-08-18 SOAP Emergency
    • Impression: D41.00 Neoplasm of uncertain behavior of unspecified kidney

==========

2023-08-21

There are no medication reconciliation issues identified after reviewing the PharmaCloud database and HIS5 records.

700133802

230818

[exam findings]

  • 2023-07-14 KUB
    • Mild dilatation of small intestine at RLQ abdomen is highly suspected.
  • 2023-07-12 KUB
    • High grade mechanical small bowel obstruction is suspected. Please correlate with CT.
  • 2023-05-19 Cell block cytology
    • bilateral pleural effusion 50cc, brown, turbid — Atypia
    • Smears and cell block show lymphocytes, mesothelial cells, histiocytes and several atypical cells.
  • 2023-05-19 Pleural tapping
    • Special Procedure
      • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml serosanguineous
      • echo-assisted Pleural tapping 16 #-needle Right side 1200 ml bloody
    • Echo diagnosis
      • left side small amount of pleural effusion
      • right side moderate amount of pleural effusion, 1200cc bloody fluid was aspirated for analysis.
  • 2023-05-18 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Pleura effusion of right and left costal-phrenic angle
  • 2023-05-16 CXR
    • Bilateral pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-05-10 All-RAS + BRAF mutation
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-05-05 Cell block cytology
    • 35cc orange cloudy ascites — Positive for malignancy, compatible with colonic origin
    • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin. Clinical correlation is advised.
  • 2023-05-05 Acites tapping
    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 1800 ml straw to orange color ascites was drained.
  • 2023-05-05 ECG
    • Sinus rhythm with Premature supraventricular complexes with aberrant conduction
    • Otherwise normal ECG
  • 2023-04-21 Gynecologic ultrasonography
    • Findingws
      • Uterus Position : AVF
        • Size: 96 * 28 mm
      • Endometrium:
        • Thickness: 10.1 mm, Fluid: with fluid
      • Adnexae:
        • ROV: Mass: 72 * 49 mm
        • LOV: Mass: 56 * 42 mm
      • CUL-DE-SAC: with fluid
    • IMP:
      • Ascites
      • R/O Bilateral Ovarian mass
  • 2023-04-20 SONO - chest
    • Special Procedure
      • echo-assisted Pleural tapping 16 #-needle Right side 1000 ml serosanguineous
    • Echo diagnosis
      • pleural effusion
    • Suggestion:
      • Send pleural effusion about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-04-19 ECG
    • Sinus tachycardia
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-04-14 CT - abdomen
    • Indication: 20220130 CT: D-colon cancer with acute obstruction, pT3N2a cM0, stage IIIB
    • Findings:
      • There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. Please correlate with ascites cytology.
      • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
      • There is mild left side hydroureteronephrosis and mild delayed contrast excretion of left kidney that is c/w obstructive uropathy.
        • The transition zone locates at left M3 ureter but nature?
        • Please correlate with retrograde pyelography.
      • There are bilateral Pleura effusion (more severe on right side).
    • Impression:
      • Carcinomatosis is noted. Please correlate with ascites cytology.
      • There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer. Please correlate with CEA and CA125.
  • 2023-04-11 Colonoscopy
    • Diagnosis: DS colon s/p OP with uncertain anastomosis region
    • Suggestion: follow CT to evaluation colon condition ( high risk before confirm anastomosis )
  • 2022-11-07 CT - abdomen
    • No evidence of recurrent/residual tumor in the study.
  • 2022-10-24 CT - brain
    • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • The brain shows age-related cortical atrophy, sulcal space widening, proportionate ventricular dilatation and white matter ischemic change including the periventricular, subcortical and subinsular regions. Right frontal scalp swollen change. There is no intracranial hemorrhage seen.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal. However, the beam-hardening artifact over the skull base may hamper the film reading.
      • Please take notice that non-enhanced CT scan is limited in the detection of acute ischemic infarction (particularly within the first 6 hours), small vascular lesion, neoplasm, infectious/toxic/metabolic disease. Recommend correlate with clinical condition.
  • 2022-07-23 CT - abdomen
    • s/p left hemicolectomy. No evidence of recurrent/residual tumor in the study.
  • 2022-04-07 CT - abdomen
    • S/P colon operation.
    • Some LNs (up to 1.3cm) at mediastinum.
    • Right minimal pleural effusion.
  • 2022-02-17 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, descending-sigmoid colon, laparoscopic extensive left hemicolectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal: Free
      • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (6/13)
      • T-colostomy, closure — Confirmed
      • AJCC 8th edition Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic extensive left hemicolectomy
      • Specimen site: left descending-sigmoid colon
      • Specimen size: 22 cm in length
      • Tumor size: 4.5 cm
      • Tumor location: 3 cm away from the closest resection margin
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled as: A1-8:tumor, A9-10:LNs, B:proximal end, C:distal end, D: T colostomy
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: moderately differentiated
      • Depth of invasion: mesocolic soft tissue
      • Angiolymphatic invasion: Present
      • Perineural invasion: Present.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: N/A / Serosal margin status of colon: Uninvolved
      • Lymph node metastasis, mesocolic: Positive (6 / 13)
      • Lymph node metastasis, IMA / SMA: N/A.
      • Extranodal involvement: Present.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT) - pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN) - pN2a: Four to six regional lymph nodes are positive
        • Distant Metastasis (pM) - N/A
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A.
      • Tumor regression grading S/P CCRT: N/A.
  • 2022-02-15 Colonoscopy
    • C/W colon cancer, with nearly total luminal obstruction, D-S junction
    • S/p T-colon colostomy
  • 2022-02-09 Patho - colon biopsy
    • Colon tumor, sigmoid, biopsy — High grade dysplasia at least
    • Microscopically, the sections show a picture of high grade dysplasia at least of colonic mucosal tissue characterized by atypical glands lined by high-grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement without obvious desmoplasia due to limited specimen.
    • Immunohistochemistry of CDX2(+), PMS2(+), MLH1(+), MSH2(+) and MSH6(+) for dysplastic cell. According to clinical and radiologic findings, more advanced lesion (adenocarcinoma) should be suspect. Repeat biopsy is advised for further evaluation, if clinically indicated.
  • 2022-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66.7 - 24.1) / 66.7 = 63.87%
      • M-mode(Teichholz) = 63.9
    • Conclusion:
      • Thickened AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2022-02-08 Spirometry
    • Mild restrictive ventilatory impairment
  • 2022-01-30 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)
  • 2022-01-30 ECG
    • Sinus rhythm with Premature supraventricular complexes
    • Left ventricular hypertrophy with repolarization abnormality
    • Abnormal ECG

[consultation]

  • 2023-05-09 Hemato-Oncology
    • Q
      • 80 y/o female, a pt of D-colon colon, pT3N2a cM0, stage IIIB wt obstruction wt T loop colostomy s/p laparoscopic extensive L hemicolectomy and closure of T loop colostomy on 2/16 22 by Dr Lv ZongRu. After operation, she was referred to oncology for adjuvant chemotherapy with Oxalip 85mg/m2 + 5-Fu 2800mg/m2 since 2022/04/06 to 2022/10/06. She kept regular follow up at CRS outpatient department and hematology oncology outpatient department.
      • The patient complained about abdominal distention recent. Abdominocentesis for cell block examination on 2023-05-05.
      • The smears and cell block show lymphocytes, reactive mesothelial cells and scant atypical nest which immunocytochemistry shows CDX-2(+) and PAX-8(-). According to clinical information and cytomorphologic findings, it is compatible with metastatic adenocarcinoma with colonic origin.
      • We need your expertise for help her further management for  chemotherapy. Thanks for you help!
    • A
      • This 82-year-old female patient has past history of 1) Hypertension and hyperlipidemia under medical control for 10 years at NTUH. 2) HIVD s/p *2 times at TzuChi Hospital and NTUH 3) Descending-colon cancer, pT3N2acM0 stage IIIB with obstruction post T loop colostomy on 2022/01/30, post laparoscopic extensive left hemicolectomy + closure of T loop colostomy on 2022/03/16 with adjuvant with C/T since 2022/04/06 to 2022/10/06. 4) port-A implantation on 2022/03/28.
      • Follow up abdominal CT 2023-04-14 show 1. There is massive ascites and multiple soft tissue masses in the perihepatic space parietal peritoneum and omentum that is c/w carcinomatosis. 2. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer.
      • Ascites cell block show: Positive for malignancy, compatible with colonic origin CDX-2(+)and PAX-8(-). We are consulted for further evaluation.
      • Please arrange exploratory laparotomy as your scheduled 5/10 for tissue and send All-RAS and RAF. Palliative chemotherapy is indicated. We will discuss with patient. Thanks for your consultation.
  • 2023-04-21 Obstetrics and Gynecology
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
      • She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022. After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • We cnsultation CM. was suggest f/u chest echo and tapping 1000ml serosangumous pleural effusion at right side on 4/20. Cnsultation Hematologis who suggest we consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…).
      • Therefore, we needs your expert experience for further evaluation. Thaks a lot !!
    • A
      • This 80 y/o female with history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension.
      • She was admitted for abd distention and dyspnea. followed up CT showed bilateral pleural effusion. carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted. we were consulted for cancer evaluation
      • Lab:
        • CEA 12.36ng/mL, CA 125 ?
        • Right pleura effusion cell block ??
        • TVUS and TAS:
          • Uterus: 96*28mm, EM 10.1mm + fluid
          • RT 72*49 mm
          • LT 56*42 mm
        • Ascites (+)
      • Impression:
        • Ascites
        • R/O Bilateral Ovarian mass, or colon cancer seeding (Krukenber tumor?)
      • Suggestion:
        • Consider CT guide biopsy for tissue proof
        • Consult oncologist for chemotherapy fist
        • Consider arrange tumor team meeding when tissue proof
  • 2023-04-21 Hemato-Oncology
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. She suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
      • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed carcinomatosis is noted. There are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • Due to abdomen CT showed pleural effusion, I consulted CM, and arranged a chest echo examination at 14:30 this afternoon.
      • We needs your expert experience for further evaluation and treatment. Thaks a lot !!
    • A
      • This 80 year old woman is a case of D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. For suspect carcinomatosis, we are consulted. Abdomen CT showed there are soft tissue masses in bilateral adnexa that may be tumor seeding (carcinomatosis) or ovarian cancer is noted.
      • Complete tumor marker. Arrange chest echo for right pleura effusion (send cell block). Consult GYN for further evaluation. Get any tissue proof (colon cancer recurrent or newly diagnosis GYN cancer…) Thanks for your consultation.
  • 2023-04-20 Chest Medicine
    • Q
      • This 80-year-old female patient had past history of 1) D-colon colon, pT3N2a cM0, stage IIIB s/p laparoscopic extensive L-hemicolectomy and closure of T loop colostomy on 2022/02/16, adjuvant with C/T since 2022/04/06 to 2022/10/06. 2) Hypertension. she suffered from initial presentation of constipation for a long time & abrupt onset of abd pain in Jan 2022.
      • After operation. She kept regular follow up at our OPD. Refollow up abdomen CT showed bilateral pleura effusion (more severe on right side) and carcinomatosis is noted.
      • We needs your expert experience for further evaluation and treatment (cytology). Thaks a lot !!
    • A
      • This 80 y.o female was a case of D-colon adenocarcinoma, pT3N2aM0, stage IIIb, post operation on 111-02-16 and C/T from 111-04 to 111-10. Now, because of Abdominal CT showed bilateral pleural effusion and carcinomatosis, we were consulted for further treatment.
      • Suggestion:
        • Please arrange Chest echo + pleural effusion drainage or pig-tail insertion for right massive pleural effusion (pleural effusion will submitted for cell block exam)
        • If Colon Ca with metastasis confirmed, please consult Hematologist for further treatment

[surgical operation]

  • 2022-02-16
    • Surgery
      • Laparoscopic extensive left hemicolectomy + closure of T loop colostomy
    • Finding
      • Tumor in DS colon with adhesion to left side lumbar region peritoneum.
      • LN in IMA root, removed
      • stenosis of rectum,
      • No 29 SDH for anastomosis for cancer
      • hand sew 2 layer for T colostomy
      • moderate stool in colon
      • Tissel 4ml for both 2 anastoomsis
      • No.15 Drain into pelvis
  • 2022-01-30
    • Surgery: T loop colostomy        
    • Finding: Dilation of colon 
  • 2017-05-10
    • Diagnosis: Lumbar stenosis, L3/4/5
    • PCS code: 83002C
    • Finding
      • Lumbar spondylosis with
        • Hypertrophic changes of ligamentum flavum and facet joints at L3/4 and L4/5 levels with dura compression and bilateral L4 and L5 roots compression. left side more severe.
        • No gross instability noted.

[immunochemotherapy]

  • 2023-08-02 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-07-19 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 150mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-06-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-06-05 - irinotecan 120mg/m2 165mg D5W 250mL 90min + leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2023-05-19 - irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 300mg/m2 470mg NS 250mL 2hr + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant D1-3 + NS 250mL
  • 2022-10-06 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4370mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-21
  • 2022-09-08
  • 2022-08-25
  • 2022-08-10
  • 2022-07-22
  • 2022-07-07
  • 2022-06-22
  • 2022-06-06
  • 2022-05-09 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4190mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-22 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-06 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (FOLFOX, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-08-18

No medication reconciliation issues were identified after reviewing PharmaCloud and HIS5 records.

2023-08-04

The repeat prescription issued by NTUH was refilled on 2023-08-01 and includes Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), and Xanax (alprazolam). These medications are currently being used with no reconciliation issues identified.

2023-07-13

This patient visited NTUH on 2023-06-15 and was prescribed Norvasc (amlodipine), Aprovel (irbesartan), Lipitor (atorvastatin), Xanax (alprazolam) which were refilled at a local pharmacy on 2023-07-03. These drugs are now in the active medication list, no reconciliation issues found.

2023-06-28

Upon examining the PharmaCloud database, it appears that access to this patient’s information is currently unavailable, potentially due to lack of authorization. However, a review of the HIS5 medication records indicates that all valid prescriptions were provided by the Hemato-Oncology department. Hence, no medication reconciliation issues have been found.

700813390

230818

[exam findings]

  • 2023-08-17 Sigmoidoscopy
    • Low rectal cancer involving anal canal and anal sphincter

[MedRec]

  • 2023-08-14 SOAP Radiation Oncology Chang YouKang
    • S
      • PH: lung cancer stage Ia s/p OP in NTUH in 2018.
      • BPH s/p OP; C spine s/p OP > 10 yr.
      • No DM; no HTN.
      • Anal pain with some bleeding since 2023/05.
      • Anal fistula s/p admission and OP at HsinChu Mackay Hospital.
    • O
      • CT, 2023/08/11, HsinChu Mackay Hospital: 4-cm tumor over anal canal, small perirectal LAPs, no enlarged bilateral inquinal LAPs; cT3N1M0 at least. No lung, liver, distal LN metastasis.
      • CXR, 2023/08/08: blurred left CP angle.
      • DRE, 2023/08/14: anal canal induration and an ulcerative wound at right lateral to anterior.
      • 2023/08/10, CEA 1.77, CA199 7.77.
      • HsinChu Mackay Hospital Pathology, 2023/08/09 (S2306571): adenocarcinoma (goblet cell adenocarcinoma or signet ring cell ccarcioma with neuroendocrine differentiation)
    • Imp: Low rectal cancer (involving anal canal), cT3N1M0 at least; 83 Y/O.
    • Suggest CCRT then observation (prefered due to very old age), or local excision if good tumor response or APR.
      • RT dose: 5400cGy/30 fractions.
      • CT simulation on 8/17, 14:30.
      • Possible RT side effects are told; diet education.
  • 2023-08-14 SOAP Colorectal Surgery Xiao GuangHong
    • S
      • Anal fistula s/p admission and OP at HsinChu Mackay Hospital
      • Post-OP patho: adenocarcinoma
      • PH: lung cancer
    • O
      • CT: TxN0M0
      • DRE: anal canal induration and an ulcerative wound at right lateral to anterior
    • A
      • Suggest CCRT then evaluation of observation (prefered due to very old age) or APR
    • P
      • Arrange sigmoidoscopy for R/O colonic lesion

==========

2023-08-18

This patient received a repeat prescription on 2023-06-28 at NTUH HsinChu Branch and refilled it on 2023-07-20 at a local pharmacy for a 28-day supply of Sennapur (sennoside), Betmiga (mirabegron), Xanax (alprazolam), and Eurodin (estazolam). There is no mirabegron included in the active medication list, please confirm if the drug is no longer needed.

701300692

230816

[MedRec]

  • 2023-08-01 ~ 2023-08-07 POMR Gastroenterology
    • Discharge diagnosis
      • Para-aortic lymphadenopathy susp lymphoma
      • GB wall thickening cause ?
      • Severe persistent asthma with (acute) exacerbation
      • Allergic rhinitis, unspecified
      • Irritable bowel syndrome without diarrhea
      • Gastro-esophageal reflux disease with esophagitis
    • CC
      • Diarrhea 5-6 times /days for 6 months
    • Present illness
      • This is a 44 year old female patient.She had an underlying disease of
        • asthma
        • allergic rhinitis
        • urticaria after covid viccination
      • Patient reported in recent half year, she sufferd from upper abdominal pain, exacerbated by coughing.And diarrhea 5-6 times /days for 6 months,she also reported about fever at night, and losing 10+ kilograms body weight acompanied with night sweating. Patient was regularly followed up chest, gastroenterology OPD at our hospital.
      • At 2023/07/11 US showed diffuse symmetrical edematous wall thickening of the gallbladder, suspect adenomyomatosis.
      • 2023/07/25 CT result shoed GB adenomyomamatosus and suspect lymphoma.Hepatomegaly and splenomegaly was noted.
      • She also complain about discomfortable after receiving the fourth dose of covid vaccine on 2023/01/13 and urticaria after covid viccination last year.
      • The LAB DATA showed higher total bilirubin 2.89mg/dL.
      • 2023/07/12 CT abdominal showed diffuse symmetrical edematous wall thickening of the gallbladder.
      • Under the impression of gallblader wall thinckening and enlargement of lymphnode, highly suspect adenomyomatosis and lymphoma, the patient was admitted to our ward for further evaluation and management.
    • Course of inpatient treatment
      • After admission, we have arranged EUS for her which was revealed as
        • Hepatic hilum tumor, s/p CH-EUS & EUS/FNB (A)
        • Gallbladder wall thickening, s/p CH-EUS & EUS/FNB (B).
      • We have consulted GS for surgical evaluation and reply as waiting pathology report.
      • PET scan was arranged on 08/07. Under the stable condition, she was arranged discharge and OPD follow up.
  • 2023-03-08 SOAP Chest Medicine
    • S
      • post COVID
      • cough intermittent, without scanty sputum, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
      • Past history: Allergic rhinitis, asthma
      • Family history of asthma
      • Smoking(-)
      • Allergic history(-)
      • Traveling history(-)
    • O
      • Throat: hyperemia
      • Tonsil: enlargement
      • Neck LAP:(-)
      • Breathing sound:course, wheezing(+), crackle(-)
      • HS: RHB
      • Abdomen: soft and flat
      • Pitting edema(-)
    • Prescription
      • Symbicort Rapihaler (budesonide, formoterol) 2# BID
      • Ulstrop (famotidine 20mg) 1# BID
      • Xyzal (levocetirizine 5mg) 1# HS
      • Actein (acetylcysteine 600mg) 1# BID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Cough Mixture (platycodon) 10mL HS
      • Acetal (acetaminophen 500mg) 1# TID
  • 2022-04-25 SOAP Rheumatology
    • S: 220425 impproved mild, mild elevated Eos, headache at night
    • Prescription
      • Allegra (fexofenadine 60mg) 1# TID
  • 2022-04-18 SOAP Rheumatology
    • S: 2022 0418 facial swelling, lip swelling off and on for half an yr, urticaria rash over turnk for 1 month
    • Prescription
      • Allegra (fexofenadine 60mg) 1# TID

701483618

230816

[MedRec]

  • 2023-07-18 ~ 2023-07-24 POMR Hemato-Oncology
    • Discharge diagnosis
      • Chronic viral hepatitis B without delta-agent
      • Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
      • Chronic viral hepatitis B without delta-agent
    • CC
      • for C1D1 chemoradiotherapy with FOLFOX
    • Present illness
      • This 48-year-old woman, a patinet of rectal cancer cT4bN0M0 stage IIC was diagnosed in July by Dr Xiao GuangHong, suffered from bowel habit change and tenesmus and bloody stool for 2-3 years ago and hemorrhoid during pregnancy was also noted. She visited to our CRS OPD for further evaluation and survey.
      • Image study with abdominal CT (2023/07/02) showed rectal cancer is highly suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for rectal cancer: T4b N0 M0, stage: IIC . Colonfiberscopy (2023/07/08) showed rectal cancer s/p biopsy and pathology of Large intestine, rectum, from anal canal to 4 cm from anal verge, biopsy (2023/07/04) proved adenocarcinoma, moderately differentiated
      • Immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
      • The tumor marker showed CA-199 = 23.687; CEA = 3.627 and HBsAg(NM) = Positive on 2023/06/30.
      • Radiotherapy of 5040cGy/28 fx started since 2023/7/17 for rectal tumor.
      • Today, she was admitted for CCRT followed by C/T with FOLFOX (C1D1) on 2023/07/18.
    • Course of inpatient treatment
      • After admission, radiotherapy started since 2023-07-17 and chemoradiotherapy with 5FU (400mg/m2) plus Leucovorin (20mg/m2) was given on 7/19-7/21 & 7/24 23, smoothly without obvious side effect. She was discharged on 7/24 23 under stable condition and will follow-up at OPD.
    • Discharge prescription
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
  • 2023-07-11 SOAP Hemato-Oncology
    • O
      • Now on CCRT followed by C/T with FOLFOX, CCRT C1D1 on 2023-07-18 or 19
    • P
      • Prescribe anti-HBV medication before CCRT
  • 2023-07-11 SOAP Radiation Oncology
    • O
      • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-07-11
        • CCRT (TNT) then evaluation the of sphincter preserving surgery or APR.
    • A/P
      • IMP: Rectal cancer, 4-cm from anal verge with right levator ani muscle invasion, cT4bN0M0, stage IIC.
      • Plan: Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR.
        • RT plan: 5040cGy/28 fx.
        • CT simulation on 7/11; possible treatment toxicity is told; diet education is given.
  • 2023-07-08 SOAP Colorectal Surgery
    • S
      • Newly diagnosed rectal cancer - cT4bN0M0 stage IIC
    • A/P
      • Suggest pre-op CCRT (Favor TNT) then evaluation the possibility of sphincter preserving surgery or APR
  • 2023-06-29 SOAP Colorectal Surgery
    • S
      • Newly diagnosed rectal cancer
      • Bowel habit change and tenesmus
      • Hemorrhoid during pregnancy
      • Mucoid bloody stool noted
      • F.H: Denied
    • O
      • One mass was noted in the rectum (from anal canal up to 4 cm from anal verge, right posterior lateral)
      • Management: Biopsy

[radiotherapy]

[chemotherapy]

700033032

230814

[lab data]

2023-05-19 Anti-HBs 1.62 mIU/mL
2023-05-19 Anti-HCV Nonreactive
2023-05-19 Anti-HCV Value 0.12 S/CO
2023-05-19 HBsAg Reactive
2023-05-19 HBsAg (Value) 3220.93 S/CO
2023-05-19 Anti-HBc Reactive
2023-05-19 Anti-HBc-Value 8.80 S/CO

[exam findings]

  • 2023-05-18 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 48 dB HL; LE 41 dB HL.
    • RE mild to severe SNHL.
    • LE mild to severe SNHL.
  • 2023-05-17 Tc-99m bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in bilateral clavicles, left scapula, some C-, T- and L-spine, and bilateral femoral shaft, M/3, in whole body bone survey.
    • IMPRESSION: Cancer with multiple bone metastases should be considered. Please correlate with the findings of PET scan.
  • 2023-05-16 MRI - brain
    • Indication: esophageal cancer survey
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp:
      • No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2023-05-15 Patho - esophageal biopsy
    • Esophagus, middle, biopsy— severe squamous dysplasia
    • Microscopically, it shows pieces of esophageal mucosal tissues with severe dysplasia of the squamous cellls.
  • 2023-05-15 PET scan
    • Glucose hypermetabolic lesions in the lower third of esophagus, compatible with the primary esophageal cancer.
    • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes, highly suspected cancer with regional and distant lymph nodes metastases.
    • Increased FDG uptake in the left upper and lower lungs, in the right lower lung, and in skeleton including bilateral clavicles, scapulae, several C-, T- and L-spine, sacrum, and femurs, highly suspected cancer with lung and bone metastases.
    • Lower third of esophageal cancer, cTxN2-3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-05-15 SONO - abdomen
    • Findings
      • Liver
        • Heterogeneous echotexture. Smooth surface. Blunt liver edge.
        • Some cysts in bilateral lobes of liver, up to 1.08 cm
        • A 0.31 cm hyperechoic lesion with PAS in S7
      • Kidney
        • Cysts in both kidneys: 0.8 cm in RK, 0.59 cm in LK
      • Pancreas
        • Some parts of pancreas blocked by bowel gas, especially
    • Diagnosis
      • Parenchymal liver disease
      • Hepatic cysts
      • Hepatic calcified spot, S7
      • Renal cysts
      • Suspected pancreatic cystic lesion, body
  • 2023-05-15 Miniprobe Endoscopic Ultrasound
    • c/w, advanced esophageal cancer, lower esophagus, estimated stage, T3NxMx, with esophageal stenosis
    • Esophageal Lugol voiding area, 30cm below the incisor, s/p biopsy
  • 2023-05-10 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-05-09 Patho - esophageal biopsy
    • Diagnosis
      • Esophagus, 35-40 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, 33 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, 24 cm below incisor, biopsy — Hyperplastic polyp
  • 2023-05-06 ECG
    • Sinus tachycardia
    • Low voltage QRS of limb leads
    • Borderline ECG

[MedRec]

  • 2023-07-10 SOAP Radiation Oncology
    • A/P
      • RT dose: 5040cGy/28 fractions (6 MV photon) to L/3 tumor & LAPs, 2023/5/26 to 7/05.
      • Cisplatin/5FU: 5/22, 5/29, 6/06, 6/13, 6/27, 7/05.
      • RT Side effect evaluation, 7/10: Radiation dermatitis, grade 0; N/V, grade 1; esophagitis, grade 1; pneumonitis, grade 0.
      • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M1, with lung & bone metastasis; hypopharyngeal lesion; ECOG =1
      • s/p CCRT since 2023/5/26 to 7/05.
      • Plan: Diet education is given. BW monitoring. Psychological support. RTC 8/15. Watchout infection sign.
  • 2023-06-26 SOAP Radiation Oncology
    • Conclusion of Cancer Multidisciplinary Team Meeting, Meeting Date: 2023-05-23
      • cT3N2M1, stage IVB => CCRT

[consultation]

  • 2023-05-11 Thoracic surgery
    • Q
      • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
      • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
      • Now, we need your expertise for surgical intervention survey.
    • A
      • I will take over this case. Thanks for your consultation!!
  • 2023-05-11 Radiation Oncology
    • Q
      • This is a 67 year old male with chief complaint of poor appetite, dysphagia. Due to above reason, the patient was admitted to our GI ward for further evaluation and management.
      • Panendoscopy on 2023/05/09 showed a lesion over hypopharynx, three lesions s/p biopsy over esophagus. Pathology of esophageal lesions revealed both specimen A (35-40 cm below incisor) and specimen B (33 cm below incisor) squamous cell carcinoma, moderately differentiated, and specimen C (24 cm below incisor) hyperplastic polyp. Chest CT on 2023/05/10 revealed L/3 esophageal cancer T3N0M0.
      • Now, we need your expertise for CCRT survey.
    • A
      • Diagnosis: Esophageal cancer, L/3, squamous cell carcinoma, 33-40cm from incisor, with lumen obstruction (liquid diet now), cT3N0M0, (bone scan is pending); hypopharyngeal lesion; ECOG =1
      • Plan: Biopsy of hypopharyngeal lesion is suggested to R/O double primary cancer. Jejunostomy and Port A implantation is suggested for nutritional support and further chemotherapy. If only esophageal cancer is proved, pre-operative CCRT to esophageal tumor for 5040cGy/28 fx is suggested for tumor control. Possible radiation toxicity (radiation esophagitis and pneumonitis) is told. Diet education is given. CT simulation will be arranged next week after jejunostomy and Port A implantation are done.
  • 2023-05-11 Ear Nose and Throat
    • A1
      • The patent was absent during the visit.
      • According to the image of the EGD, the hypopharyngeal lesion was over posterior pharyngeal wall.
      • Biopsy under nasopharyngoscope is indicated.
      • VS Huang preferred biopsy at his OPD (e.g. next Monday PM). If the patient is already discharged by then, please arrange ENT OPD follow-up.
    • A2 (2023-05-16)
      • the hypopharyngeal lesion can’t be seen by nasopharyngoscopy exam
      • suggest biopsy under PES
  • 2023-05-11 Hemato-Oncology
    • A
      • This 67 year old man is a case of newly diagnosis lower third moderately differentiated esophagus squamous cell carcinoma, cT3N0M0, stage II. We are consulted for neoajuvant CCRT.
        • Please arrange EUS and PET scan for complete staging.
        • Consult chest surgeon for further evaluation (1. For esophagus cancer evaluation; 2. arrange port A insertion and consider jejunostomy if difficle oral intake due to dysphagia)
        • Consult radio-oncologist for further evaluation (CCRT)
        • For CCRT, we will give weekly cisplatin (25-30mg/m2 IVD 2hr) with 5FU (1000mg/m2 IVD 24hr). Please arrange 24 urine CCR and auditory test.

[radiotherapy]

[chemotherapy]

  • 2023-08-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-07-05 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-28 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-14 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-06-07 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-05-29 - cisplatin 25mg/m2 35mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL + NS 500mL 1hr (before cisplatin)
  • 2023-05-22 - cisplatin 25mg/m2 35mg NS 500mL 3hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL

==========

2023-08-14

No reconciliation issues found after reviewing PharmaCloud and HIS5 records.

2023-05-25

As of 2023-05-19, the patient has tested reactive for Anti-HBc. Baraclude (entecavir 0.5mg) 1# QDAC has been appropriately prescribed. The patient’s vital signs are currently stable and there are no issues with the active prescription.

700162322

230814

[exam findings]

  • 2023-07-18 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 16 dB HL, normal to mild SNHL
    • L’t : 11 dB HL, WNL.
  • 2023-07-12 CXR
    • Tortous aorta with calcification is noted.
  • 2023-07-10 Tc-99m MDP bone scan
    • No strong evidnce of bone metastasis.
    • Suspected benign lesions in both rib cages, nasal bone, some C-, T- and L-spine, sacrum, bilateral shoulders, left elbow, hips, and knees.
  • 2023-07-08 MRI - brain
    • No evidence of brain metastasis.
  • 2023-07-07 PET
    • The FDG PET findings are compatible with esophageal cancer involving the EG junction with three regional lymph node metastases.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and bilateral shoulders. Inflammatory process may show this picture.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-07-06 Treadmill Exercise Test
    • Diagnosis: Esophageal ca
    • Exam for: Pre-op evaluation
    • Exam records:
      • Ergometer protocol: incrementa
      • Ergometer type: cycle ergometer,work rate:7 watt/min
      • Load time: 10.1 min
      • ΔVO2/ΔWR (Normal>8.6~10.3): 8.6
      • AT: 556 / 1182 = 47
    • Predict
      • MIP :104 -( 0.51 * 64 ) = 71.36
      • MEP :170 -( 0.53 * 64 ) = 136.08
      • Meas
        • MIP :96 / 71.36 )= 135
        • MEP :74 / 136.08 )= 54
      • Cause of stop:
        • CAT: 11341001 = 11
      • Rest BP: 110/70 mmHg
      • Max Exercise: 71 watts
      • Max BP: 179/65 mmHg
      • Max Borg: 5
      • Max leg fatigue: 10
      • Recovery 1st minute HR:104, BP:156/57 mmHg
      • Recovery 3rd minute BP:136/61 mmHg
      • Recovery 5th minute BP:107/61 mmHg
    • Conclustions
      • maximal exercise by RER>1.01
      • normal exercise capacity ( VO2 85%, WR 100%) ( normal value >85%)
      • spirometry: normal (FVC 88%, FEV1 85%)
      • respiratory muscle strength: low ( MIP 96%, MEP 54%)
      • No desaturation below 90%
      • low cardiac response during exercise
      • HR response during exercise: normal slope
      • work efficiency normal
      • anaerobic threshold normal
      • oxygen pulse normal
      • BP response: normal response during exercise
      • EKG: nonspecific findings
      • Health-related quality of life, CAT= 11, chest tightness 3, dyspnea 4
    • suggestion:
      • Treat underlying disease
      • For low cardiac response, suggest patient to intake adequate fluid for keeping adequate preload, suggest to survey cardiac function such as cardiac echo
      • For low respiratory muscle strength, do breathing exercise
  • 2023-07-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 23) / 93 = 75.27%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild MR; mild to moderate TR; mild PR.
  • 2023-07-05 SONO - abdomen
    • Findings: A 4 cm hypoechoic mass near EC junction
    • Diagnosis: C/W esophageal tumor
  • 2023-07-04 CT - chest
    • Indication: lower 1/3 esophageal SCC
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at dilstal esophagus near EG junction measuring 4.1cm is found. Regional lymph nodes (n=4) are also noted.
        • Calcified coronary arteries is found.
    • Imp: Esophageal cancer at EG junction with regional lymphadenopathy.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-06-20 Patho - stomach biopsy
    • Stomach, cardia, biopsy —- Moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of tumor cells in infiltrative growth pattern, squamous differentiation and focal dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, nuclear pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
  • 2023-06-20 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
    • Gastric erosion, prepyloric antrum, LC
    • Gastric tumor, cardia R/O SET with ulcer or cancer, s/p biopsy(A)
    • Gastric polyps, body and fundus, s/p biopsy(B)
  • 2023-06-14 Esophagography
    • A polypoid lesion at lower esophagus.
  • 2022-07-28 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed: Hip, BMD is 0.562 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.5 SD below the mean of age-matched people (92%).
    • IMP: osteoporosis
  • 2020-03-25 Patho - esophageal biopsy “distal esophague near EG junction”, biopsy — low grade dysplasia.

[consultation]

  • 2023-07-11 Radiation Oncology
    • A
      • This 64-years-old female sufferred from dysphagia for 6 months. She can only eat semisolid or liquid diet. Thus she was brought to our Gastroenterology clinic on 2023/06/06. Upper Gastrointestinal endoscopy revelaed gastric tumor and Gastric polyps. Stomach biopsy was done and the pathology report showed moderately differentiated squamous cell carcinoma. The cancer staging revealed esophago-cardiac junction cancer, staging at least cT3N2M0.  
      • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/07/17. Plan to deliver 45 Gy/ 25 fx to the esophagus and adjacent lymphatic drainage area. Then boost the EC junction tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20230719 or 20. Thank you very much.

[radiotherapy]

[chemotherapy]

  • 2023-08-14 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-20 - cisplatin 75mg/m2 110mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr D2 + furosemide 20mg NS 30mL 10min D2 + fluorouracil 1000mg/m2 1500mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-20

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

700301305

230814

[diagnosis] - 2023-03-22 discharge note

  • Peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum , celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions.
    • In addition,lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
  • Paroxysmal atrial fibrillation
  • Hypertensive heart disease without heart failure
  • Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-05 admission note

  • Hypertension for 10 years with regular medication control.
  • Denied history of DM        

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-08-10 CT - chest
    • Indication: T cell lymphoma, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group
    • Findings
      • Lungs: no abnormal nodule or mass in the lungs.
        • dependent partail atelectasis over RLL.
      • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
        • mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
      • Pleura: moderate Rt and small Lt effusion, in progression.
      • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
        • many bilateral renal cysts measuaring up to 4.8cm
        • multiple hepatic cysts measuaring up to 17mm
        • unremarkable of the spleen and pancreas,
        • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral iliac chaind and inguinal regions. mild ascites.
      • Visualized bones:
        • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis. no lytic or blastic destruction.
      • Impression:
        • lymphoma extensive involving both sides of the diaphgram, in progression as compared with CT on 2023/04/05
  • 2023-08-09 KUB
    • Spondylosis of the L-spine is noted.
    • Gallstone is highly suspected.
  • 2023-08-08 ECG
    • Sinus tachycardia with Premature atrial complexes
    • Left atrial enlargement
  • 2023-08-01 Bronchodilator Test
    • Mild restrictive ventilatory impairment
    • Not significant bronchodilator reversibility
  • 2023-07-14 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Enlargement of cardiac silhouette.
  • 2023-06-27, -05-29, -05-15 CXR
    • Band-like opacity projecting at RLL of the lung.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Fibrosis projecting at bilateral middle lung is suspected.
  • 2023-05-03 24hr ECG
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • A few episodes short run atrial tachycardia (longest: 4 beats)
    • A few isolated vpcs
    • No long pause
    • No significant tachyarrhythmia
  • 2023-04-25 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, antrum
    • Suggestion
      • PPI use
  • 2023-04-17 SONO - chest
    • Echo diagnosis
      • Bilateral pleural effusion, R>L
      • Post tapping at right side, about 520cc seroanguinous
      • Left side minimal pleural effusion
    • Suggestion
      • sent for anlysis and culture, and CXR follow up
  • 2023-04-05 CTA - chest
    • CTA of chest revealed:
      • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
      • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
      • Liver and renal cysts (up to 5.0cm).
      • Gallbladder stone (6mm).
    • IMP:
      • Enlarged LNs at bil. neck, axillary regions, mediastinum, retroperitonum and mesentery.
      • A patchy density (1.7x6.0cm) at RML. Ground glass opacities at bil. lungs. Right pleural effusion.
      • Gallbladder stone (6mm).
  • 2023-04-05 CXR
    • Ground glass opacities in bil. lungs.
  • 2023-04-03 Bladder Sonography
    • PVR 3.67 mL
  • 2023-04-03 Uroflowmetry
    • Q max: fair
    • flow pattern: obstructive
  • 2023-03-20 CXR
    • Right pleura effusion.
    • Partial atelectasis in RLL is suspected.
  • 2023-03-06 SONO - kidney, urology
    • bilateral renal cyst
  • 2023-03-06 Bladder Sonography
    • PVR 3.3 mL
  • 2023-02-23 CXR
    • Bilateral pleura effusion.
  • 2023-02-22 PET
    • Glucose-hypermetabolism in the right palatine tonsil and above-mentioned lymph node regions (Deauville score 5), highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
    • Glucose-hypermetabolism in some lower T- and L-spine (Deauville score 4), the nature is to be determined (DJD or lymphoma with involvement of bone marrow), suggesting further investigation.
    • T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm, stage III at least (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-21 CT - chest
    • Indication: T cell lymphoma, pending staging
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: no abnormal nodule or mass in the lungs.
        • dependent partail atelectasis over RLL.
      • Chest wall, visible neck, mediastinum and hila: extensive lymphadenopathy in the visceral space and anterior prevascular spaces of mediaastinum, cardiophrenic angles, bilateral axillary and supraclavicular regions.
        • mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: moderate Rt and small Lt effusion.
      • Visible abdominal-pelvic contents: hyperplasia of left adrenal gland. distended gall bladder with a 5mm stone.
        • many bilateral renal cysts measuaring up to 4.8cm
        • multiple hepatic cysts measuaring up to 17mm
        • unremarkable of the spleen and pancreas,
        • extensive enlarged lymph nodes in retroperitoneum, mesentery root, and bilateral inguinal regions. mild ascites.
        • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones:
        • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis.
    • Impression:
      • T-cell lymphoma extensive involving both sides of the diaphgram.
  • 2023-02-21 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • IHC stains: CD117: <1%; CD34: <1 %; LCA: 10 %; CD3 and CD20: no predominant sub-population. (of the nucleated cells).
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (106 - 22) / 106 = 79.25%
      • M-mode (Teichholz) = 78
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild MR, TR
      • Pulmonary hypertension, RV hypertrophy
  • 2023-02-14 Patho - soft tissue biopsy/simple excision (non lipoma)
    • Lymph node, right neck, excision — Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma
    • Section show lymph nodes with diffusely infiltration of medium to large-sized lymphoid cells.
    • The immunohistochemical stains reveal CD3(+), CD20(-), CD4(+), CD8(-), CD10(-), BCL2(+), BCL6(-), Cyclin D1(-), CD30(-), ALK-1(-), CD56(-), Granzyme-B(-), TdT(-), CD21(-), and CK(-). The Ki-67 is about 60%. The results are consistent with peripheral T-cell lymphoma. Please correlate with the clinical presentation and image study.
  • 2023-02-07 CT - neck
    • Indication:
      • 2023/02/06 multiple painless neck swelling for 3-4 months (suspect lymphoma)
      • productive cough with mild sputum for 2 months
      • referred from endocrinologist, sonogram revealed multiple neck LAP
    • Pre- and post-contrast CT scans of the head and neck region from skull base to lower neck were performed on a spiral CT scanner and axial, coronal and sagittal images of a slice thickness of 3 mm were reconstructed and show:
      • Numerous enlarged lymph nodes, some with necrotic change, at bilateral levels I-V, supraclavicular fossas and axillary regions and also in superior mediastinum.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • Presence of right pleural effusion.
      • No skull base lesion, nor abnormality at visible intracranial regions.
    • IMP:
      • Bilateral cervical lymphadenopathies. R/O TB lymphadenitis. D/D: metasatses, lymphoma.
  • 2023-02-06 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
    • fair inf. turbinate, L with clear mucus, NSD to L
  • 2023-01-30 SONO - thyroid
    • autoimmune thyroid disease
    • bilateral cervical lymph nodes
  • 2022-11-21 Clinical Dementia Rating
    • CDR score: 0.5
  • 2022-11-21 Mini-Mental State Examination
    • MMSE score: 24
  • 2021-11-22 Clinical Dementia Rating
    • CDR score: 0.5
  • 2021-11-22 Mini-Mental State Examination
    • MMSE score: 24

[MedRec]

  • 2023-03-06 SOAP Hemato-Oncology
    • Sick sinus syndrome
    • Bradycardia
  • 2023-02-20 SOAP Hemato-Oncology
    • Peripheral T cell lymphoma with bil neck enlargement, anr Rt pleural effusion
    • Hypertension
    • History of bradycardia treated by CV
    • Af under anticoagulation
    • Dementia

[consultation]

  • 2023-08-11 Radiation Oncology

    • A
      • A: Malignant T-cell lymphoma, consistent with peripheral T-cell lymphoma, Lugano stage III, s/p chemotherapy, with progression.
      • P: Radiotherapy is indicated for this patient with the following indicators: tonsil tumor with easy choking, and dyspnea.
        • Goal: palliation
        • Treatment target and volume: tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the tonsil tumor, peripheral involved, to bilateral involved neck nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2023-08-14.
  • 2023-08-11 Family Medicine

    • Q
      • The 86 y/o has peripheral T-cell lymphoma with right palatine tonsil, bilateral nasopharyngeal, cervical and axillary regions, bilateral SCF, ICF, bilateral pulmonary hilar regions and mediastinum, celiac chains, bilateral para-aortic space, common iliac chains, external and internal iliac chains, inguinal and thigh regions, lower T- and L-spine involvement, Lugano stageIII, IPI Score:3, High-intermediate risk group. Due to disease progress, family asks for hospice assessment. Thanks!
    • A
      • A 86 years old male, case of peripheral T-cell lymphoma.
      • He was admitted for pneumonia but status of lymphoma was in progression.
      • Cons: E4V5M6, ECOG:1-2
      • complained dyspnea and easy chocking
      • Patient could understand hospice and palliative care.
      • We will arrange combine care and follow his condition.
      • Consider hospice ward if agreed with palliative treatment.
  • 2023-08-11 Ear Nose Throat

    • Q
      • Due to dysphagia and easy choking, so he need your help use scope for NG insertion. Thanks!
    • A
      • Nasogastric tube was inserted smoothly under nasopharyngoscopy.
  • 2023-04-07 Infectious Disease

  • 2023-04-07 Chest Medicine

  • 2023-04-07 Cardiology

  • 2023-02-22 Vascular Surgery

    • A: insertion of port-A will be scheduled on 20230223.

[chemotherapy]

  • 2023-07-14 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-16 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-05-15 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-20 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D2-6 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-24 - cyclophosphamide 750mg/m2 1200mg NS 250mL 30min + liposome doxorubicin 30mg/m2 54mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 50mg PO BID D1-5 (mCHOP, cyclophosphamide 10% off due to old age)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-08-14

[tube feeding: Detrusitol SR (tolterodine), Valcyte F.C (valganciclovir)]

  • Based on the information for Valcyte F.C (valganciclovir), the drug should not be crushed for tube feeding because animal data suggests that valganciclovir has the potential to be carcinogenic in humans. As this hospital does not have access to foscarnet or cidofovir, and ganciclovir shares a similar potential carcinogenic risk, it seems that continuing with Valcyte for tube feeding is the only option at this stage.

  • Detrusitol SR (tolterodine) is an extended-release capsule, and crushing it for tube feeding could compromise its prolonged-release properties. This could result in a more pronounced fluctuation in its concentration in the bloodstream, potentially affecting its therapeutic efficacy. All other in-hospital available drugs within the same class as tolterodine, such as Urotrol F.C (propiverine 15mg), Oxbu ER (oxybutynin 5mg), Vesicare F.C (solifenacin 5mg), and Betmiga (mirabegron 50mg), are designed as film-coated or extended-release. It might be beneficial to divide the dosage of Detrusitol into two administrations per day to stabilize the concentration in the bloodstream for tube feeding.

2023-06-16

  • The patient had an appointment at a local eye clinic in XinDian on 2023-06-06 for his left eye aqueous misdirection and was prescribed brimonidine tartrate and timolol maleate eye drops, which should last for a duration of 28 days. Although the prescription is not yet expired, these two eye drops are not reflected in the current active medication list. It is suggested to confirm if the related eye condition has been resolved.

2023-05-15

  • Patients undergoing treatment with immunosuppressive drugs are at an increased risk of developing Pneumocystis pneumonia (PCP). This risk is particularly heightened in patients who are receiving glucocorticoids in combination with cytotoxic agents such as cyclophosphamide, and in those receiving multiple chemotherapeutic agents, especially during periods of leukopenia. As a measure against PCP, the patient has been prescribed Morcasin (containing trimethoprim 80mg and sulfamethoxazole 400mg, also known as TMP-SMX). Given that the patient doesn’t show signs of renal insufficiency (based on 2023-05-15 lab data), there is no need for a dose adjustment.

  • Lab data reveals that the patient’s CMV viral load, which had peaked at 803 IU/mL on 2023-05-02, has now decreased to less than 35 IU/mL as of today, 2023-05-15. Valganciclovir, the active ingredient in Valcyte, is an oral prodrug that is rapidly converted into ganciclovir, a substance instrumental in the treatment and prevention of CMV infections in immunocompromised hosts. The marked decrease in CMV viral load suggests that the prescribed Valcyte is effectively managing the CMV infection.

    • 2023-05-15 CMV viral load assay <35 IU/mL
    • 2023-05-02 CMV viral load assay 803 IU/mL
    • 2023-04-24 CMV viral load assay 159 IU/mL
    • 2023-04-12 CMV viral load assay 141 IU/mL
  • As per the PharmaCloud records, all of the patient’s recent medications have been prescribed by our hospital, and no issues related to medication reconciliation have been identified.

2023-04-06

  • 2023-04-05 lab data showed elevated CRP, NT-proBNP, hs-Troponin I, D-dimer, as well as hyponatremia, leukopenia and anemia. Liver and kidney functions were normal. Cardiologist has been consulted.

    • 2023-04-05 CRP 8.35 mg/dL
    • 2023-04-05 NT-proBNP 581 pg/mL
    • 2023-04-05 hs-Troponin I 27.6 pg/mL
    • 2023-04-05 D-dimer 1228.12 ng/mL(FEU)
    • 2023-04-05 Na (Sodium) 127 mmol/L
    • 2023-04-05 WBC 2.84 x10^3/uL
    • 2023-04-05 HGB 10.3 g/dL
  • Pneumonia with exaggerated dyspnea and hypoxemia was observed on admission; planned chemotherapy is withheld until respiratory symptoms resolve. Brosym (cefoperazone + sulbactam) has been prescribed since the day the patient was admitted.

  • Rivaroxaban and amlodipine have been prescribed properly as self-carried items with no medication reconciliation issues.

701443315

230814

[exam findings]

  • 2023-08-11 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2023-07-24 MRI - nasopharynx
    • Indication: Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start and weekly chemotherapy with TP
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows - Comparison: 2023/04/29, 2022/09/22 HN MRI - prominent motion artifacts were found on most the images
      • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor, seems stationary.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Necrotic right IB LAP, seems stationary.
      • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
  • 2023-07-21 CT - chest
    • Indication:
      • Right upper lung adenocarcinoma, cT3N1M0, stage IIIA s/p weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06, progression for right upper lobe and left upper lobe tumor s/p chemotherapy with GP (Gemzar 800mg/m2, CDDP 60mg/m2) from 2023/05/02 ~
      • Right lower gum squamous cell carcinoma, grade I, cT3N2aM0, stage IVA s/p concurrent chemoradiotherapy to H&N tumors for 7140cGy/34 fractions, start from 2022/12/12 to 2023/2/13 and weekly chemotherapy with TP (Carboplatin AUC:2 / Docetaxel 35mg/m2) from 2022/12/12 to 2023/02/06
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • Mass like lesion at right upper lobe measuring 4.87cm and left upper lobe measuring 3.18cm are found. In comparison with CT dated on 2023-02-17, the right upper lobe mass decreased in size but the left upper lobe tumor progressed.
        • Another spiculated mass at right lower lobe measuring 3.67cm and 2.3cm in largest dimension are found. In progression.
        • Bronchiectatic change over right lower lobe and left lower lobe with tree in bud appearance at left lower lobe is found.
        • No evidence of bilateral pleural effusion.
        • Lymphadenopathy at both sides of the mediastinum.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Right upper lobe mass, in regression.
      • Left upper lobe and right lower lobe mass like lesion. In progression. However, lung meta or recent inflammation should be differentiated.
      • Bilateral lower lung Bronchiectatic changes
  • 2023-06-14 CXR
    • Prior plain film identified Patchy opacity of the right upper lung zone is noted. again, decreasing in size. Please correlate with CT.
    • Linear infiltration over left upper lung zone and nodular opacity projecting at right lower lung is noted. please correlate with clinical condition.
    • Atherosclerotic change of aortic arch
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2023-04-29 MRI - nasopharynx
    • Comparison: 2022/09/22 HN MRI
      • Right low gum, bucco-gingival tumor mass, seems invading to mouth floor.
      • Invasion of right anterior mandible bone, a 4A lesion?
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor, with mild regression.
      • Necrotic right left IB LAP, mild regressed size.
      • Presence of soft tissue swelling over bil. neck, post CCRT change favored.
  • 2023-02-17 CT - chest
    • History: This 71 years-old man has noted a 3x3 cm growing mass over right level I cervical lymph node since 2022/06. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at right upper lobe measuring 5.48cm in largest dimension is found. Another spiuclated lesion at left upper lobe measuring 2.97cm in largest dimension. In comparison with CT dated on 2022-09-24, the right upper lobe mass enlarged and left upper lobe mass is new.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas,and adrenals are intact.
        • Left renal stone up to 0.4cm is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Right upper lobe and left upper lobe mass, in enlargement.
  • 2023-01-27 ALK IHC (EGFR positive needs self-paid)
    • S2022-16336: Negative
  • 2022-12-01 CXR
    • Patch density at RUL.
    • Presence of scoliosis of the lumbar spine.
    • A calcified spot at right neck.
  • 2022-11-24 PD-L1 IHC
    • Tumor cell (TC) staining assessment: >= 10% and < 50%
    • Percent of PD-L1 expression in tumor cells (TC): 10%
  • 2022-11-24 PD-L1 22C3
    • Tumor Proportion Score (TPS) assessment: >= 1% and < 50%
    • Tumor Proportion Score (TPS) : 10%
  • 2022-11-24 PD-L1 SP142
    • Result
      • Tumor cell (TC) staining assessment: TC category: TC >= 1% and < 5%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-11-22 Pure tone audiometry
    • Reliability FAIR
    • Average RE 65 dB HL; LE 60 dB HL.
    • R’t moderate to severe MHL. (BC masking dilemma)
    • L’t mild to severe MHL.
      • Note: There are three kinds of hearing loss.
        • Conductive Hearing Loss (CHL) happens when there is a problem with the outer or middle ear that blocks sound from traveling to your inner ear. Often this is caused by wax build-up, fluid in the ears, a perforated eardrum, or damage to the bones in your ears.
        • Sensorineural Hearing Loss (SHL) happens when there is a problem in the inner ear that prevents sound from traveling to the cochlea or the auditory nerve. This can be caused by trauma, aging, disease, or being exposed to loud noise.
        • Mixed Hearing Loss (MHL) is a combination of both.
  • 2022-10-05, -10-03, -10-02, -09-29, -09-26, -09-20 CXR
    • One mass lesion over RUL.
    • Tortuosity of the aorta with atherosclerotic change.
    • Degenerative change of T-L spines with marginal osteophytes.
    • Scoliosis of the T-L spine.
  • 2022-10-05 Bronchodilator Test
    • moderate obstructive impairment; non-significant bronchodilator response.
  • 2022-10-04 Patho - bronchus biopsy
    • Lung, RUL, bronchoscopic biopsy — mild chronic inflammation
  • 2022-10-04 Bronchoscopy
    • Abnormal Endobronchial tumor over RUL
  • 2022-10-03 Tc-99m MDP whole body bone scan
    • Increased activity in the right aspect of mandible, the nature is to be determined (oral cancer with adjcent bone involvement, dental problem or other nature ?), suggesting investigation.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, elbows, hips, femurs, and knees.
  • 2022-10-03 MRI - brain
    • Old insults in right frontal lobe. Cerebral small vessel disease. Mild general brain atrophy. A small enhancing nodule (5 mm) at left frontal base, may be due to confluent cortical veins. Suggest follow-up.
  • 2022-10-03 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report - rearrangement of ROS1 gene is NOT detected. Patient with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-10-03 EGFR mutation
    • No mutation was detected at exon 18, 19, 20, 21 of EGFR gene in this specimen.
  • 2022-09-26 Patho - lung transbronchial biopsy
    • Lung, right, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • 2022-09-24 CT - chest
    • Indication
      • 71 y/o man with RUL tumor for many years, stroke 5 years ago without hemiplegiaRight lower gum squamous cell carcinoma, grade I
    • Findings
      • Chest:
        • Mass like lesion at right upper lobe up to 6.9cm with attachement with interlobar fissure is found.
        • Some lymph nodes are found at right hilar region.
      • Visible abdomen:
        • Left renal stone is found.
    • Imp: Right upper lobe lung cancer with right hilar lymphadenopathy is favored.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-09-23 Whole body PET scan
    • Glucose hypermetabolism in the right lower gum with possible invasion to adjcent mandible and mouth floor, compatible with primary malignancy involving these regions.
    • Glucose hypermetabolism in a right neck level I lymph node and a right neck level IV lymph node, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in a large focal area in the upper lobe of right lung. Primary lung malignancy should be wached out. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-09-22 MRI - nasopharynx
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-09-21 SONO - abdomen
    • Diagnosis
      • Parenchymal liver disease
      • Gallbladder stone and sludge
      • Gallbladder wall thicking, suspected cholecystopathy
      • suspected Calcified spot, right kidney
    • Suggestion
      • Regular ultrasound follow up
  • 2022-09-21 Panendoscopy
    • Diagnosis
      • Reflux esophagitis, LA B
      • Superficial gastritis and erosions, whole stomach, s/p CLO test
    • Suggestion
      • Please pursue CLO test
      • No evidence of esophageal lesion

[consultation]

  • 2022-10-06 Hemato-Oncology
    • Q
      • Consultation for evaluation and treatment advice for right lower gum squamous cell carcinoma, grade I
      • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The mass was fixed and solid, there was no tenderness, no redness or pus secretion. Irregular palpable lesion over right lower gum was noticed. There was no bleeding or pus. The patient denied drooling, pain, choking, decreased appetite or body weight loss. Biopsy of right lower gum was done in 804 Hospital and showed squamous cell carcinoma, grade I, well differentiated. This time he is admitted for tumor survey.
      • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
      • Under the impression of right lower gum , our tentative plan will be either operation or CCRT. Therefore we need your advice for his further treatment. Thank you very much! We appreciate your help.
    • A
      • Impression:
        • Right lower gum, squamous cell carcinoma, grade I, well differentiated
        • Right upper lung mass
        • Stroke 5 years ago with right eye blindness
        • Superficial gastritis and erosion
      • Suggestion:
        • Pending PET data. May consider check EGFR
        • Arrange chest CT (+/-contrast) for right upper lung mass evaluation. And then CT guide biopsy if available
  • 2022-09-29 Infectious Disease
    • Q
      • This 71 year-old man, has lung tumor and stroke 5 years ago with right eye nearly blindness. He denied any other systemic disease or surgical history. 3 months ago he noted a 3x3 cm growing mass over right level I cervical lymph node. Dysphagia with solid food was also mentioned. The patient came to our ENT OPD for help, after examination, right lower gum cancer was impressed. He was admitted for cancer work up. After a series of examination right lower gum, squamous cell carcinoma, grade I was diagnosed.
      • Since his left lung nodule persist for a logn time, radio-oncologist suggest for further lung CT and CT guide biopsy for rule out malignancy.
      • The patient underwent lung CT on 20220924 which revealed right upper lung cancer, cT3N1M0. We arrange CT guide biopsy on 20220926. After CT guide biopsy, room air SPO2:88~90%. We recheck CXR today showed right lung pneumothorax. Right chest pig-tail was placed on 20220926.
      • According to his serum lab data revealed RPR/VDRL: reactive 1:2. We request your consultation for further treatment.
    • A
      • The Lab data discloses the information, I suggest my opinions as follows:
        • RPR (1:2x) with negative TPHA: false positive for syphilis.
        • RPR (1:2x) with elevated TPHA, not exceeding 1:320, follow-up (RPR and TPHA) 1 month apart; pre-emptive treatment with single dose Retarpen 2.4 MU IM may be considered.
        • RPR (1:2x) with TPHA exceeding exceeding 1:320, follow-up 3 months apart.
      • Suggestion: Check TPHA
  • 2022-09-23 Radiation Oncology
    • A
      • Impression: Rt right lower gum cancer with Rt level I LAP metastasis, WD SqCC, cT2N2M0 at least, with synchronous lung cancer, RUL; ECOG =1.
      • Plan: Chest CT and CT-guided biopsy of RUL tumor for staging and tissue proof of RUL tumor. I will follow up him with his son next Tuesday after reports of MRI and PET scan, and clinical staging are available.
  • 2022-09-23 Oral and Maxillofacial Surgery
    • Q
      • MRI showed one 2.5x2.5 cm well-shaped homogenous nodule over right lower gum. There was no finding of metastasis or lymphadenopathy over opposite side of neck. PET will be done today.
      • Under the impression of right lower gum, our tentative plan will be either operation or CCRT. Therefore we need your expertise to evaluate the condition of his teeth before radiotherapy. Thank you very much! We appreciate your help.
    • A
      • this 71-year-old man came for dental evaluation before radiotherapy.
      • O:
        • Residual root of tooth #17, #46
        • Severe peridontitis of tooth #18, #24, #41, #44, #45
        • Poor oral hygiene is noted.
      • A:
        • Residual root of tooth #17, #46
        • Severe peridontitis of tooth #18, #24, #41, #44, #45
      • P:
        • take panoramic X-ray film to check
        • explain the findings and treatment plan to the patient
        • suggest extraction of tooth #17, 18, #24, #41, #44, #45, #46
        • tooth extraction would be arranged on 2022/09/26 and 2022/09/29
        • please prescribe Amoxicillin 250mg 2# PO Q8H 2 days before tooth extraction

[chemoimmunotherapy]

  • 2023-07-25 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-05 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-31 - gemcitabine 800mg/m2 1000mg NS 100mL 30min D1 + cisplatin 60mg/m2 80mg NS 500mL 24hr D1 + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) (gencitabine + cisplatin, Q3W, NSCLC)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-10 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-02 - gemcitabine 800mg/m2 1000mg NS 100mL 30min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-06 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 110mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-14 - docetaxel 25mg/m2 40mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-04 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-21 - docetaxel 25mg/m2 35mg D5W 100mL 1hr + carboplatin AUC2 120mg NS 500mL 2hr
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - carboplatin AUC 2 120mg NS 500mL 2hr D1 + docetaxel 25mg/m2 35mg D5W 100mL 1hr D2 (reverse sequence?)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-08-14

  • According to the PharmaCloud database, the patient only visited our hemato-oncology and radiation oncology departments in the last 3 months, no reconciliation issues were identified.

2022-12-13

  • The patient admitted to receive carboplatin/docetaxel treatment for the first time to treat his right lower gum squamous cell carcinoma.
  • In the lab results of 2022-12-12, no extreme abnormalities were observed.
  • In previous lab analyses of lung adenocarcinoma, EGFR mutation or ROS1 rearrangement was not detected, and PD-L1 TPS and TC were 10%. (no ALK results available yet)
  • Patients with NSCLC who are positive for PD-L1 and negative for actionable molecular biomarkers might benefit from atezolizumab treatment. The NHI covers atezolizumab under certain conditions.
  • Except for a higher SBP of 156mmHg (2022-12-12 20:30), all vital signs were stable. There is no issue with the active prescription.

700515575

230811

[exam findings]

  • 2023-08-04 CT - chest
    • Indication: Malignant neoplasm of liver, primary, unspecified as to type
    • Findings:
      • Low density lesions are found at both lobes of thyroid measuring 2.8cm in largest dimension.
      • Enlarged lymph nodes are found at hepatic hilar region. In comparison with CT dated on 2023-06-23, these lymph nodes enlarged slightly.
      • s/p op. over S4/5 of liver.
      • Bilateral renal cysts up to 5.2cm is found.
    • Imp:
      • Hepatic hilar lymphadenopathy, slightly enlarged.
      • No evidence of pulmonary meta.
      • Thyroid nodules. Suggest sonography.
  • 2023-07-20 Patho - liver biopsy needle/wedge
    • Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma
    • The sections show a picture of metastatic poorly differentiated carcinoma, composed of nests of pleomorphic polygonal neoplastic cells, arranged in solid pattern with moderate inflammatory cell infiltrate, embedded in fibrous stroma.
    • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
  • 2023-06-23 CT - abdomen
    • Hx
      • 20221018 CT: liver tumor 7cm in S4 shows contrast enhancement in arterial phase and contrast washout at late phase, r/o HCC.
      • 20221121 Liver, S4-5, segmentectomy: HCC, pT2Nx; Stage II at least
    • Findings:
      • S/P S4-5 segmentectomy of the liver and cholecystectomy.
        • Biloma 2.5 x 2 cm in S5 liver bed is noted.
      • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
        • Metastatic nodes are highly suspected.
        • The differential diagnosis includes reactive nodes and lymphoma.
        • please correlate with clinical condition and PET scan.
        • In addition, there is one enlarged node 1.4 x 0.8 cm in left para-aortic space.
      • There are several renal cysts on both kidney and the largest one measuring 5.7 cm in size at left lower pole.
      • Abdominal aorta shows atherosclerosis and aneurysm 3.8 cm.
      • S/P hysterectomy
      • There is a diverticulum measuring 4 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
      • Hyperplasia of left adrenal gland is noted.
      • There is mild irregular contour of the left lobe liver that may be early cirrhosis.
    • Impression:
      • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size.
      • Metastatic nodes are highly suspected.
      • The differential diagnosis includes reactive nodes and lymphoma.
      • please correlate with clinical condition and PET scan.
  • 2022-11-21 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS:
      • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma
      • Pathologic Staging: pT2Nx; Stage II at least
    • MACROSCOPIC EXAMINATION
      • Specimen Type: S4-5 laparoscopic segmentectomy
      • Specimen Size: 10.2 x 8.1 x 4.0 cm; Weight: 162.5 gm
      • Focality: Solitary, well-defined, yellow and tan mass, 1.4 cm away from the nearest resection margin
      • Tumor Size: 7.0 x 6.0 x 3.5 cm
      • Satellite nodules: None
      • Tumor necrosis: Present
      • Venous (Large Vessel) Invasion: Absent
      • Non-tumor Liver Tissue: Cirrhotic
      • Representative parts are taken for section and labeled as: A1= tumor + margin, A2-A4= tumor, A5= non-tumor
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Hepatocellular carcinoma, mixed trabecular and pseudoglandular patterns
      • Histologic Grade: Poorly differentiated (G3)
      • Tumor Growth Pattern: Mass-forming
      • Tumor Necrosis: Present (<10%)
      • Tumor Extension: Tumor confined to hepatic parenchyma
      • Large Vessel Invasion: Not identified
      • Small Vessel Invasion: Present
      • Perineural Invasion: Not identified
      • Margins
        • Parenchymal Margin: Free, 1.6 cm from closest margin
        • Hepatic Capsule: Involved by invasive carcinoma
      • Pathologic Staging (pTNM): Stage II at least (pT2Nx)
      • Additional Pathologic Findings: Marked intratumoral neutrophils and chronic inflammatory cells infiltration
      • Hepatitis (specify type): Non-B and non-C
      • Ishak Modified HAI Grading: Score=4 (interphase hepatitis=1/4, confluent necrosis=0/6, focal necrosis=1/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
      • Ishak Staging: F6 (Corresponding Metavir F4, cirrhosis)
      • Fatty change: Minimal (1%)
      • IHC: CK7(+ for pseudoglandular component), CK20(-), Hepa-1(+), Arginase-1(+)
  • 2022-10-25 Bronchodilator Test
    • mild restrictive impairment; non-significant bronchodilator response
  • 2022-10-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 29) / 111 = 73.87%
      • M-mode (Teichholz) = 74
  • 2022-10-18 CT - abdomen
    • Clinical history: 83 y/o female patient with RUQ for 2 weeks, symptoms improving now, No fever. aggravated when breath?.
    • With and without contrast enhancement CT: ABD — liver, spleen, biliary duct, pancreas
      • There is liver tumor, 7cm in S4 with mild enhancement and some washout at late phase, with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
      • Bilateral renal cysts, up to 4.7cm.
      • Presence of duodenal diverticulum.
      • Aneurysmal dilatation of abdominal aorta.
      • Bulging contour at left adrenal gland, r/o adrenal hyperplasia.
    • Impression:
      • Liver tumor (S4) with abdominal wall abutting, r/o atypical HCC, cholangiocarcinoma or mixed type.
      • Bilateral renal cysts.
      • Duodenal diverticulum.
      • Aneurysmal dilatation of abdominal aorta.
      • R/O left adrenal hyperplasia.
    • Post-OP:
      • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma, Pathologic Staging: pT2Nx; Stage II at least
    • Imaging Report Form for Hepatocellular Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)

[MedRec]

  • 2023-08-10 SOAP Radiation Oncology

    • O: RT (2023-08-09 ~): at 360cGy/2 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
  • 2023-08-02 SOAP Hemato-Oncology Xia HeXiong

    • P: Port-A and admission for CCRT with CDDP or 5-FU
  • 2023-07-27 SOAP Hemato-Oncology Gao WeiYao

    • O
      • 2023/07/20 PATHO - Liver biopsy needle/wedge
        • IHC, tumor cells reveal: CK7(-), CK20(-), Hepa-1(-) and Arginase-1(-). Neither hepatocytic nor cholangiocytic differentiation can be found.
    • P
      • Recommend to be checked with PET for searching with possible primary origin.
  • 2023-07-27 SOAP Radiation Oncology

    • O
      • Cytology (N2023-02815, 2023-07-21): EUS guide NA/B of liver: posiitve for malignancy; see description. The differential diagnoses include but not limited to cholangiocarcinoma or hepatocellular carcinoma with the former favored.
      • Pathology (S2023-14355, 2023-07-24): Lymph node, hepatoduodenal ligament, EUS-guided FNA/B — Metastatic poorly differentiated carcinoma.
    • A:
      • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
    • P:
      • Radiotherapy is indicated for this patient with the following indicators: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
      • Goal: palliation
      • Treatment target and volume: metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions of the metastatic poorly differentiated carcinoma nodes in the hepatoduodenal ligament and partaaortic space.
      • The treatment planning of radiotherapy will be started at 1030, 2023-08-01.
  • 2023-07-19 ~ 2023-07-20 POMR Gastroenterology

    • Discharge diagnosis
      • Hepatocellular carcinoma, s/p partial resection and cholecystectomy in 2022/11, r/o hepatoduodenal ligment LN metastases, s/p endoscopic ultrasound biopsy on 2023/07/20
    • CC
      • For scheduled endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement
    • Present illness
      • This 85 y/o female patient had the following underlying diseases,
        • Type 2 diabetes mellitus,
        • Hypertension and
        • Hepatocellular carcinoma,s/p S4/5 partial resection, PT2Nx stage II and cholecystectomy on 2022/11/21
      • She was regular followed up at our GI OPD follow-up. The 2023/06/21 CT showed several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size and one enlarged node 1.4 x 0.8 cm in left para-aortic space. Metastatic nodes are highly suspected. She denied body weight loss or poor appetite or abdominal discomfort. The aFP level was not elevated (3.3).
      • Under suspicious hepatocellular carcinoma lymph node metastases, she was admitted for endoscopic ultrasound and fine needle biopsy for lymph nodes enlargement.
    • Course of inpatient treatment
      • She was admitted for EUS + biopsy for suspicious HCC lymph nodes metastases. The EUS + biopsy was performed on 7/20 and showed Multipe hypoechoic lesions with hypoechoic component noted at hilum near the pancrea; Largest one was about 35 mm.
      • Mild ascites was noted. s/p lymph node biopsy.
      • The pathology report was pending.
      • There was no obvious abdominal pain after the procedure, she then was arranged todischarge on 7/20 and GI/GS OPD follow-up.
  • 2023-07-04 SOAP Hemato-Oncology Gao WeiYao

    • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space with NORMAL AFP
  • 2023-07-04 SOAP Radiation Oncology

    • S: For evaluation due to several enlarged nodes in the hepatoduodenal ligament and partaaortic space.
      • PI: Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy (on 2022-11-21), with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
      • Family history: (-)
      • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
      • Personal Hx: DM (+); HTN (+)
      • Allergy (+)
      • Previous RT Hx: (-)
    • O:
      • O: ECOG: 0
      • PE: neck and bil SCF: neg.
      • Operation (2022-11-21): Laparotomy S4-5 partial resection & cholecystectomy
      • Pathology (S2022-20594, 2022-11-23):
        • Liver, S4-5, laparoscopic segmentectomy — Hepatocellular carcinoma.
        • Pathologic Staging: pT2Nx; Stage II at least
      • Abd sono (2023-3-24):
        • S/P surgical resection of S4 liver.
        • S/P cholecystectomy.
        • There is a hypoechoic lesion 3.55 x 2.87 cm in the peripancreatic neck area that may be enlarged node.
        • Abdominal aortic aneurysm 3.4 x 3.7 cm (width x depth).
        • Several renal cysts on both kidneys.
        • Otherwise, no significant abnormal finding is noted.
      • CT scan of abdomen (2023-6-23):
        • There are several enlarged nodes in the hepatoduodenal ligament and the largest one measuring 4.5 x 3 cm in size. Metastatic nodes are highly suspected. The differential diagnosis includes reactive nodes and lymphoma. please correlate with clinical condition and PET scan.
      • Lab data
        • 2023/06/23 AFP = 3.3 ng/mL;
    • A:
      • Hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least), s/p laparotomy S4-5 partial resection & cholecystectomy, with suspicious metastatic nodes in the hepatoduodenal ligament and partaaortic space.
    • P:
      • Refer to medical oncology for further evaluation the nature of suspicious nodal lesions.
      • RTC: 2 weeks.
  • 2023-06-21 SOAP Cardiology

    • Prescription
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# PRNQD
      • Eurodin (estazolam 2mg) 1# HS
      • Concor (bisoprolol 5mg) 0.5# QD
      • Sevikar (amlodipine 5mg, olmesartan 20mg) 1# QD
  • 2023-06-20 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertention, unspecified [I10]
      • Heart failure,unspecified [I50.9],
    • Prescription x2
      • Tulip (atorvastatin 20mg) 0.5# QD
      • Glimet (glimepiride 2mg, metformin 500mg) 0.5# QD
      • Dibose (acarbose 100mg) 1# QD
      • Trajenta (linagliptin 5mg) 1# QD

[consultation]

  • 2023-08-10 Psychosomatic Medicine
    • Q
      • Cancer inpatients with suicidal thoughts score >= 2.
    • A
      • Psychiatric impression:
        • Adjustment disorder, with depressive and anxious mood.
      • Clinical course:
        • This is a 84 y/o female who lives with her family. She was admitted today for preparing chemotherapy for hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least).
        • According to the patient, she has right upper abdominal discomfort about 2 months ago, and after a serial of examination, hepatocellular carcinoma of the liver, stage pT2Nx (Stage II at least) was impressed, and she is receiving treatment now, underwent radiotherapy and now preparing for chemotherapy. She also mentioned about stressfulness feeling and worry about her husband because he suffered from COVID infection, worrisome behaviors, and fell down in recent 1 month.
        • In recent 1 month, she has dysphoric mood, less happy feeling , decrease appetite, sometimes insomia (difficulty falling asleep, shallow sleep), intermittent death thoughs (The patient mentioned that about a month ago, when her husband was less stable, she would think about leaving and giving up. Currently, her husband’s condition has improved, and she doesn’t have those thoughts of wanting to die as much. However, she still feels distressed due to dealing with health issues like the tumor.)
        • MSE: kempt, sitting at her bedside, concious clear, frowning, worry, low mood, polite and social smile, fluent speech, appropriate tone and volume
      • Suggestion:
        • Acute intervention, supportive psychotherapy
        • Suggest Mirtazapine (30mg) 0.5# HS with Eurodin (2mg) 0.5-1# HSPRN if insomnia

[radiotherapy]

[chemotherapy]

==========

2023-08-11

[reconciliation]

A repeat prescription was issued by our cardiologist on 2023-06-21 and was refilled on 2023-08-06 for Algitab (alginic acid, MgCO3, Al(OH)3), Eurodin (estazolam), Concor (bisoprolol), and Sevikar (amlodipine 5mg, olmesartan 20mg). All of these refilled drugs, except for Algitab, have been included in the formulary. Please confirm whether Algitab is still necessary for the patient.

[FDG-PET/CT in detecting cancers with unknown primary site depends on histological subtype]

On 2023-07-20, the pathologic analysis results of the liver biopsy needle/wedge did not reveal any evidence of hepatocytic or cholangiocytic differentiation based on ICH staining. Therefore, the primary origin of the condition remains unidentified. An article titled “The usefulness of FDG-PET/CT in detecting and managing cancers with unknown primary site depends on histological subtype. Sci Rep. 2021;11(1):17732. Published 2021 Sep 6” highlighted the following key points:

  • The study evaluated the usefulness of FDG-PET/CT for detecting primary tumors and guiding treatment in 64 patients with cancers of unknown primary site (CUP).
  • PET/CT detected the primary tumor in 44% of patients overall. Detection rate was lower for squamous cell carcinoma (SCC) at 10% vs 50% for non-SCC tumors.
  • PET/CT detection did not differ by age, SUVmax, or sites of metastases between groups. However, SCC patients had fewer metastatic lesions than non-SCC.

In light of this, the use of PET could be an optional tool to help identify the origin of the biopsy liver lesion.

700048952

230810

[exam findings]

  • 2019-08-16 Colon fiberscopy
    • A sessile 0.8cm polyp at proximal T-colon and biopsy removal was done. Previous rectal cancer (10cm AAV) s/p CCRT was seen.
  • 2019-07-03 CTA - pelvis
    • CT on 2018/12/21: cT3N2M1, paraaortic LN (+) potentially resectable
    • Findings Comparison: prior CT dated 2019/03/28.
      • Prior CT identified enhanceing focal wall thickening in the rectum about 1.2 cm in wall thickness is noted again, decreasing in size to 1 cm in the current CT that is c/w rectal cancer S/P C/T with partial response.
      • Prior CT identified enlarged node 0.88 cm in left common iliac chain is noted again, stable in size.
        • It is compatible with metastatic node S/P C/T with partial response.
      • There are several renal cysts on both kidney and the largest one is measured about 3.1 cm in size at the right upper pole.
      • A small hepatic cyst 4 mm in S2/3 shows stable in size.
      • A gallstone 7 mm also shows stable in size.
    • Impression:
      • Rectal cancer and metastatic node in left common iliac chain S/P C/T show partial response. please correlate with clinical condition.
  • 2019-03-28 Sigmoidfiberscopy
    • Rectal cancer at 80 cm from AV s/p CCRT with significant tumor regression
  • 2019-03-28 CT - abdomen
    • Much regression of rectal cancer. Decreased size of non-regional LNs.
    • Renal cysts (up to 2.8cm).
    • Gall stone (7mm).
  • 2018-12-26 MRI - pelvis
    • History and indication: Rectal cancer
    • With and without contrast MRI of upper abdomen revealed:
      • Wall thickening of rectum (1.6cm in thickness) with regional and non-regional LAP.
      • Renal cysts (up to 3.2cm).
    • Impression:
      • Rectal cancer with LNs metastases.
  • 2018-12-21 CT - abdomen
    • Clinical history: 59 y/o male patient with newly diagnosed rectal cancer at 8 cm from AV.
    • With and without contrast enhancement CT, ABD — Liver, Spleen, Biliary duct:
      • Thickening wall at rectum, r/o rectal malignancy.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Rectal cancer with perirectal involvement and lymph nodes in pelvic cavity and paraaortic region, cstage T3N2M1.
      • GB stone.
      • Renal cysts.
  • 2012-12-14 SONO - hepatobiliary
    • Sonography of hepatobiliary system revealed:
      • Increased echogenicity of the liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
      • Gallbladder stone (0.87cm).
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of spleen.
      • No evidence of pleural effusion.
      • Right renal cyst (2.34x2.69cm). Left renal cyst (1.08x1.17cm).
    • IMP:
      • Mild fatty liver. A hypoechoic nodule (1.12x1.50cm) at S5 of liver.
      • Gallbladder stone (0.87cm). Bil. renal cysts.
  • 2018-12-04 Surgical pathology Level IV
    • Rectum, 8 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-07-10 SOAP Colorectal Surgery

  • 2020-06-16 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension , malignant [I10]
      • Gouty arthropathy [M10.00]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.09]
      • Malignant neoplasm of rectum [C20] *
    • Prescription
      • repaglinide 1mg 2# TIDAC15
      • Blopress (candesartan 8mg) 1# QD
      • Dibose (acarbose 100mg) 1# TIDAC
      • Tresiba FlexTouch (insulin degludec) 56 unit QN SC
      • Victoza (liraglutide) 1.8mg QDAC SC
      • Zulitor (pitavastatin 4mg) 1# QN
  • 2018-12-04 SOAP Colorectal Surgery

    • S
      • A case of newly diagnosed rectal cancer at 8 cm from AV
  • 2018-11-05 SOAP Colorectal Surgery

    • S
      • The patient received physical check up and was positive for FOBT.
      • Family hx of colon cancer (-)
      • Systemic disease/ Past history: Type 2 DM since 2007, HCVD
      • Op history: back lipoma s/p op
      • FOBT(+) noted on routine health exam / colon cancer screening
      • Small caliber stool
      • Anal discomfort and bloody stool
      • Ocupation: Driver
      • Anal fresh bleeding off and on and noted again these days
  • 2017-03-06 SOAP Metabolism and Endocrinology

    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension , malignant [I10]
      • Gouty arthropathy [M10.00]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.09]
    • Prescription
      • Levemir FlexPen (insulin detemir) 24 unit HS SC
      • Victoza (liraglutide) 1.8mg QDAC SC
      • NovoNorm (repaglinide 1mg) 2# TIDAC
      • Preterax (perindopril 2mg, indapamide 0.625mg) 1# BIDAC
      • Uformin (metformin 500mg) 1# TIDCC

[chemotherapy]

  • 2020-05-20 - irinotecan 150mg/m2 270mg D5W 100mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 500mL + atropine 0.3mg
  • 2020-05-06 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 250mL
  • 2020-04-17 - oxaliplatin 85mg/m2 150mg D5W 150mL 2hr
    • dexamethasone 6mg + granisetron 3mg + NS 250mL

==========

2023-08-10

On 2023-08-01, this patient obtained a 28-day supply of metformin, repaglinide, bisoprolol, olmesartan, and pitavastatin from Cheng Hsin General Hospital. It is noted that GLP-1 agonist (such as semaglutide) and HMG-CoA reductase inhibitor (like pitavastatin) are not currently listed in the active medication profile. It is advisable to closely observe the patient’s blood lipid and blood sugar levels to determine whether these medications or similar drugs within the same therapeutic class are necessary for his ongoing treatment.

700329331

230809

[lab data]

2023-07-26 Anti-HBc Reactive
2023-07-26 Anti-HBc-Value 6.35 S/CO
2023-07-26 Anti-HBs 7.41 mIU/mL
2023-07-26 Anti-HCV Nonreactive
2023-07-26 Anti-HCV Value 0.23 S/CO
2023-07-26 HBsAg Nonreactive
2023-07-26 HBsAg (Value) 0.26 S/CO

[exam findings]

  • 2023-08-04 MRI - pelvis
    • CC: Bloody stools for 2-3 months. BW loss 6-7 Kg/half year
      • 20230705 colonoscopy: One hemi-circular tumor with ulceration and friability was noted at 10cm AAV, and the scope was unable to pass the lumen. Biopsy was done. pathology: adenocarcinoma.
      • 20230718 CT: rectal cancer with suspicious uterus invasion
    • Indication: Rectal cancer, MRI to R/O uterus invasion.
    • Findings:
      • There is segmental circumferential wall thickening at the upper rectum, measuring 5.5 cm in size, with suggestive intussusception from the sigmoid colon invagination into the rectum that is c/w Adenocarcinoma (T3).
        • In addition, the fat plane between the rectal cancer and uterine cervix area is still clear.
        • Rectal cancer with uterine cervix invasion is less likely.
      • There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There are few cystic lesions in the uterine cervix area, the largest one 1 cm, that are c/w Nabothian cysts.
      • There are two hypodense nodule 1.4 cm and 0.7 cm in the uterine myometrium on T2WI that are c/w myoma.
      • There is no cystic lesion in left adnexa.
    • IMP:
      • Rectal cancer is noted.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for colon cancer: T3 N2b M0, stage: IIIC
  • 2023-07-18 CT - abdomen
    • With and without contrast enhancement CT of abdomen–whole:
      • Thickening wall at rectosigmoid colon, r/o colon malignancy.
      • Presence of pericolonic lymph nodes, r/o lymph nodes metastasis.
      • Cystic lesion, 1.5cm in left adnexa, r/o left ovarian cyst.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M0(M_value) STAGE: IIIB_(Stage_value)
    • Impression:
      • Rectosigmoid cancer with regional lymph nodes, cstage T3N2M0.
      • R/O left ovarian cyst.
  • 2023-07-06 Patho - colon biopsy
    • Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).

[MedRec]

  • 2023-07-25 SOAP Radiation Oncology
    • RT planning: 5040cGy/28 fx (pre-operative) to rectosigmoid cancer and LAPs. CT simulation on 8/01 13:30. Possible GI/GU toxicity and menopause are told to her and her husband. Diet education (BW loss 6-7 kg in half yr).
  • 2023-07-25 SOAP Hemato-Oncology
    • P
      • Simulation on 2023-08-01
      • Admission for 5-FU/LV
  • 2023-07-22 SOAP Colorectal Surgery
    • S
      • A case of newly diagnosed rectal cancer
      • Poor appetite
      • BWloss 6-7 Kg in half year
    • A/P
      • Suggest TNT then OP
  • 2023-07-17 SOAP Gastroenterology
    • O: 2023/07/06 PATHO-Colon biopsy - Colorectum, rectum 10 cm above anal verge, biopsy — Adenocarcinoma. IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1
  • 2017-03-02 SOAP Cardiology
    • Diagnosis
      • Pure hypercholesterolemia [E78.0]
      • Essential (primary) hypertension [I10]
    • Prescription
      • Hyzaar (losartan 100mg, hydrochlorothiazide 12.5mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
      • Tulip (atorvastatin 20mg) 0.5# QD

701101946

230809

[lab data]

2023-07-22 Anti-HBc Reactive
2023-07-22 Anti-HBc-Value 4.23 S/CO
2023-07-22 Anti-HCV Nonreactive
2023-07-22 Anti-HCV Value 0.13 S/CO
2023-07-22 Anti-HBs 5.84 mIU/mL
2023-07-22 HBsAg Nonreactive
2023-07-22 HBsAg (Value) 0.49 S/CO

[exam findings]

  • 2023-08-07 CXR
    • RUL lobar consolidation with occuded lobar bronchus and involving the hilum
    • there is pulmonary fibrosis at lower lung and LUL
    • moderate enlarged cardiac silhoutte due prominent cardiophrenic angle mediastinal fat pad / supine position
    • Port-A catheter inserted into RA via left subclavian vein.
  • 2023-07-28 PET
    • Glucose hypermetabolism in a focal area in the upper lobe of right lung with invasion to the right pulmonary hilar region and adjacent right aspect of the mediastinumm, compatible with metastatic neuroendocrine carcinoma involving these regions.
    • Mild glucose hypermetabolism in the left shoulder. Inflammatory process may show this picture.
    • Mild glucose hypermetabolism in some focal areas in the mandible. Dental problem is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureter. Physiological FDG accumulation may show this picture. Please correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2023-07-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (103 - 42.2) / 103 = 59.03%
      • M-mode(Teichholz) = 59
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
      • One nodule lesion with diamter about 1.27x1.1 cm at RA cavity
  • 2023-07-27 BronchoDilator Test
    • Diagnosis: Lung cancer
    • Conclusion: POOR PERFORMANCE
      • mild obstructive ventilatory impairment without significant reversibility, combine restrictive
  • 2023-07-26 24hr ECG
    • Baseline was sinus rhythm
    • A few isolated VPCs / VPC couplet
    • A few isolated APCs / APC couplets (with some blocked APC)
    • 9 episodes of short-run At, max 4 beats
    • No long pause
  • 2023-07-26 Tc-99m MDP bone scan
    • Two hot spots at the lower T- and upper L-spine, the nature is to be determined (severe DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, some upper T-spine, sacrum, right sternoclavicular junction, bilateral shoulders, left elbow, S-I joints, hips, and left knee.
  • 2023-07-26 Neurosonology
    • Mild (to moderate) atheromatous lesions in R middle to distal CCA and L ICA; mild atheromatous lesions in L middle CCA to CCA bifurcation, R CCA bifurcation and R ICA
    • Smaller caliber with decreased flow in R cervical VA, possible R VA hypoplasia.
    • Normal extracranial carotid and L vertebral arterial flows.
  • 2023-07-25 MRI - brain
    • Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
    • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
    • No evidence of brain metastasis.
  • 2023-07-24 Patho - pleural/pericardial biopsy
    • Lung, right, CT-guide biopsy — metastatic neuroendocrine carcinoma
    • Sections show nests of pleomorphic tumor cells infiltrating in a fibrotic stroma with focal tumor necrosis.
    • The immunohistochemical stains reveal CK7(focal +) , CK20(-), Synaptophysin(focal +), TTF-1(-), Napsin A(-), and p40(-). The results are consistent with metastatic neuroendocrine carcinoma.
  • 2021-07-16 CT - abdomen
    • S/P total gastrectomy and partial resection of S7 of the liver. There is no evidence of tumor recurrence.
  • 2017-11-01 Surgical pathology level VI
    • PATHOLOGIC DIAGNOSIS
      • Stomach, cardia, radical total gastrectomy with frozen section for margin (S2017-17868) —- Neuroendocrine carcinoma, grade 3.
        • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), Ki-67: 80%. (on S17-17911A4)
      • Margin: free
      • Lymph node, LN1-2-3, LN4, LN5-6, LN7-8-9, LN 10-11, LN12, D2 dissection — Metastatic neuroendocrine carcinoma (2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
      • Pathology stage: pT3N1 (cMx); pStage: IIB.
        • IHC stain: (S17-17753 biopsy specimen): Her2/neu: (-).
    • MACROSCOPIC EXAMINATION
      • Specimen type: radical total gastrectomy with frozen section for margin
      • Specimen size: Greater curvature: 20 cm, Lesser curvature: 15 cm
      • Number of lesions: 1
      • Tumor site: cardial region, greater curvature side
      • Tumor size: 6 x 6 cm.
      • Tumor configuration: For advanced cancer (Borrmann’s classification)
        • Type III ulcerated and infiltrating.
      • Tissue for sections: S2017-17898FS: Esophageal end margin; S2017-17911A1: distal margin; A2-5: tumor with serosal surface; B: omentum; C1-3: LN1-2-3, D: LN4, E1-2: LN5-6, F1-2: LN7-8-9, G1-2: LN 10-11, H: LN12.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Neuroendocrine carcinoma
      • Histologic grade: Grade 3
      • Depth of tumor invasion: serosal adipose tissue.
      • Lymph node
        • Lymph node as designated NO. positive / NO. total
        • 2/27 = serosal surface LN: (1/2), LN 1-2-3: (1/9), LN4: (0/1), LN5-6: (0/1), LN 7-8-9: (0/11), LN 10-11: (0/2), LN12: (0/1).
      • Pathology Staging: pT3N1 (cMx); pStage: IIB.
        • Tumor invasion: T3 Tumor penetrates subserosal connective tissue without invasion of visceral
        • Lymph node status: N1 Metastasis in 1 to 2 regional lymph nodes
      • Margins
        • Proximal Margin: Free, 5 mm from the margin
        • Distal Margin: Free, 9.5 cm from the margin
        • Circumferential (Adventitial) Margin: Free, 0.2 cm from the margin
      • Additional pathologic findings:
        • Mitotic count: 10 mitoses/10HPFs. Ki-67: 80%.
        • IHC stains: synaptophysin (+), chromogranin A (-), NSE (-), S-100 protein (-), CD56 (-), (on S17-17911A4)
  • 2017-10-30 Surgical pathology level IV
    • Stomach, fundus, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular glands.
    • IHC stain of cytokeratin (CK) highlights irregular neoplastic glands. Her2/neu: (-).

[MedRec]

  • 2023-07-21 SOAP Gastroenterology Zhao YouCheng
    • Diagnosis: Gastric cacner [C16.9]
    • Prescription x3
      • Nexium (esomeprazole 40mg) 1# QN
      • B-Red (hydroxocobalamin 1mg) 1# ST IM
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Allegra (fexofenadine 60mg) 1# QN
      • Stogamet (cimetidine 300mg) 1# QN
  • 2018-08-30 SOAP Rheumatology
    • Diagnosis
      • Gouty arthropathy [M10.00]
      • Malignant neoplasm of stomach, unspecified [C16.9]
    • Prescription x2
      • Feburic (febuxostat 80mg) 1# QD
      • Paran (acetaminophen 500mg) 1# PRNBID
      • Compesolon (prednisolone 5mg) 1# PRNBID
      • colchichine 0.5mg 1# QD
  • 2017-12-18 SOAP Rheumatology
    • Diagnosis
      • Gouty arthropathy [M10.00]
      • Malignant neoplasm of stomach, unspecified [C16.9]
    • Prescription x2
      • Mopik (meloxicam 7.5mg) 1# PRNQD
      • Euricon (benzbromarone 50mg) 1# QD
  • 2017-11-20 SOAP Hemato-Oncology Gao WeiYao
    • Diagnosis
      • Malignant neoplasm of stomach, unspecified [C16.9]
      • Drug-induced gout, right ankle and foot [M10.271]
      • Iron deficiency anemia, unspecified [D50.9]
      • Acute nasopharyngitis [common cold] [J00]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# BID
  • 2017-10-27 SOAP Gastroenterology Zhao YouCheng
    • Diagnosis: Gastric cacner [C16.9]

[consultation]

  • 2023-08-04 Hemato-Oncology
    • A
      • This 79 year old man is a case of Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG = 2. We are consulted for further treatment.
      • We will take over this case. Please book 11A (fisrt) or 10B. Thanks for your consultation.
  • 2023-07-31 Radiation Oncology
    • A
      • Diagnosis: Gastric cancer, neuroendocrine carcinoma, grade 3, pT3N1 cM0 s/p radical total gastrectomy on 2017/10/31 with liver metastasis s/p S7 segmental hepatectomy on 2018/4/12 s/p C/T with EP, shift to carboplatin plus irinotecan regimen since 2018/05/14 with RUL metastasis; ECOG =2.
      • Plan: Palliative RT to RUL tumor for 4900cGy/14 fx is suggested for tumor control. CT simulation is arranged on July 31 15:30. Possible toxicity is told; diet education is given. Treatment will be started 2-3 days later.
  • 2023-07-26 Neurology
    • Q
      • For brain MRI showed Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
      • This is 79 years-old male has had history of gouty. And he was diagnosed with gastric neuroendocrine carcinoma s/p radical total gastrectomy on 2017/10/31. The surgery pathology reports Neuroendocrine carcinoma, grade 3, pT3N1(2/27)(cMx); pStage: IIB, Free Margin, 9.5cm, KI-67: 80%.
      • This time, Cough for days, Fall down on 2023-07-16. COVID-19 virus infection on 2023-07-17. Had a CT scan done in Kinmen, suspected lung cancer, further examination recommended (case details available in the cloud). Poor appetite and Body weight loss (don’t remember how many kilograms) were noted. He came to our GI OPD refer to CM OPD, CXR and CT showed right upper lung collapse and tumor obstruction.
      • Admission from ER. At ER, Vital sign: TPR: 36.3/63/18, BP: 119/56mmHg, Conscious clear, GCS: E4V5M6, SpO2: 97%, Laboratory: Covid-19 PCR: Not Detected, No leukocytosis. D-dimer: 838.28 ng/mL(FEU).
      • Under the impression of right upper lung collapse and tumor obstruction, suspect lung cancer, he was admitted for lung cancer survey.
    • A
      • According to the patient and his wife’s statement, he denied focal weakness, slurred speech, easy choking, blurred vision or other symptoms except generalized weakness.
      • NE E4V5M6 relatively cachexia
        • CNs: intact
        • MP symmetric and weak MP 3
        • sensation: intact for touch
        • FNF/HNS: no dysmetria
      • brain MRI on 7/25: Multifocal areas of acute ischemic cortical infarct over both frontal, parietal & occipital lobes and left temporal lobe. Also multiple embolic infarcts over both corona radiata.
      • impression: embolic stroke, suspect cardiogenic etiology, r/o Trousseau syndrome
      • suggestion:
        • please do heart echography, 24H holter EKG and CPA/TCD for embolic stroke survey; be cautious of infectious endocarditis
        • use DOAC if no contraindication and Af or Trousseau syndrome was confirmed
        • neurology OPD follow-up after discharge if indicated.
      • Contact me if any questions and thank you for consultation.

[surgical operation]

  • 2018-04-12
    • Diagnosis: Gastric neuroendocrine tumor, pstage IIB with liver metastasis, S7
    • PCS code: 75003B
    • Finding
      • A 2.5x1.5 cm tumor over S7 noted from intra-op Sono. No daughter nodule. no vein thrombosis.
      • Two nodules over R`t abdominal wall peritoneum and biopsy was done.
      • Severe peritoneal adhesion due to previous total gastrectomy & D2 LN dissection. We lysis all of them with electrocautery.
  • 2017-10-31
    • Diagnosis: Gastric cardial Ca, cT2N0M0
    • PCS code: 72032A
    • Finding
      • 7x7 cm gatric tumor over gastric cardial region, greater curvature side with suspect serosal invasion
      • Preigastric lymph nodes (area 3, 7, 8, 9, 10, 11, & 12) enlargement were noted and D2 lymph node dissection was done.
      • Proximal cutting end about 2 cm and frozen section was free
      • Blood loss about 300 ml

==========

2023-08-09

[prophylactic antiviral therapy prior to immunosuppressive agent use]

The patient’s hepatitis B serology results indicate that he is immune due to natural infection, with negative HBsAg, positive anti-HBc, and positive anti-HBs. However, he remains vulnerable to reactivation if exposed to immunosuppressive agents.

Given this situation, if the treatment plan involves immunosuppressive agents, it is advisable to consider prophylactic antiviral therapy. Possible options include prescribing either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD. This preventive approach can effectively lower the risk of potential HBV reactivation induced by the immunosuppressive effects of the treatment.

ref: Pharmacy FAQ - Hepatitis B reactivation and screening. http://www.bccancer.bc.ca/pharmacy-site/Documents/Pharmacy%20FAQs/Pharmacy-FAQ-Hepatitis-B.pdf

701016342

230808

[MedRec]

  • 2023-08-07 DutyNote
    • Problem List
      • left breast invasive ductal carcinoma cT2N1 stage IIB at least
      • left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 112/7/3
      • acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic.
      • type 2 diabetes mellitus
      • hypertension
    • Course of treatment
      • This 71-year-old female, a patient had history of hypertension & stroke of left pontine/right caudate infracts in 2013. This time, fall down was noted for 1-2 weeks and visited to WanFang hospital for evaluation and CXR showed rib fructure. Owing to sudden onest of dyspnea and chest discoomfort was developed and came to WanFang hospital ER again and left multiple rib fructure and hemothorax status oist left video-assisted thoracoscopic surgery evacuation of hematoma on 2023/07/03. suspected aphasia was noted on 2023/07/08 and brain CT showed acute to subacute multiple embolic storke over bilateral frontal parietal, temproal and left occipital lobe suspect related to tumor embolic. Elevated CEA &CA-199 level was noted during storke survey thrtrgore vaginal ultrasound was done and no specific finding was noted.
      • Breast sono revealed highly suspected breast cancer at left 2.5 with left axillary lymphadenopathy. Breast biopsy proved microscopically incasive ductal carcinoma with ER (+) , PgR(+) , Her2: negative (1+) and Ki-67 with 5-10%positive nuclei. Owing to disease progression noted and for further treatment by her family and she was transferred to our hospital on 2023/08/07.
  • 2023-11-20 ~ 2013-11-29 Discharge Note
    • CC
      • Right limbs weakness for about 2 days
    • Present illness
      • This 63 y/o female patient is a case of right OA knee and patella fracture s/p op. Before this episode, she could walk with a regular cane but with right leg weakness. This time, she seemed to suffer from right side limbs weakness for about 2 days. She became unable to walk this morning and was brought to our ER for help. Neurological examination revealed right central facial palsy, mild dysarthria and right muscle power UE = 4+; LE = 4+. Brain CT was performed and no ICH. Under the impression of left hemisphere ischemic stroke, she was advised to admission for further evaluate and management.
    • Course of inpatient treatment
      • After admission, adequated hydration and antiplatlet were given. TCD/CCD was done and showed minimal atherosclerosis in bilateral CCA and right BIF; mild atheromatous lesions in left proximal CCA. Brain MRA was done and revealed an acute infarct in left pons. An old infarct in right caudate nuscleus. Cardiac echo was done and showed mild MR and TR; trivial AR. Rehab. dept was consulted and rehab. program was started smoothly. General skin itching but no rash was found, so we check autoimmune profile and showed normal. So CTM and sinbaby was given. Bilateral leg pain was controlled by Scanol. Under stable condition, she was discharged and OPD follow up was arranged.

==========

2023-08-08

Concor (bisoprolol) and Nexium (esomeprazole) should be prepared by the simple suspension method before tube feeding.

The simple suspension method refers to the process of placing tablets and capsules in warm water for a period of time and gently shaking them to promote disintegration and suspension of the medication, rather than grinding them into powder for tube feeding.

701280715

230807

{rectal cancer with LNs, lung, sacrum, sacroiliac joints mets, stage IV}

[lab data]

2023-07-19 HBsAg (NM) Negative
2023-07-19 HBsAg Value (NM) 0.420
2023-07-19 Anti-HBs (NM) Negative
2023-07-19 Anti-HBs value (NM) <2.000 mIU/mL
2023-07-19 Anti-HBc (NM) Negative
2023-07-19 Anti-HBc Value (NM) 2.190

2021-06-02 KRAS 12/13 Sample No S2021-6919
2021-06-02 KRAS 12/13 mutation detected
2021-06-02 NRAS/KRAS Sample No S2021-6919
2021-06-02 NRAS/KRAS mutation Not detected

2021-05-14 HBsAg Nonreactive
2021-05-14 HBsAg (Value) 0.34 S/CO
2021-05-14 Anti-HBc Nonreactive
2021-05-14 Anti-HBc-Value 0.44 S/CO
2021-05-14 Anti-HCV Nonreactive
2021-05-14 Anti-HCV Value 0.06 S/CO

[exam finding]

  • 2023-07-19 CT - chest
    • Impression: rectal cancer with lung metastases, sligthly in regression as compared with CT on 2023/2/7
  • 2023-06-21 MRI - L-spine
    • Indication: Pain over sacral region and bil SI joint area for 2 yrs
    • Without- and with-contrast MRI of lumbar spine, including sagittal T2W FSE, sagittal T1W, coronal STIR, axial T2W and axial T1W images (3 mm thickness for sagittal images and 4 mm thickness for the others) reveals:
      • Wedge-shaped deformity, fracture lines, T1-hypointensity, mottled T2-hyperintensity and heterogeneous enhancement involving L4 vertebral body, associating with left paraspinal soft tissue mass (mainly T1-hypointensity, mild T2-hyperintensity and faint peripheral enhancement). D/D: compression fracture with spondylitis and left paraspinal abscess, metastases (less likely).
      • Mild general bulging disc at L1-2-3-4-5-S1.
      • No intramedullary lesion.
    • IMP: L4 vertebral body facture with left paraspinal lesion. D/D: compression fracture with spondylitis/left paraspinal abscess; metastases (less likely).
  • 2023-06-13 L-spine AP + Lat. (including sacrum)
    • Compression fracture of L4 vertebral body.
    • S/P metalic stent in the rectum.
  • 2023-05-15 CT - abdomen
    • Imp:
      • Rectal cancer s/p stent placement. Stable in the local region.
      • Lymphadenopathy at right pelvic side wall. Stationary.
      • Bilateral lung meta. In regression.
      • Compression fracture. L4.
  • 2023-02-07 CT - chest
    • Impression: rectal cancer with pelvic LNs metastasis and lung metastases, in progression as compared with CT on 2022/12/07
  • 2022-12-07 CT - chest
    • Impression: rectal cancer with pelvic LNs metastasis and stationary of lung metastases as compared with CT on 2022/08/30
  • 2022-11-28 Tc-99m MDP bone scan
    • Increased activity at bilaterl S-I joints comes to more evident and some new lesions of increased activity in some T-spine are noted compred with the previous study on 2022-04-28; the nature is to be determined (severe DJD, bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in bilateral rib cages, some L-spine, bilateral sternoclavicular junctions, shoulders, and hips.
  • 2022-10-05 CT - abdomen
    • Impression:
      • Rectal cancer with bowel obstruction.
      • Lymph nodes metastasis and multiple lung metastasis.
  • 2022-10-05 Sigmoidoscopy
    • Findings:
      • Colonoscopy and Seld-expandable metalic stent (SEMS. 12cm, uncovered stent) was inserted smoothly
      • Stool passage was noted immediately after stent placement
    • Diagnosis:
      • Rectal cancer obstruction s/p SEMS
    • Suggestion:
      • Elective colectomy
    • Complication:
      • No immediate complication
  • 2022-08-30 CT - chest
    • Impression: rectal cancer with progressive lung metastases compared with CT on 2022/05/28
  • 2022-07-10 CXR
    • There are few nodular opacity projecting in both lung that are c/w metastases.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-05-28 CT - abdomen, pelvis
    • Findings
      • Mild progression of rectal cancer with LNs and lung metastases.
      • Right renal cyst (1.4cm).
    • IMP:
      • Mild progression of rectal cancer with LNs and lung metastases.
  • 2022-04-28 Tc-99m MDP whole body bone scan
    • Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Probably benign joint lesions in bilateral sternoclavicular junctions, shoulders, hips, and knees.
  • 2022-03-08 Chest PA erect view
    • There are few nodular opacity projecting in both lung that are c/w metastases.
  • 2022-02-21 CT - abdomen, pelvis
    • Mild progression of rectal cancer with LNs and lung metastases.
  • 2021-12-21 Chest PA erect view
    • There are few nodular opacity projecting in both lung that are c/w metastases.
  • 2021-11-18 CT - abdomen, pelvis
    • Mild regression of rectal cancer with LNs and lung metastases.
  • 2021-08-10 CT - abdomen, pelvis
    • Rectal malignancy with lymph nodes and lung metastasis, regression.
  • 2021-05-06 Chest PA eract view
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2021-05-05 Tc-99m MDP whole body bone scan
    • Markedly increased tracer uptake in the sacrum and bilateral S-I joints, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months for further evaluation.
    • Probably benign lesions in both rib cages, bilateral sternoclavicular junctions, shoulders, hips, and knees.
  • 2021-05-03 Patho - colon biopsy
    • Rectum, 5 cm above anal verge, biopsy — Adenocarcinoma.
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2021-05-03 CT - abdomen, pelvis
    • Impression (Imaging stage): T4aN2bM1a, stage IVA
  • 2021-05-03 Chest PA erect view
    • Multiple nodules at bil. lungs.
  • 2021-05-03 Colonoscopy
    • Diagnosis: Rectal ulcerative lesion, s/p biopsy, suspected malignancy.
    • Suggestion: F/U pathology report; suggest admission for more evaluation and management.

[MedRec]

  • 2023-06-30 SOAP Neurology
    • Prescription
      • Arcoxia (etoricoxib 60mg) 1# PRNQD
      • Neurontin (gabapentin 100mg) 1# PRNBID

[chemoimmunotherapy]

  • 2023-08-07 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-24 - irinotecan 180mg/m2 175mg D5W 250mL 90min + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2800mg/m2 4535mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-10 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-06-26 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-06-13 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-05-30 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-05-12 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4580mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea, 5FU revised to added in NS 148mL in Baster infusor)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-21 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-03 - irinotecan 180mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W, Iri 40% off due to severe diarrhea)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-03-09 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4815mg NS 500mL 46hr (FOLFIRI Q2W)

    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2022-09-19 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-14 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-01 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-07-11 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 158mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-06-27 - ramucirumab 600mg NS 250mL 1hr + oxaliplatin 85mg/m2 157mg D5W 250mL 2hr + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2600mg/m2 4800mg NS 500mL 46hr (Cyramza + FOLFOX)

  • 2022-06-06 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 336mg 1.5hr + leucovorin 400mg/m2 748mg 2hr + fluorouracil 2800mg/m2 5235mg 46hr

  • 2022-05-19 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

  • 2022-04-29 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5190mg 46hr

  • 2022-04-15 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 330mg 1.5hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5130mg 46hr

  • 2022-03-23 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-03-09 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 347mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-02-22 - ramucirumab 600mg 1hr + irinotecan 180mg/m2 348mg 1.5hr + leucovorin 400mg/m2 770mg 2hr + fluorouracil 2800mg/m2 5400mg 46hr

  • 2022-02-08 - irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2022-01-18 - bevacizumab 5mg/kg 200mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2022-01-04 - bevacizumab 5mg/kg 380mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

  • 2021-06-29 ~ 2022-01-18 - FOLFIRI + bevacizumab

  • 2021-05-13 ~ 2021-06-11 - FOLFIRI

==========

2023-08-07

[anemia]

Since 2023-02, the patient has been receiving FOLFIRI regimen. On 2023-08-06, there was an episode of grade 3 anemia (HGB < 8 g/dL) (another grade 3 anemia was recorded on 2023-04-03 with a HGB level of 7.6g/dL). To address the anemia, blood transfusions were administered on 2023-03-14, 2023-04-03, 2023-05-12, and 2023-08-06.

Starting from 2023-04-03, the dose of Irinotecan was reduced to 60% (300mg -> 180mg -> 175mg).

2023-07-25

According to the PharmaCloud database, this patient has only received his medical needs from our hospital in the past 3 months, no medication reconciliation issues identified.

2022-06-07

  • This is a stage IV rectal cancer patient with a LN and lung mets (EGFR+, pMMR, mutated KRAS codon 12/13) who is currently being treated with FOLFIRI plus ramucirumab.
  • The presence of KRAS mutations have been identified as predictors of resistance to anti-EGFR therapy in patients with mCRC. PFS was significantly improved with ramucirumab (currently used) compared to placebo in the RAS mutation subgroup (P=0.021) ( https://pubmed.ncbi.nlm.nih.gov/30339194/ )
  • The imaging studies revealed regression (2021-11-18 CT) followed by mild progression (2022-02-21 CT, 2022-04-28 bone scan, 2022-05-28 CT) with CEA (2022-05-10 7.474 ng/mL) and CA199 (2022-05-10 38.630 U/ml) remaining elevated.
  • As the effect of the current treatment is still being observed, [trifluridine + tipiracil] might be an option if the results do not meet expectations (the drug is covered by national health insurance).
  • The patient had primary hypertension and his BP readings have been around 150/100 since this hospital stay under Sevikar (amlodipine 5mg plus olmesartan 20mg) 1# PO QD. If the high pressure does not go down and becomes symptomatic, then increasing the dose of Sevikar could be an option. (Maximum daily dose: amlodipine 10 mg, olmesartan 40 mg).

2022-04-18

  • This is a patient with stage IV rectal cancer with a LN and lung metastasis being treated with FOLFIRI since 2021-05-13.
  • Earlier tests indicated that EGFR(+), MMR-proficient, and mutated KRAS codon 12/13.
  • CT images revealed first regression (2021-11-18) and then progression (2022-02-21). Bevacizumab was added from 2021-06-29 to 2022-01-18, then ramucirumab was added from 20202-22-22.
  • Lab readings were generally normal (2022-04-15), however CEA (2022-04-01) and CA199 (2022-04-08) remained elevated.
  • Current updated treatment effect is still being observed, and if the results are not as expected, then [trifluridine + tipiracil] might be an option (the drug is covered by national health insurance).
  • Besides analgesics, non-pharmacological interventions that can control pain over a longer period of time might also be considered. The following interventions are available to treat metastatic bone cancer pain (not exhaustive, reference: https://pubmed.ncbi.nlm.nih.gov/31140913/):
    • Epidural and selective nerve root block
    • Radiofrequency ablation and cryoablation
    • Vertebral augmentation
    • Intrathecal drug delivery
    • Spinal cord stimulation
    • Dorsal root ganglion stimulation

700573987

230804

[exam findings]

  • 2023-06-20 CXR
    • Solitary pulmonary nodule at right lung.
    • Presence of radiopaque gallbladder stones.
  • 2023-06-13 SONO - abdomen
    • GB stone, multiple
  • 2023-05-24 Patho - lymph node region resction
    • DIAGNOSIS:
      • Lymph node, level II, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma ( 1 / 7 )
      • Lymph node, level Ia, midline, modified radical neck dissection — Negative for malignancy ( 0 / 2 )
      • Lymph node, level Ib, right, modified radical neck dissection — Negative for malignancy ( 0 / 4 )
      • Lymph node, level III, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 5 )
      • Lymph node, level IV, right, modified radical neck dissection — Positive for moderately differentiated squamous cell carcinoma. ( 1 / 9 )
      • Lymph node, level Va, right, modified radical neck dissection — Negative for malignancy ( 0 / 1 )
      • Lymph node, level Vb, right, modified radical neck dissection — Negative for malignancy ( 0 / 3 )
      • Salivary gland, submandibular, right, modified radical neck dissection — Negative for malignancy
      • Skin, neck,level II, right, modified radical neck dissection — Negative for malignancy
    • MICROSCOPIC EXAMINATION
      • Neck Lymph Nodes: Positive for moderately differentiated squamous cell carcinoma (see above)
        • Size (greatest dimension) of the largest positive lymph node: 5 cm
        • Extranodal extension: Absent
      • Submandibular gland, right: Negative for malignancy
      • Skin, level II, right neck: Negative for malignancy
  • 2023-04-28 Patho - tonsil and/or adenoid
    • DIAGNOSIS:
      • Nasopharyngeal lesion, right, biopsy— Lymphoid hyperplasia
      • Nasopharyngeal lesion, left, biopsy— Lymphoid hyperplasia
      • Tongue base, right, laryngomicrosurgery — Lymphoid hyperplasia
      • Tonsil, right, tonsillectomy— Lymphoid hyperplasia
    • Microscopically, sections A, B, C and D shows bland tissues with lymphoid hyperplasia. There are no evidence of malignancy.
    • Immunohistochemical stain reveals CK (-).
  • 2023-04-19 PET scan
    • Increased FDG uptake in the right oropharynx, highly suspected the primary oral malignancy, suggesting biopsy for investigation.
    • Increased FDG uptake in lymph nodes of the right neck region, compatible with metastatic lymph nodes.
    • Mildly increased FDG uptake in 2 lesions in the right lower lung, the nature is to be determined (chronic inflammation process, benign/malignant neoplasm, or other nature ?), suggesting further investigation and follow-up.
    • Increased FDG uptake in bilateral pulmonary hilar regions, probably physiological uptake of FDG.
    • Right oropharyngeal cancer, cTxN1M0, by this F-18 FDG PET scan.
  • 2023-04-12 Patho - lymphonode biopsy
    • Lymph node, neck, right, excision — Non-keratinizing squamous cell carcinoma, metastatic
    • The sections show a picture of metastatic non-keratinizing squamous cell carcinoma, poorly differentiated, composed of lymphoid tissue with nests of large neoplastic cells with oval nuclei, arranged in solid pattern. Keratin formation is absent.
    • IHC, tumor cells reveal: CK7(-), CK20(-), p40(+) and p16(-).
    • EBER in situ hybridization — Negative
  • 2023-04-06 CT - neck
    • Indication: the R’t neck mass get enlarged progressively in recent 6 months
    • Finding:
      • Enlarged lymph nodes at right level II (46 mm) and level III (15 mm), both with heterogeneous enhancement. Mass effect on right submandibular gland and internal jugular vein also noted.
      • Calcification along aortic arch.
    • IMP:
      • Enlarged lymph nodes at right level II and III.
      • D/D: lymphoma, reactive lympadenitis.
  • 2023-02-07 CT - abdomen
    • A nodule (1.9cm) at RLL.
    • Gallbladder and distal CBD stones (2-4mm).
    • Colonic diverticula.
  • 2022-08-02 CT - chest
    • Finding: a dense calcified nodule (13mm) and adjacent 3mm calcification at superior segment and a lobulated soft-tisue nodule with two tiny eccentric calcification (18mm) with surrounding interlobular septal thickening at posterobasal segment of RLL. Multiple subleural bullae in bilateral apical lungs
    • Impression:
      • two granulomas up to 13mm and a calcified nodule (18mm) in RLL of lung, stationary as compared with CT on 2016/07/05.
      • multiple subleural bullae in bilateral apical lungs
  • 2020-08-06 CT - brain
    • Mild cortical brain atrophy.
  • 2018-02-23 CT - brain
    • No intracranial abnormality
  • 2017-08-05 SNCV, MNCV
    • Comments
      • Normal motor and sensory conduction studies of the arms and legs.
      • Normal F-wave latencies followed all sampling nerve stimulations.
      • Normal H-reflex study in both legs..
    • Conclusion
      • This is a normal NCV study.

[surgical operation]

  • 2023-05-24
    • Surgery
      • Modified radical neck dissection, right
    • Finding
      • Enlarged indurated lymphadenopathy over right level II, III
      • Right SCM (upper part partially removed with level II LN), IJV, SAN preserved
  • 2023-04-27
    • Surgery
      • Nasopharyngeal biopsy, bilateral    
      • Laryngomicrosurgery        
      • Right tonsillectomy        
    • Finding
      • Granular surface over upper pole of right tonsils  
  • 2023-04-12
    • Surgery
      • Excision        
    • Finding
      • A 4 cm hard tumor over R’t lateral neck and we excise part of it for biopsy

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology Gao WeiYiao
    • P: ENT Dr Hwang will perfomed to receive operation first followed by CCRT
  • 2023-05-04 SOAP Ear Nose Throat Huang TongCuan
    • A/P
      • right neck metastatic SCC
      • s/p Right tonsillectomy, biopsy of right base lesion and bi nasopharynx on 2023/04/27, no primary lesion found
      • cTxN2aM0 >>> explanation about treatment option:
        • Op + post-op RT or CCRT
        • CCRT
  • 2023-04-25 SOAP Ear Nose Throat Huang TongCuan
    • A/P: right neck metastatic cancer >>> arrange admission for endoscope exam + biopsy (NP, tongue base) + tonsillectomy
  • 2017-08-01 SOAP Neurology
    • S
      • P’t suffered from bilateral hands and feet numbness for 2~3 months. Left side dominent, worse when sit.
    • O
      • E4V5M6
      • Normal cranial nerve sign
      • MP: Full
      • Sensation: distal hyperalgesia
      • DTR: bilateral ankle +
    • A
      • Polyneuropathy [G62.9]
    • Prescription
      • Euclidan (nicametate citrate 50mg) 1# BID

[radiotherapy]

[chemotherapy]

  • 2023-07-25 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-07-18 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-07-07 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL
  • 2023-06-30 - NS 500mL 1hr (pre-cisplatin) + cisplatin 35mg/m2 50mg NS 500mL 1.5hr + NS 500mL 1hr (post-cisplatin) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 500mL

==========

2023-08-04

The package insert for Dicetel (pinaverium bromide) advises against oral ingestion or chewing. It is recommended to swallow the medication with a large glass of water during meals to prevent contact with the esophageal mucosa (risk of esophageal injury) and not be taken while lying down or before bedtime. This indicates that tube feeding is not recommended.

700902773

230804

[MedRec]

  • 2023-07-03 Metabolism and Endocrinology
    • Prescription x3
      • Eltroxin (levothyroxine 50ug) 2# QDAC
  • 2023-06-26 Orthopedics
    • Prescription x3
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# BID
      • Neurontin (gabapentin 100mg) 1# HS
      • Toricam (piroxicam) ASORDER TOPI
  • 2023-05-25 Cardiology
    • Diagnosis
      • Atrial fibrillation [I48.0]
      • Sick sinus syndrome [I49.5]
      • Presence of cardiac pacemaker [Z95.0]
      • Conduction disorder, unspecified [I45.9]
      • Chronic renal failure [N18.6]
      • Unspecified hypothyrodism [E03.9]
      • Anemia, unspecified [D64.9]
    • Prescription x3
      • Cordarone (amiodarone 200mg) 0.5# QD
      • Ulstop (famotidine 20mg) 1# QD
      • midorine 2.5mg 2# PRNTID
  • 2022-07-31 ~ 2022-08-04 POMR Hemato-Oncology Gao WeiYao
    • Discharge diagnosis
      • Urothelial carcinoma, low grade, papillary type, of the right renal pelvis, s/p NU, cystectomy, hysterectomy, urethrectomy, with local recurrence (vaginal metastases) .
      • End stage renal disease under hemodialysis on QW 246 (clinic)
      • Paroxysmal atrial fibrillation
      • Sick sinus syndrome
      • Presence of cardiac pacemaker
      • Hypothyroidism, unspecified
    • CC
      • for CCRT
    • Present illness
      • The 73-year-old woman has histories of
        • ESRD on regular hemodialysis QW246 since 2016.
        • Thyroid goiter s/p partial thyroidectomy under Thyroxin control for 20+ years.
        • Left ureteral urothelial carcinoma, high grade, pT2N0cM0, status post anterior pelvic exenteration and left nephroureterectomy on 2016/08/31
        • Bladder urothelial carcinoma, high grade, pT1N0cM0, status post radical cystectomy on 2016/08/31
        • Urothelial carcinoma over the right renal pelvis, left upper ureter, bladder and urethra s/p bilateral neprhectomy, cystectomy, abdominal total hysterectomy with bilateral salpingo-oophorectomy and urethrectomy on 2014/11/05
        • Sick sinus syndrome pacemaker implantation on 2017/4/19
      • In 2022/06 she had suffered from bloody stool. She had visited CRS OPD and colonoscopy showed extra-rectal tumor with external compression. She was referred to GYN OPD. DRE test found extra-rectal large solid tumor at anterior. PV exam found ulcerative mass at posterior vaginal wall. Malignancy was highly suspected. GYN echo showed one 48x39mm mass. Cervical biopsy was done and showed malignancy with urothelial origin. Urothelial cell carcinoma with vaginal metastasis was diagnosed.
      • Under the impression of urothelial cell carcinoma with vaginal metastasis, radiotherapy was suggested. The patient agreed to undergo the therapy. Therefore she was admitted on 2022/7/31 for further evaluation and radiotherapy localization was scheduled on 2022/8/3.
    • Course of inpatient treatment
      • After admission, she received LPRBC 2u and EPO for anemia. Nephro was consulted and arranged HD qw 246. Chemotherapy as C1 Gemzar (200mg/m2) during RT- RT positioning on 2022/8/4. Under the stable condition, she can be discharged on 2022/08/04. OPD follow up is arranged.

[chemotherapy]

  • 2022-09-14 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-31 - gemcitabine 200mg/m2 280mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-12 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-02 - gemcitabine 200mg/m2 282mg NS 100mL (after hemodialysis) (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-08-04

All repeat prescriptions from our endocrinologist, orthopedist, and cardiologist were added to the active medication list, with the exception of midorine. During this hospitalization, there is no evidence of symptomatic orthostatic hypotension in the HIS5 records, so no reconciliation issues were identified.

701168936

230804

[MedRec]

  • 2023-07-11 ~ 2023-08-02 POMR Family Medicine
    • Discharge diagnosis
      • hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
      • Type 2 diabetes mellitus without complications
    • CC
      • dyspnea with chest pain for two days.
    • Present illness
      • This 74 year old female has history of 1) Diabetes Mellitus 2) hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27
      • This time she had suffered from dyspnea with chest pain for two days.Therefore,she was brought to our ER for help. There were no fever,no abdominal pain or tarry stool. At ER, her vital sign was BP:181/104mmHg;HR:114bpm; BT:37.4 ℃; RR:28 bpm; SpO2:86%. Physical examination showed pitting edema 4+. Laboratory test revealed leukocytosis(WBC 10.1k/ul),elevated CRP level(14.4 mg/dL),hypoalbuminemia(2.9 g/dL ),hyperbililubinemia(2.25 mg/dL),hyponatriemia(122 mmol/L).Chest film disclosed Nodular lesions in both lung fields,lung metastasis.Empiric antibiotics with Brosym was prescribed.
      • Under the impression of hepatocellular carcinoma, cT4N0M1 with multiple metastases on both lungs status post C1 selfpaid of Avastin plus Tecentriq on 2023/6/27 with acute respiratory failure, she was admitted to our ward for further management
    • Course of inpatient treatment
      • After admission, selfpaid of Albumin 100mg QD with diuretic was prescribed from 7/12-. Methyprednisolone 40mg Q12H IVD for dyspnea relief. Empiric antibiotics with Brosym 4g Q12H from 7/11, blood culture was negative. Patient refused the NG tube insertion. Followed chest film on 7/13 disclosed multiple nodular opacity projecting in both lung that are c/w metastases. Desaturation was noted during Bipap used. Hospice was also consulted and DNR had signed after we explained the current condition, but not all of family agree hospice care and some families hesitated to continue active treatment. Thus, respiratory failure was noted under RT weaning as NRM or V-M, Finally, all family members agreed transfer to hospice ward on 2023/8/2.
      • After transferred to hospice ward, the patient showed drowsy consciousness with nearly air-huger breathing pattern, and we had informed the family on the patient’s clinical condition. The family had agreed on discontinuing IV fluid and adding PRN Morphine for the patient’s dyspnea. The patient’s condition continued downhill, and she expired at 17:46 on 2023-08-02.
  • 2023-06-20 ~ 2023-06-30 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of liver, primary, unspecified as to type, AFP positive hepatocellular carcinoma, stage IV
      • Secondary malignant neoplasm of unspecified lung. multiple lung metastases from AFP positive hepatocellular carcinoma
      • Type 2 diabetes mellitus without complications
    • CC
      • for CT guide biopsy
    • Present illness
      • This 74 y/o with underlying disease of type 2 DM was admitted for CT guide biopsy.
      • She was found to have multiple lung tumor with elevated AFP 1210 via CT at local clinic. She had Falling down injury over Rt shoulder. She had mild dyspnea after walking. Leg edema 2+ was noted. Lab data showed 2023/06/12 S-GOT/AST = 91 U/L; Bilirubin direct = 0.30 mg/dL; HGB = 9.4 g/dL.
      • Under the impression of multiple lung tumor with elevated AFP 1210 via CT, she was admitted to our ward for further treatment adn evaluation.
    • Course of inpatient treatment
      • After admission, CT-guide biopsy was done and revealed Consistent with metastatic hepatocellular carcinoma. ABD contrast CT showed HCC, cT4N0M1 with multiple metastases on both lungs. Pitting edema was noted, laxis 1# QD (06/23-27) was given > 1# BID (06/27- ). Heart echo was arranged. Heart echo: Preserved LV and RV systolic function. She started avastin (06/27)+ tecentriq (06/27).
      • On 06/28, we DC forxiga and pioglitazone on 06/28 for pitting edema.
      • Under stable condition, she was discharged with OPD follow up.
    • Discharge prescription
      • Apidra (insulin glulisine) 3 unit TIDAC
      • Tresiba FlexTouch (insulin degludec) 6 unit HS
      • Allegra (fexofenadine 60mg) 1# BID
      • Diovan (valsartan 160mg) 0.5# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# QD
      • Januvia (sitagliptin 100mg) 1# QD
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H if pain
      • Ulstop (famotidine 20mg) 1# BID
      • Uretropic (furosemide 40mg) 0.5# QD hold if SBP < 120

700610703

230801

==========

2023-08-01

[fluconazole dosing for HD patients]

For patients undergoing intermittent (thrice weekly) hemodialysis, whether intravenous or oral fluconazole is used, the dosing should be administered three times a week after each dialysis session. No dosage adjustment is required for indication-specific loading/initial or maintenance doses recommended in the adult dosing section. However, it is important to administer maintenance doses only three times per week on dialysis days after the dialysis session.

700308626

230731

[exam findings]

  • 2023-07-29 CT - abdomen
    • Clinical history: 59 y/o female patient with RLQ (VAS 4-7). Hx of samll intestine GIST with liver and spleen metastasis.
    • With and without contrast enhancement CT of abdomen–whole:
      • Mutiple low density liver tumors in both lobes of liver(up to 2.5cm), r/o liver metastasis.
      • Multiple soft tissue tumors (up to 11.4cm) in right subphrenic region and right lower abdomen, r/o metastasis.
      • R/O tumor invasion of right kidney.
      • Unremarkable change of the spleen, pancreas and left kidney.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
    • Impression:
      • Clnical history of small bowel GIST.
      • Liver metastasis, multiple peritoneal metastasis (mainly in right) and ascites, with invasion of right kidney.
  • 2019-01-30 SONO - abdomen
    • CC: right upper to middle abdominal pain
    • Findings
      • Liver: The liver parenchyma is homogenous. A heterogenous mixed echoic lesion with hypoechoic rim: size 4.7cm, at right lobe: metastatic tumor or primary liver tumor both considered.
      • Gallbladder and bile ducts: some gallstones: size up to 0.6-0.7cm
      • Others: a mixed echoic lesion in right abdomen, adjacent to right kidney and liver, size about 6.3cm
    • Diagnosis
      • liver tumor: cause to be considered
      • gallstones
      • suspect intra-abdominal tumor or focal inflammation in right abdomen
    • Suggestion
      • suggest admission for treatment and emergent CT scan: but patient hesitated: she requested for the second opinion at TMUH, suggest go to ER of TMUH, suggest her go to ER directly because of acute abdominal pain
  • 2018-09-19 Mammography
    • Screening Digital mammography of both breasts with MLO and CC views:
    • Old mammographic study: 2012-7-17 (BIRADS 0)
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There are benign calcifications in bilateral breasts.
      • Bilateral axillary lymph nodes.
    • Impression: Dense breast.
      • Benign calcifications in bilateral breasts.
    • BI-RADS: Category 2

[MedRec]

  • 2023-07-18 SOAP Hemato-Oncology Xia HeXiong
    • S
      • Hx of Jejunal GIST s/p LPS excision of intestial tumor and resection of inerinal tumor on 2015-02-10, pT3N0M0, Stage II
        • s/p imatinib from 2015-03 to 2019-03
        • s/p liver mets -> RFA x 4 on 2020-04-21
        • s/p intra-abdominal recurrence GIST, LPS tumor eccision on 2020-05-12
        • s/p LIver mets and LPS S6/7 hepatectomy and peritoneal nodule resection on 2021-05-28
        • s/p liver and peritoneal mets, then sunitinib 3# from 2023-03-27 to 2023-07-14
    • O
      • CT in 2023-07: Disease in progression
      • s/p imatinib and sunitinib -> PD
    • P
      • Apply regorafenib
  • 2019-01-30 SOAP Gastroenterology
    • S
      • RUQ to RMQ pain for 3-4 days
      • dull pain with fullness sensation. without vomiting.
      • nausea (-)
      • fever yesterday, the day before yesterday
      • explained high CRP: we’ve suggested admission for thorough exam, IV antibiotic, close observation.
      • patient denied pregnancy
      • constipation sometimes. denied tarry/bloody stool; denied dysuria
      • we’ve informed the patient and family: if symptoms recur or aggravate: should back to OPD or ER immediately
      • suggest admission for treatment and emergent CT scan but patient and her family hesitated: they requested to go to TMUH. Direct referral to the Emergency Department has been recommended.
    • O
      • history of small bowel GIST post surgery in TMUH. Last follow-up (TMUH) 6 months ago
      • abd echo on 1/30 PM
      • PE abd soft tenderness at RUQ to RMQ area. no muscle guarding; no rebound pain.
    • Diagnosis
      • right upper quadrant pain [R10.11]
      • small bowel GIST post surgery [C17.9]

==========

2023-07-31

[medication reconciliation]

The patient was prescribed famotidine, cyanocobalamin, and betamethasone on 2023-07-28 for a 7-day duration at JingMei Hospital to address her malignant neoplasm of the small intestine. However, these medications are currently not included in the active medication list. It is advised to review whether they are still necessary for the patient’s current condition.

700357530

230731

[exam findings]

  • 2023-06-10 Bladder sonography
    • PVR: 44.2 ml
  • 2023-06-10 Urology SONO - kidney
    • CC:
      • Bladder lymphoma s/p TUR-BT, pathology proven lymphoma
      • repeat TUR-BT revealed bladder lymphoma,
      • Under C/T for lymphoma
    • Diagnosis:
      • Grossly normal, bilateral kidneys
  • 2023-05-30 CT - abdomen
    • Clinical history: 81 y/o male patient with Triple diffuse arge B cell lymphoma with urinary bladder wall,gastric wall, distal descending colon, and sigmoid colon, left upper neck, bilateral pulmonary hila, and right lower paratracheal area, involvement, Lugano stage I.
    • With and without contrast enhancement CT of abdomen - whole:
      • Liver cysts, up to 5.5cm in S2 liver.
      • Aneurysmal dilatation of distal abdominal aorta.
    • Impression:
      • Clinical urinary bladder diffuse arge B cell lymphoma. Suggest follow up.
      • Liver cysts.
      • Aneurysmal dilatation of distal abdominal aorta.
  • 2023-05-01, -04-06, -02-15 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-18 Bladder sonography
    • PVR: 32.3 ml
  • 2023-02-17 Patho - colorectal polyp
    • Colorectum, cecum, s/p cold snare polypectomy (A) — Hyperplastic polyp
    • Colorectum, transverse colon, 55cm AAV, s/p cold snare polypectomy (B) — Hyperplastic polyp
    • Colorectum, transverse colon, 50cm AAV s/p cold snare polypectomy (C) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon, s/p biopsy removal (D) — Tubular adenoma with low grade dysplasia
  • 2023-02-17 Patho - stomach biopsy
    • Stomach, angle, s/p biopsy (A) — Chronic gastritis with intestinal metaplasia, H pylori NOT present
    • Stomach, GC site of middle body, s/p biopsy (B) — Ulcer, H pylori and candida present
  • 2023-02-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 27) / 101 = 73.27%
      • LVEF(%) = 73
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Mild AR; mild MR; mild TR; mild PR.
  • 2023-02-13 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — No evidence of lymphoma involvement
    • The sections show normocellular marrow (25%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology. No lymphoid aggregates can be found. No increased blasts in CD34 and CD117 immunostains. Scattered CD3+ small T lymphocytes, and CD20+ and/or CD79a+ small B-cells in interstitium can be identified. There is no evidence of large B-cell lymphoma involvement in the sections examined. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-02-11 Bladder sonography
    • PVR: 83.2 ml
  • 2023-02-07 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-08-04 CT - abdomen
    • History and indication: Bladder cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P foley catheter indwelling. Collapse of urinary bladder with wall thickening. Fat stranding with some air in periventricular region r/o rupture. Several LNs at pelvic cavity.
      • Some tiny nodules at bil. lungs r/o metastases.
      • Liver cysts (up to 5.1cm).
      • Mild dilatation of infrarenal abdominal aorta (3.7cm).
      • Atherosclerosis of aorta, iliac arteries.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N2(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-08-03 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: Mixed high grade urothelial carcinoma and diffuse large B cell lymhpoma
      • Tumor location: urinary bladder
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category:TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): <1%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >=1% and <5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): <5%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2022-08-03 PD-L1 IHC
    • PD-L1 Immunostaining Result
      • Tissue blocks/unstained slides received labeled as: S2022-12650A1
      • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
      • Control slide result: [V]Pass
      • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
    • Result:
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cells (TC): 0%
  • 2022-08-03 PD-L1 22C3
    • PD-L1 Immunostaining Result
      • Tissue blocks/unstained slides received labeled as: S2022-12650A1
      • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
      • Control slide result: [V]Pass
      • Adequate tumor cells present (>= 100 viable tumor cells): [V]Pass
    • Result:
      • Combined Positive Score (CPS) assessment: CPS >= 10
      • Combined Positive Score (CPS): 15
  • 2022-08-03 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Tumor, urianry bladder, TURBT — Mixed invasive papillary urothelial carcinoma, high-grade and diffuse large B cell lymphoma
      • Muscularis propria — Free of tumor invasion
    • MICROSCOPIC EXAMINATION
      • Histologic type: Mixed invasive papillary urothelial carcinoma and diffuse large B cell lymphoma
      • Histologic grade: High grade
      • Tumor configuration: Papillary
      • Muscularis propria: Present and free
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      • Immunohistochemistry:
        • Urothelial carcinoma: CK7(+), CK20(+, scatter), GATA-3(+), CD3(-) and CD20(-)
        • Malignant lymphoma: CD20(+), CD3(-), CD10(-), CD30(-), Bcl-2(+), Bcl-6(+), C-MYC(+, 60-70%), MUM-1(+) and Ki-97:>90%
  • 2022-08-02 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2022-08-02 CXR
    • Incrased density in right lower lung, suggest chest CT for further study.
    • Plate atelectasis in left lower lung.
  • 2022-07-07 Transrectal Ultrasound of Prostate - TRUS-P
    • CC
      • 2022/07/07 recurred hematuria with blood clot
      • 2022/06/16 keep Tx
      • 2022/03/24 nocturia (several times at learly beginning and improved after SLEEP PILLS)
      • 2021/12/30 for report and improved hematuria now
      • 2021/12/20 gross hematuria with blood and visited ER
      • 2021/12/02 urinary burning sensation
      • low abd discomfort on foley at ER, no AUR?
      • hematuria now
      • nocturia 4-5 with voiding difficulty for a while
      • BPH on med at Cathay H and Sutien for 1 year
      • BIH s/p op 10 years ago here
    • Diagnosis:
      • Benign prostatic hyperplasia

[consultation]

  • 2021-11-17 Urology
    • Q
      • for acute urine retension with hematuria
      • He was admitted due to # CAD s/p Robotic CABG x1 on 2021/11/12. Suddent AUR s/p foley insertion. We need your help for further care.
      • Hx of enlarged prostate with lower urinary tract symptoms status post transurethral resection of the prostate on 2020/07/29
    • A
      • This 80yo male received CABG on 2021-11-12.
        • Aspirin +
        • AUR was noted this morning and a 18 Fr. 2-way Foley was inserted.
        • Gross hematuria was noted after Foley. Blood clots (+)
        • active ozzing now (+), manual irrigation: some littile blodd clots
      • Plan:
        • continuous irrigation
        • if Foley obstructed, then consider manual irrigation and 22 Fr. 3-way Foley
  • 2021-10-24 Cardiology
    • Q
      • Suspected cardiac chest pain/chest discomfort with cold sweats
        • noted since 9AM today, lasting for around half an hour
        • feeling better now
        • chronic cough also noted
        • no fever
        • deny chest/abdomen/back pain
        • 2021/09/23 2nd dose Moderna
      • PH: HTN; BPH s/p op ; chronic insomnia
      • NKA
    • A
      • SUFFERED from PSVT a few months before.
        • This time, came for different symptom and chest tightnes spontaneous resolved
        • At ER, his ECG showed sinus rhythm and gradual trop-I elevation noted.
        • Bedside echo: normal LV wall motion
      • Suggestion:
        • could be and not excluded NSTEMI
        • recommended empirical DAPT (Aspirin / Plavix) and Q8H trop-I follow up

[immunochemotherapy]

  • 2023-07-03 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-29 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-05-02 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-04-06 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-03-13 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2023-02-20 - rituximab 375mg/m2 694mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1390mg NS 250mL 30min D2 + liposome doxorubicin 30mg/m2 55mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-mCHOP)
    • acetaminophen 500mg PO D1 + dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2
  • 2022-08-04 - mitomycin-C 30mg/m2 30mg BI 1hr

==========

2023-07-31

On 2023-06-10, our urologist wrote a 3-time refill prescription (valid for 84 days) for Harnalidge (tamsulosin) and Betmiga (mirabegron). Additionally, on 2023-06-12, our cardiac surgeon issued a 3-time repeat prescription (also valid for 84 days) for Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin). These medications have been included in the active medication list, and no reconciliation issues have been identified.

2023-07-03

In accordance with the PharmaCloud database, this patient has only been a patient of our hospital for the last 3 months. In addition to our hemato-oncology department, our urologist prescribed Harnalidge (tamsulosin) and Betmiga (mirabegron) on 2023-06-10. In addition, our cardiac surgeon prescribed Blopress (candesartan), Bokey (aspirin), Concor (bisoprolol), Eurodin (estazolam), and Crestor (rosuvastatin) on 2023-06-12. These medications have been accurately added to the list of active medications and no discrepancies have been identified in the reconciliation.

700061972

230728

[exam findings]

  • 2023-07-17 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-06-23 Patho - oral cancer (wide excision + lymph node)
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left tongue, wide excision — Squamous cell carcinoma
      • Resection margins — Free of tumor invasion
        • Deep margin, left, frozen section (F2023-00293) — Free of tumor invasion
      • Lymph nodes
        • Lymph node, bilateral level Ia, dissection — Free of tumor metastasis (0/6)
        • Lymph node, left level Ib, ditto — Free of tumor metastasis (0/1)
        • Lymph node, left level III, ditto — Free of tumor metastasis (0/3)
        • Lymph node, left level IIa+III, ditto — Free of tumor metastasis (0/3)
      • Salivary gland, left level Ib — Free of tumor invasion
      • AJCC Pathologic staging — pT3N0, if cM0, stage III
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: tongue
        • Other part(s) included: N/A
        • Lymph node dissection: Yes
      • Specimen Integrity: Intact
      • Specimen Size: 5 x 3.9 x 2.3 cm
      • Tumor Site: left tongue
      • Tumor Focality: solitary
      • Tumor Size: 2.2 x 2.1 cm
        • Tumor thickness: 1.3 cm
      • Mucosal Surface: elevated tumor
      • Gross Tumor Extension (specify) : 1.3 cm in depth
      • Salivary gland at level Ib: 3.7 x 2.8 x 1.7 cm
      • Representative sections as follows: A: bilateral level Ia LN, B1: left level Ib LN, B2: salivary gland at level Ib, C:left level III LN, D: left level IIa+III LN, E1, E3 and E5: tumor + anterior margin + base, E2, E4 and E6: tumor + posterior margin, E7: tumor + medial margin, E8:-E10: tumor + lateral margin [Reference: Frozen section: F2023-00293FS left deep margin, one small piece of muscle tissue measured 1.1 x 0.9 x 0.3 cm in size]
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2, moderately differentiated
      • Microscopic Tumor Extension: 1.3 cm in depth
      • Margins: Free, 0.6 cm from base, 0.7 cm from anterior, 2.0 cm from posterior, 0.5 cm from medial and 0.4 cm from lateral margin
      • Lymph-Vascular Space Invasion: Not identified
      • Perineural Invasion: Present
      • Neck Lymph Nodes: free of tumor metastasis (0/13) in total number
  • 2023-06-21 ECG
    • Sinus rhythm with 1st degree A-V block
    • Inferior infarct, age undetermined
    • Poor wave progression
    • Abnormal ECG
  • 2023-06-12 Nasopharyngoscopy
    • smooth NPx, OPx, HPx
    • fair inf. turbinate, with clear mucus
    • 3 cm protruding mass with ulcer over left posterior tongue, with suture
  • 2023-05-26 Tc-99m MDP bone scan
    • Mildly increased activity in the middle C-spine and lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips, right knee and right foot, compatible with benign joint lesions.
  • 2023-05-24 Patho - tongue biopsy
    • Labeled as “left dorsal tongue”, incisional biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-05-23 MRI - nasopharynx
    • Findings: Left dorsal ventral tongue tumor mass, extending to right, up to 31mm, seems with extrinsic muscle invasion (likely the styloglossus).
    • IMP: Left tongue CA, T4aN0M0 stage IVA.
    • Oralcavity - Impression (Imaging stage) : T:4A N:0 M:0 STAGE:IVA

[MedRec]

  • 2023-06-21 ~ 2023-07-11 POMR Ear Nose Throat
    • Course of inpatient treatment
      • ENT ward 6/21-23
        • After admission, pre-operative evaluation was done. We also consulted plastic surgeon for free flap reconstruction. Operation was perforemed on 6/23, and he was tranferred to intensive care unit after operation.
      • ICU 6/23-24
        • During SICU, under Pain control with Fentanyl titration, Tracheostoym with ventilator support. After when patient conscious recover to clear, try weaning ventilator to T-mask use it well. Today, try on EN feeding with NG diet 1000 kcal/day, due to stable hemodynamic condition and pulmonary condition, we arrange transfer this patietn to ENT ward for care.
      • ENT ward 6/24-7/11
        • We removed foley catheter and femoral CVC smoothly on 6/27, and shifted antibiotics from Cefmetazole IVD to Cefaclor PO from 6/30. We removed JP drain and shifted tracheostomy from low pressure to shiley on 7/03, and removed suture over left neck surgical wound on 7/04. Under stable condition, he will be discharged on 7/10, and outpatient depatment following up will be arranged then.
    • Discharge prescription
      • Biomycin Ointment (neomycin, tyrothricin) QD TOPI
      • Parmason Gargle Solution (chlorhexidine) TID GAR
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# PRNQ6H
      • Through (sennoside 12mg) 2# HS
      • MgO 250mg 1# Q6H
      • Cero (cefaclor monohydrate 250mg) 2# Q8H
  • 2023-05-22 ~ 2023-05-27 POMR Oral and Maxillofacial Surgery
    • Discharge diagnosis
      • squamous cell carcinoma of the left posterior tongue (near lingual tonsil) (cT4aN0M0, MRI images)
      • infection of the tongue
      • Old cerebrovascular accident with left hemiparesis
      • Parkinson’s disease
      • Hypertensive heart disease without heart failure
      • Enlarged prostate with lower urinary tract symptoms
      • Paroxysmal atrial fibrillation
      • Primary insomnia
      • Unspecified kidney failure
      • Parenchymal liver disease
      • Splenomegaly
      • Gout, unspecified
    • CC
      • I had A painful red lump at my left tongue for few weeks.
    • Present illness
      • According to his statement, this 56-year-old male patient had history of the left tongue cancer after operation and oral chemotherapy for 20+ years in ShinKong Hospital. He did not go to ShinKong Hospital for regular opd follow-up. lately, he noted a mass lesion at his left tongue for few weeks. He visited to our Oral and Maxillofacial Surgery clinic on 2023/05/16, where an ulcerative, red malignant lesion at the left posterior tongue (near lingual tonsil) was noted. His panoramic film showed no bone destruction by tumor but periodontal bone loss. Because a malignancy tongue lesion was highly suspected, we had to do a biopsy for him. Unfortunately, trismus and posterior location of this malignant lesion were noted. After we explained his treatment plans to the patinet, he was admitted for tumor survey and further surgical management.
    • Course of inpatient treatment
      • During the hospitalized time, he underwent nasopharynx MRI examinaton on 05/23, which shows tumor size over 4cm with DOI over 10mm. No regional nodal metastasis was noted. Then the biopsy of left tongue under general anesthesia was performed on 2023/05/24. Empirical antibiotic agent with cefazolin were prescribed. Along with algesic agent for surgical wound pain control. Mouth care and mouth gargling with Parmason solution Q3H and PRN was educated.
      • Because his general condition was acceptable after the operation. After his abdomen sona on 05/25 and whole body bone scan on 05/26 were done and showed no tumor metastasis. He was discharged on 2023/05/26.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ4H
  • 2023-05-18 SOAP Urology
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
    • Prescription
      • Anxiedin (lorazepam 0.5mg) 1# HS
      • Doxaben XL (doxazosin 4mg) 1# QD
      • Betmiga (mirabegron 50mg) 1# QD
    • ChatGPT
      • Doxazosin and Mirabegron can be coadministered in the management of urinary symptoms, particularly in the context of conditions like benign prostatic hyperplasia (BPH) and overactive bladder (OAB).
      • Doxazosin is an alpha-1 adrenergic receptor blocker used to relax the smooth muscles of the prostate and bladder neck, which can improve urine flow and decrease symptoms of BPH. It can also be used in hypertension as it relaxes blood vessels.
      • Mirabegron is a beta-3 adrenergic receptor agonist used to treat overactive bladder (OAB) symptoms. It works by relaxing the detrusor muscle during the storage phase of the bladder fill-void cycle, leading to increased bladder capacity.
  • 2019-07-25 SOAP Urology
    • Prescription
      • Doxaben XL (doxazosin 4mg) 1# QD
  • 2019-06-17 SOAP Urology
    • Diagnosis
      • Enlarged prostate with lower urinary tract symptoms [N40.1]
    • Prescription
      • Harnalidge (tamsulosin 0.4mg) 1# HS
  • 2019-05-25 SOAP Orthopedics
    • Prescription x3
      • Arcoxia (etoricoxib 60mg) 1# QD
  • 2019-04-22 SOAP Orthopedics
    • S: left toe pain during walking
    • O: mild swelling and ecchymosis, imflammatory sign+
    • Prescription
      • Celebrex (celecoxib 200mg) 1# QD
      • colchicine 0.5mg 1# QD
  • 2017-10-24 SOAP Neurology
    • Diagnosis
      • Nontraumatic intracerebral hemorrhage in hemisphere, subcortical [I61.0]
      • Parkinsonism [G21.4]
    • Prescription x3
      • Madopar (levodopa, benserazide; 250mg) 0.5# QID
  • 2017-01-18 SOAP Cardiology
    • Diagnosis
      • HCVD, unspecified, without CHF [I11.9]
      • Unspecified late effect of cerebrovascular disease [I69.90]
      • Peristent disorder of initiating or maintaining sleep [F51.01]
      • Gout, unspecified [M10.9]
      • Mixed hyperlipidemia [E78.2]
    • Prescription x3
      • Modipanol (flunitrazepam 1mg) 1# HS
      • Ancogen (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNBID
      • Through (sennosides 12mg) 2# HS
      • Bokey (aspirin 100mg) 1# QD
      • Pitator (pitavastatin 2mg) 1# QN
      • Blopress (candesartan 8mg) 1# QD
      • Euricon (benzbromarone 50mg) 1# QD
      • Adalatoros (nifedipine 30mg) 1# QD

[consultation]

  • 2023-07-07 Oral and Maxillofacial Surgery
    • A
      • we are consulted prior to postoperative radiotherapy
      • poorly-fitted bridge of right lower tooth was pulled out along with previous cancer ablation surgery.
      • the rest of the dentition was in acceptable condition

[surgical operation]

  • 2023-06-23
    • Surgery
      • resurface of mucosal defect of left oral base with tongue flap
    • Finding
      • missing at least left 3/5 of the tongue and most of its inner muscles
      • 9cm X 5cm mucosal defect over left oral base and tongue base
      • Although free flap was palnned, the tongue flap was thought to be OK to fill the intra-oral defect; so the remaining part of the tongue after cancer ablasion was used to form a flap.
      • a 10F JP drain was placed over left-anterior neck fro post operative drainage
    • Procedure
      • after cancer ablasion, re-drape the patient
      • design, elevation, and transposition of the flap
      • suture inset of the flap
      • placement of the JP drain
      • closure and dressing of the wound of the neck
  • 2023-06-23
    • Surgery
      • Composite resection of oral cancer, left
      • Glossectomy, near-total
      • Selective neck dissection, left (level Ia, Ib, IIa, III)
      • Tracheotomy
    • Finding
      • MRI = tongue cancer, left, cT4aN0
      • floor-of-mouth in communication with neck, left posterolateral (mylohoid and digastric muscle were meticulously preserved since no gross invasion of cancer could be identified)
      • left lingual nerve, CN 12, sacrifice
      • left lingual artery ligated
      • right lingual artery ligated
      • frozen section (deep margin)= free from tumor
      • carotid bifurcation, IJV, superior thyroid artery exposed after dissection
      • enlarged LN over L level IIa
      • poor oral hygiene with caries (foul smell), yet all the teeth were not loose
  • 2023-05-24
    • Surgery
      • Soft tissue biopsy (92067C * 1)
      • Complicated tooth extraction of #47 (92014C * 1)
      • Removal of casting crown of #45 (90007C * 1)
    • Finding
      • An ulcerative malignant-like lesion on the left posterior tongue
      • Underbridge deep caries of #47

==========

2023-07-28

[reconciliation]

Our hospital is the only medical provider for this patient according to the PharmaCloud database, no medication reconciliation issues identified.

[tube feeding]

Betmiga (mirabegron) is a long acting formulation, it is not recommended to crush or halve for tube feeding. As the effect of mirabegron 50mg is approximately equivalent to that of propiverine 30mg, it is recommended to switch to Urotrol (propiverine 15mg), 1# BID for tube feeding. Doxaben XL (doxazosin) is a sustained-release formulation. It is suggested to consider switching to Urief (silodosin) as an alternative to Doxaben.

700062834

230728

[diagnosis] - 2023-04-06 admission note

  • Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17
  • Insomnia, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Hypothyroidism, unspecified

[past history]

  • Hypothyroidism history without drug control
  • DM(-), HTN(-)   

[allergy]

  • NKDA     

[family history]

There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-07-06 CT - chest
    • Indication: Double hit, diffuse large B cell lymphoma, non-germinal center type with right oropharynx involving and mediastinal lymphadenopathy, stage II, Lugano stage II, IPI score:2 s/p chemotherapy with R-CHOP from 2023/03/17~
    • Chest CT with and without IV contrast ehnancement shows:
      • Lower neck :
        • Regression of the lymphadenopathy at right neck is found.
        • Patent airway is found.
      • Chest:
        • Small lymph nodes are found at paratracheal region. In comparison with CT dated on 2023-03-10, the lesions are stationary.
        • The lung fields are clear.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Non-specific bowel gas at abdominal cavity is found.
    • Imp:
      • Marked regression of right neck lymphadenopathy.
      • No residual lymphadenopathy at right neck is found.
      • Small lymph nodes at mediastinum. Stable.
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 32) / 110 = 70.91%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Normal LV filling pressure.
      • Normal LV and RV systolic function
      • Mild aortic valve sclerosis; trivial MR
  • 2023-03-15 CXR
    • Spondylosis of the T-spine
  • 2023-03-14 PET scan
    • The FDG PET findings are compatible with lymphoma involving the right nasopharynx, soft palate, right oropharynx and in a large confluent area with some small adjacent focal areas in the right parotid region and right neck level II to V regions.
    • Mildly increased FDG uptake in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-03-10 CT - chest
    • oropharyngeal lymphoma, for cancer work up
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Visible neck
        • Huge necrotic soft tissue mass at right neck with extension into oral cavity measuring 10.3cm is found.
      • Chest:
        • Mild centrilobular Emphysematous change over both lungs is found.
        • Lymphadenopathy at bilateral paratracheal and AP window is found.
          • ChatGPT: AP window in CXR stands for “anterior-posterior window”, which is an area seen on the front to back view of a chest X-ray. It refers to the space between the aortic arch and the left pulmonary artery, which can be obscured by structures such as the trachea or mediastinal lymph nodes. Abnormalities in the AP window can indicate the presence of tumors, enlarged lymph nodes or other pathologies.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • No evidence of abnormal soft tissue mass at pelvic cavity.
        • No definite inguinal or pelvic sidewall LAP
        • Suggest clinical correlation
    • Imp:
      • Extensive right neck mass with mediastinal lymphadenopathy.
      • Mild COPD.
  • 2023-03-09 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • IHC stains: CD3 <5% and CD20: <5% and no predoimnant subpopulation. (of the nucleated cells).
  • 2023-03-09 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-01 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “right oropharynx”, biopsy — B cell lymphoma.
    • Section shows soft tissue with diffuse infiltration of paternless round blue neoplastic cells.
    • IHC stains: CK (-), CD3 and CD20: a predominant B cell sub-population. Bcl-2 (+), bcl-6 (+, >30%), MUM-1 (+, >30%), c-myc (-), CD10(-), Ki-67: 90%, cyclin-D1 (-), CD23 (-), a pattern of diffuse large B cell lymphoma, non-germinal center type.
  • 2023-02-27 Nasopharyngoscopy
    • Findings
      • smooth NPx; boggy inf. turbinate with clear mucus
      • smooth bulging over right lateral pharyngeal wall; granular tumor at right soft palate, right anterior and posterior
      • pillar, right tonsillar fossa; biopsy from right tonsilar fossa done; right RMT smooth bulging
    • Diagnosis/Conclusion
      • right oropharyngeal tumor, favor malignancy, biopsy done

[consultation]

  • 2023-03-10 Hemato-Oncology
    • Q
      • for transferred for lymphoma evaluation
      • This is a 57-year-old man with past history of hypothyroidism.
      • This time, he was admitted to our ward for right neck mass and right oropharyngeal tumor. Pathology report for oropharyngeal lesion revealed B cell lymphoma. We need your expertise for further examination suggestion and possible taking over.
    • A
      • This 57 year old man is a case of B cell lymphoma, pending IHC stain. Initial presentation was progressive painless right neck mass for 2 months, accompanying with right side otalgia and lumping throat. He has underline of hypothyroidism under levothyroxine treatment. We are consulted for lymphoma treatment.
      • Please arrange PET CT scan, CT scan of neck extending chest, abdomen to pelvis and bone marrow for complete staging. Transfer to 11A on Dr Xia service.

[chemoimmunotherapy]

  • 2023-07-27 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-07-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-06-09 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-05-08 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-04-07 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3
  • 2023-03-17 - rituximab 375mg/m2 550mg NS 500mL 12hr + cyclophosphamide 750mg/m2 1100mg NS 250mL 30min + doxorubicin 50mg/m2 75mg NS 50mL 30min + vincristine 1.4mg/m2 2mg NS 50mL 10min + prednisolone 60mg/m2 45mg BID PO D1-5 (R-CHOP)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + acetaminophen 500mg PO + NS 250mL + aprepitant D1-3

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hemato-oncology department in the last 3 months. As a result, no medication reconciliation issues are identified for this admission.

2023-06-09

  • A leucopenia episode occurred on 2023-05-18, just ten days following the initiation of the 3rd cycle of the R-CHOP regimen on 2023-05-08. The patient was treated with Granocyte (lenograstim 250ug) for 3 consecutive days starting on 2023-05-18. Since then, no further instances of leucopenia have been detected.
    • 2023-06-09 WBC 5.23 x10^3/uL
    • 2023-05-25 WBC 7.25 x10^3/uL
    • 2023-05-18 WBC 1.33 x10^3/uL
    • 2023-05-08 WBC 5.66 x10^3/uL
    • 2023-04-25 WBC 9.45 x10^3/uL
    • 2023-04-20 WBC 5.48 x10^3/uL
  • The risk of febrile neutropenia with R-CHOP regimen is 10 to 20%; primary prophylaxis with hematopoietic growth factors might be considered on an individual basis, particularly for high-risk patients such as those with preexisting neutropenia, advanced disease, poor performance status, or patients age 65 years or older.

2023-04-10

  • Leucopenia was observed on 2023-03-28, the 11th day since the start of the first R-CHOP regimen on 2023-03-17. Granocyte (lenograstim) was administered for 3 consecutive days starting on the observed day. The patient’s WBC count should be closely monitored 1 to 2 weeks after the start of the second dose, which was administered on 2023-04-07.
    • 2023-04-06 WBC 12.36 x10^3/uL
    • 2023-03-28 WBC 1.09 x10^3/uL
    • 2023-03-20 WBC 7.21 x10^3/uL
    • 2023-03-18 WBC 6.23 x10^3/uL
    • 2023-03-16 WBC 9.96 x10^3/uL
    • 2023-03-13 WBC 10.03 x10^3/uL
    • 2023-03-08 WBC 10.82 x10^3/uL
  • Rapid weight loss
    • The patient has recently experienced rapid weight loss, from 50.6 kg on 2023-03-09 to 46.3 kg on 2023-04-06. To address this issue, it is recommended that the patient’s nutritional intake be increased. If there is no dysphagia, megestrol can be used as an appetite stimulant at a dose of 200 to 600 mg/day to alleviate anorexia.
  • Constipation
    • Based on the TPR panel indicating no bowel movement for three consecutive days (2023-04-06 to 2023-04-08), it is recommended to rule out the possibility of ileus.
    • For functional constipation or fecal impaction
      • Suppositories:
        • For treatment of defecatory dysfunction, we favor an initial trial of suppositories (glycerin or bisacodyl) since suppositories can be effective in liquifying stool and thereby overcoming obstructive defecation.
      • Disimpaction:
        • Patients with a fecal impaction (a solid immobile bulk of stool in the rectum) should initially be disimpacted starting with manual fragmentation if necessary. After this is accomplished, an enema with mineral oil will help to soften the stool and provide lubrication.
        • If disimpaction is unsuccessful or only partially successful, we may order a water-soluble contrast enema (Gastrografin or Hypaque) administered under fluoroscopy to assure absence of any obstruction and to eliminate more proximal impactions. Occasionally, fractionation of impacted stool beyond the reach of the finger must be accomplished using flexible or rigid sigmoidoscopy with instrumentation. The colon must then be thoroughly evacuated. This can be accomplished with daily warm water enemas for up to three days, or by drinking a balanced electrolyte solution containing polyethylene glycol (PEG) until cleansing is complete.

700601390

230728

[exam findings]

  • 2023-05-19 CT - abdomen
    • 20230313 ATH + BSO + omentectomy + BPLND + vaginectomy.
      • PATHOLOGIC DIAGNOSIS
        • Ovary, left: Endometroid carcinoma, FIGO grade 3
        • Endometrium, uterus: Endometroid carcinoma, FIGO grade 2
        • Lymph nodes, pelvic and para-aortic: Negative for malignancy (0/78)
        • Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
    • Findings:
      • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
      • There is mild fatty stranding of the mesentery at the pelvis.
      • S/P hysterectomy
      • S/P catheter insertion from right upper pelvic wall and the tip located at the dependent portion of the lower pelvis for HIPAC. please correlate with clinical history.
    • Impression:
      • There are three kissing cystic lesions in left lateral pelvis and one cystic lesion in right lateral pelvis that may be lymphocele.
      • There is mild fatty stranding of the mesentery at the pelvis.
      • Follow up is indicated.
  • 2023-03-14 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, staging surgery — Endometroid carcinoma, FIGO grade 3
      • Endometrium, uterus, staging surgery — Endometroid carcinoma, FIGO grade 2
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/78)
      • AJCC 8 th edition, Pathology stage: pT1c2N0; stage IC (ovary); and stage IA (endometrium)
    • MACROSCOPIC EXAMINATION
      • Procedure: ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy
      • Specimen Size: 7.5 x 4.6 x 2.4 cm (Lt ovary, received for frozen section), 5.5 x 0.6 cm (Lt tube), 3.2 x 2.5 x 2.2 cm (Rt ovary), 6.0 x 0.9 cm (Rt tube), 12.0 x 8.0 x 5.0 cm (uterus), 6.0 x 4.0 x 3.0 cm (vagina), 28 x 12 x 3.0 cm (omentum)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Capsule not intact
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary and endometrium
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: 7.5 x 4.6 x 2.4 cm (Lt ovary), diffuse thickening, up to 0.9 cm in thickness (endometrium)
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, right para-aortic and left para-aortic
      • Representative parts are taken for section and labeled as: F2023-00098FS and A2-A5= left ovary, A1= left fallopian tube. S2023-04575 A= left iliac LNs, B1-B2= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1-G6= cervix, G7-G12= endocervix, G12-G27= uterine endometrium, G20= corpus, G29= right ovary, G30= right fallopian tube, H1-H4= vagina, I1-I2= omentum.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Synchronous endometroid carcinoma of ovary and endometrium
      • Histologic grade: Grade 3 (ovary) and grade 2 (endometrium)
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Negative
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells (0/78)
      • Pathologic Stage
        • Primary Tumor: pT1c2 (ovary, tumor ruptured) and pT1a (endometrium, tumor limit to endometrium)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IC (ovary) and Stage IA (endometrium)
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with Nabothian cysts and squamous metaplasia
        • Endometrium: Endometroid carcinoma
        • Myometrium: Leiomyoma
        • Ovary, right: Compatible with steroid cell tumor NOS (1.0 x 0.5 cm)
        • Fallopian tubes, bilateral: No remarkable change
        • Vagina: Chronic vaginitis
        • Omentum: No remarkable chang
      • IHC for ovarian tumor: ER(+), PR(+), WT1(-), Napsin A(-), p53 (aberrant exprssion)
  • 2023-03-13 Patho - stomach biopsy
    • Stomach, GC/AW site of low body (A), biopsy — Hyperplastic polyp
    • Labeled as “esophagus, 30cm below the insicor”, s/p biopsy(B) — papilloma
  • 2023-03-09 MRI - pelvis
    • Clinical history: 41 y/o female patient with Uterus, cervix, polypectomy — Adenocarcinoma.
    • With and without contrast enhancement MRI: Pelvis
      • There is cystic tumor, 6cm in left adnexa, with internal soft tissue, r/o left ovarian malignancy.
      • Diffuse endometrial thickening, hyperplasia or malignancy?
      • Focal tubular lesion in the endocervical region, protrusion from uterine body.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
      • Nodularity at peritoneum, r/o carcinomatosis.
    • Impression:
      • Left ovarian cystic tumor, r/o ovarian malignancy.
      • Nodularity at peritoneum, r/o carcinomatosis.
      • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study.
      • Focal tubular lesion in the endocervical region, protrusion from uterine body. Nature?
      • Ascites.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T: T1a_(T_value) N: N0(N_value) M:M0(M_value) STAGE:IA__(Stage_value)
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic____(Stage_value)
  • 2023-03-08 PET
    • Increased FDG uptake in the left ovary, highly suspected the primary ovarian cancer, suggesting biopsy for further investigation.
    • Increased FDG uptake in the uterus, compatible with the pathological findings of adenocarcinoma of uterus.
    • Increased FDG uptake in the in the posterior wall of upper hypopharynx, probably chronic inflammation process or other nature. Please also correlate with other clinical findings for further evaluation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Left ovarian cancer, cTxN0M0, by this F-18 FDG PET scan.
  • 2023-03-06 CT - abdomen
    • Clinical history: 41 y/o female patient with Polyp of cervix uteri
    • With and without contrast enhancement CT of abdomen - whole:
      • There is cystic tumor, 5.7cm in left adnexa, with internal hyperdensity and septum, r/o left ovarian malignancy. DDx: endometrioma.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites. Mild nodularity and loculated ascites in left upper abdomen. Reative or carcinomatosis?
    • If proven ovarian malignancy:
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1c(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ic (Stage_value)
  • 2023-03-02 Patho - cervix/endometrial polyp
    • Uterus, cervix, polypectomy — Adenocarcinoma
      • NOTE: Please check endometrium or ovary for the possibility of tumor origin.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with invasive growth pattern and areas of necrosis. The tumor cells display hyperchromatic nuclei, pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • Immunohistochemical stain reveals vimentin (+), p53: abberrant-type (strong diffuse positive, 90%), ER: positive (moderate, 90%), P40(-), p16 ( patchy strong focal+, 30%).
  • 2023-03-01 Gynecologic ultrasonography
    • Cul-De-Sac: with fluid
    • LT: fluid
    • IMP: Suspected Lt Ovarian mass (47 x 32 mm)

[SOAP]

  • 2023-03-28 Hemato-Oncology
    • Arrange admission for 24 hours CCr, audiometry, Chest CT, then IP C/T and systemic C/T

[surgical operation]

  • 2023-03-13
    • Operation
      • Excision of intraabdominal malignant tumor, omentectomy
      • Tenckhoff tube insertion
    • Finding
      • Moderate ascites with positive cytology
      • Tenckhoff tube: over RLQ
  • 2023-03-13
    • Surgery
      • Diagnosis:
        • Left ovarian tumor, r/o malignancy.
        • Pelvis MRI on 2023/03/09 showed:
          • Left ovarian cystic tumor, r/o ovarian malignancy.
          • Nodularity at peritoneum, r/o carcinomatosis.
          • Diffuse endometrial thickening, hyperplasia or malignancy, suggest further study..
          • Focal tubular lesion in the endocervical region, protrusion from uterine body.
          • Ascites.
    • Operation:
      • Debulking surgery (ATH + BSO + BPLND + paraaortic lymphadectomy + infracolic omentectomy + vaginectomy)
    • Frozen:
      • Left ovary with malignancy.
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size,
      • Adnexa:
        • LOV: 6x5x3 cm , capsule not intact with mass protruding out
        • ROV: 3x2x2 cm , capsule intact , smooth surface.
        • Fallopian tube: bilateral grossly normal
      • CDS: ascites+
      • Ascites: yellowish and clear , about 550 ml
      • Bilateral pelvic and paraaortic lymph nodes: normal(+), enlarged(+), indurated(-)
      • Omentum: grossly normal, no variablesized nodules, infracolic omentectomy was done by GS surgeon.
      • Liver: grossly normal & smooth
        • Subdiaphragmatic surface: miliary tumorseeding(-).
      • Appendix: grosslt normal.
      • After the operation, Optimal debulking surgery was achieved.
      • Residue tumor: R0
      • Estimated blood loss: 200 ml
      • Blood transfusion: nil
      • Complication: nil

[chemotherapy]

  • 2023-07-27 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-07-07 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-13 - paclitaxel 175mg/m2 240mg D5W 250mL 3hr + cisplatin 75mg/m2 110mg NS 500mL 24hr + NS 1000mL 24hr (Y-sited cisplatin)
    • dexamethasone 4mg + diphenhydramine 50mg + palonosetron 250ug + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-25 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2
  • 2023-04-11 - paclitaxel 60mg/m2 90mg NS 250mL 1hr (previous D8)
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL
  • 2023-04-05 - paclitaxel 135mg/m2 200mg NS 250mL 24hr D1 + cisplatin 75mg/m2 110mg NS 500mL IP 1hr D2
    • [dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL] D1 + [palonosetron 250ug + aprepitant 125mg PO + NS 250mL] D2

==========

2023-07-28

Based on the PharmaCloud database, we see that the patient has only visited our hospital. No medication reconciliation issues are identified for this admission after reviewing HIS5 records..

On 2023-07-26, the serum magnesium level was measured at 1.5mg/dL, indicating a low value. As a result, it is advised to add magnesium supplementation for the patient.

2023-04-06

  • This patient, who is a nurse on our staff, was diagnosed with endometroid carcinoma pathology stage pT1c2N0 stage IC (ovary) and stage IA (endometrium). She underwent surgical operation ATH + BSO + infracolic omentectomy + BPLND + para-aortic LN dissection + vaginectomy on 2023-03-13. Currently, she has been admitted for her first cycle of chemotherapy, which includes paclitaxel 135mg/m2 200mg IV on day 1 (yesterday) and cisplatin 75mg/m2 110mg IP on day 2 (today).
  • As of the latest lab data on 2023-04-04, her values are grossly normal except for elevated D-dimer (3137ng/mL FEU) and U-Cr 24hr (1185mg/kg/24hr), which do not contraindicate the planned chemotherapy.
  • To date, there have been no apparent side effects from the patient’s chemotherapy according to the nursing notes.

700415083

230727

[exam findings]

  • 2023-07-04 SONO - abdomen
    • Findings
      • Liver: Fine echotexture. Several hyperechoic lesions up to 9.6 cm in GB. A 1.2 cm anechoic lesion at S8
      • Portal vein: Echogenic lesion in right portal vein.
      • Pancreas: Part of head and part of tail masked
      • Others: Bilateral plerual effusion was noted
    • Diagnosis:
      • Hepatoma with right portal vein thrombosis
      • Pleural effusion, bilateral
  • 2023-07-02 CT - abdomen
    • Indication: Epigatric pain and back pain since yesterday. Mild cold sweating. No N/V, no tarry stool, no fever, no cough, no sputum, no SOB, no chest pain, no dysuria
    • With and without contrast enhancement CT of abdomen shows:
      • Multiple HCCs, s/p TACE. Uneven surface and left lobe hypertrophy of liver, suggestive of liver cirrhosis. Patent portal vein.
      • Swelling of pancreas with fluid density in retroperitoneum.
    • Impression
      • HCCs, s/p TACE
      • Suspect acute pancreatitis, grade D. Suggest clinical correlation.
  • 2023-07-02 ER SONO
    • fluid collection in abdomen: mild over spleno-renal fossa
    • heterogenous mass over bilateral lobe of liver
  • 2023-06-30 CT - abdomen
    • history: Right HCC, cT4N0M0 stage IIIB, post TACE on 2023/03/21 and 1st immunotherapy and Target therapy (Tecentriq + Avastin) on 2023/03/23.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
      • There are multiple hyperdense lesions in both hepatic lobes that are c/w HCCs S/P TACE with lipiodol retention.
      • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
      • There is mild ascites.
    • Impression:
      • Multiple HCCs on both hepatic lobes show stable disease.
      • Tumor thrombosis in right superior segment portal vein.
  • 2023-06-13 Embolization (TAE) - abdomen for tumor
    • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • Hypervascular tumors at both hepatic lobes with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p right TACE.
  • 2023-05-22 Embolization (TAE) - abdomen for tumor
    • TACE of left HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • Hypervascular tumors at bil. hepatic lobes with multifeeders. TACE of left HCCs was performed using 10mg adriblastina plus 7 cc lipiodol via microcatheter. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p left TACE.
  • 2023-05-17 CT - abdomen
    • CC: LUQ pain and fever up to 38’C since last night
    • Past history:
      • right HCC, cT4N0M0 stage IIIB, post Transcatheter arterial chemoembolization on 2023/03/21 and 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23.
      • hepatitis B carrier with regular medication control with Entecavir since 2023/03/23.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes at portal venous phase images that are c/w multiple HCCs.
      • There are hyperdense lesions in the superior segment of right lobe liver that are c/w HCCs S/P TACE with lipiodol retention.
      • There is filling defect at right superior portal vein that is c/w tumor thrombosis.
      • There is mild ascites.
    • Impression:
      • Multiple HCCs on both hepatic lobes.
      • Tumor thrombosis in right superior segment portal vein.
  • 2023-03-23 Tc-99m MDP bone scan
    • Increased activity in the right aspect of mandible. Dental problem may show this picture. Please correlate with other clinical findings for further evaluation.
    • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right elbow, bilateral hips and knees, compatible with benign joint lesions.
  • 2023-03-23 Esophagogastroduodenoscopy, EGD
    • Gastric ulcers and erosions, antrum, s/p biopsy
    • Shallow duodenal ulcers, bulb
    • Superficial gastritis
  • 2023-03-21 Embolization (TAE) - abdomen for tumor
    • TACE of RIGHT HCCs via right common femoral artery puncture using Seldinger technique revealed:
      • Presence of liver cirrhosis.
      • The RH-catheter was inserted into distal branch of right hepatic artery.
      • Hypervascular tumors at both hepatic lobes (up to 10.6cm) with multifeeders. TACE was performed using 10mg adriblastina plus 10 cc lipiodol. Decreased the blood flow of the feeding arteries using some gelfoam pieces also performed.
    • IMP: Bil. HCCs s/p right TACE.

[MedRec]

  • 2023-07-20 SOAP Dermatology
    • S
      • severe itchy papules and plaques erupition over trunk after medication.
      • HBV carrier.
      • compesolon 0.5# initally up to 2# QD
    • O
      • urticaria/angioedema type
      • maculopapular type
      • urticaria-purpura type
      • erythema multiforme SJS/TEM
      • fixed drug eruption or AGEP rapid onset type
      • drug hypersensitivity syndrome as DRESS
      • lichenoid chronic progressive type
      • Suspect related medication: mopride. morbilliform drug eruption.
    • Plan:
      • education about drug side effec and explain
      • Strongly suggested OPD f/u
    • Prescription
      • Compesolon (prednisolone 5mg) 2# QD
      • Xyzal (levocetirizine 5mg) 1# BID
      • Asthan (ketotifen 1mg) 1# BID
      • Pilan (cyproheptadine 4mg) 1# HS
      • Topsym Cream (fluocinonide 0.05%) BID EXT
  • 2023-03-20 ~ 2023-03-25 POMR General and Gastroenterological Surgery
    • Discharge diagnosis
      • Hepatocellular carcinoma, cT4N0M0 stage IIIB, status post Transcatheter arterial chemoembolization on 2023/03/21; 1st immunotherapy and Target therapy with Tecentriq + Avastin on 2023/03/23. BCLC:B, ECOG:0
      • Carrier of viral hepatitis B
      • Gastric ulcer
      • Duodenal ulcer
    • CC
      • RUQ pain after chest contussion during work for 2 weeks since 1 month ago
    • Present illness
      • This 40 y/o male with past history of hepatitis B carrier without regular control. This time, he sufferred from RUQ pain after chest contussion during work for 2 weeks. The pain with aggravated if deep breathing, hiccup. He ever visited to CM OPD on 2023/02/14 for follow up and CXR with no evidence of rib fracture. Analgesic agent was given but in vain. However, sever right upper quadrant pain was noted on 2023/03/17 then he visited to ChangGung hospital for help. Abdomen CT was performed and showed multiple liver tumors at both lobes, the largest one > 10.2 cm in S7/8 encasing the right hepatic vein, firstly consider HCC (T4N0), DDx: liver metastasis from other primary cancer. Admission was sugested but patient refused. Due to persised of RUQ pain, he came to our ER for help. Pain control was given, GS was consuted who suggested TACE first. Under impressed of HCC, he was admitted to our ward for TACE management.
    • Course of inpatient treatment
      • After admission, we consulted Diagnostic Radiology for arranging TACE. The procedure was performed on 2023/03/21 uneventfully. He tolerated the treatment well. After bedrest for 8 hours, no significant oozing was found over TACE wound. He also decided to received immunotherapy+target therapy with tecentriq + Avastin after well discussion on 2023/03/23. The medication was applied and no significant discomfort was complained of. UGI scope was also performed before immunoteherapy which showed gastric and duodenal ulcer. We keep PPI with nexium treatment for GU. On the other side, HBV DNA showed 1090IU/mL, then Baraclude (self-pay) for HBV control since 2023/03/23. Under a relative stable condition, he was discharged and OPD will be arranged.
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC
      • Nexiuum (esomeprazole 40mg) 1# QDAC
      • Celebrex (celecoxib 200mg) 1# Q12H
      • Tramacet (tramadol 37.5mg, acetaminophen 325mg) 1# Q6H
      • Smecta (dioctahedral simeclite 3mg) 1# PRNTIDAC
      • loperamide 2mg 1# PRNQ12H
      • Naproxen (naproxen 250mg) 1# PRNQ12H
  • 2023-02-21 SOAP Chest Medicine
    • S/O: chest contussion during work for 2 weeks, aggravated if deep breathing, hiccup, no dyspnea, no cough,
    • A/P: s/s Tx, arrange CXR
    • Prescription
      • Gaslan (dimethylpolysiloxane 40mg) 1# TID
      • Keto (ketorolac 10mg) 1# Q6H
      • Algitab (alginic acid, MgCO3, Al(OH)3; 200mg) 1# Q6H

[immunochemotherapy]

  • 2023-06-14 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-21 - nivolumab 3mg/kg 160mg NS 100mL 1hr
    • none
  • 2023-03-23 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 500mg NS 100mL 1hr
    • none

==========

2023-07-27

[reconciliation]

Our dermatologist prescribed a 7-day course of Compesolon (prednisolone), Xyzal (levocetirizine), Asthan (ketotifen), Pilan (cyproheptadine), and Topsym Cream (fluocinonide) for the patient’s severe itchy papules and plaques eruption over the trunk on 2023-07-20. However, these drugs are not currently included in the list of active medications. It is advisable to check whether the skin symptoms have improved before continuing or adjusting the treatment plan.

701251392

230727

[lab data]

2023-07-19 HSV 1 IgM Negative NTU
2023-07-19 HSV 1 IgM Value 1.52 NTU
2023-07-19 HSV 2 IgM Negative NTU
2023-07-19 HSV 2 IgM Value 1.37 NTU
2023-07-19 HLA A-high 11:01
2023-07-19 HLA A-high 33:03
2023-07-19 HLA B-high 38:02
2023-07-19 HLA B-high 39:01
2023-07-19 HLA C-high 07:02
2023-07-19 HLA C-high -

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DQ-high 03:03
2023-07-19 HLA DQ-high 05:02

2023-07-19 HLA DRB1-high rsolution 2023-07-19 HLA DR-high 09:01
2023-07-19 HLA DR-high 14:54

[exam findings]

  • 2023-06-23 SONO - abdomen
    • Liver cyst, S6
    • Gallbladder adenomyomatosis
    • Gall stones
    • Renal stone, left kidney
    • Renal cyst, left kidney
  • 2023-05-26 Patho - spleen
    • Spleen, laparoscopic splenectomy — N/K T cell lymphoma.
    • Sections show multiple pieces of splenic tissue with prominent white pulps and markedly dilated congested sinuses.
    • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
  • 2023-05-25 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — residual N/K T cell lymphoma.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are rare minute lymphoid aggregates (< 1mm in sizes).
    • IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
  • 2023-05-23 PET
    • Glucose hypermetabolism in two focal areas in the spleen. The nature is to be determined (lymphoma? other nature?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right anterior upper chest wall and bilateral pulmonary hilar regions. Inflammatory process is more likely.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-05-17 CT - abdomen
    • CC: intermittent fever for 3 days, general malaise, mild dysuria, no cough, no SOB
    • History: Mature T/NK-cell lymphomas
    • Findings:
      • There is splenomegaly and the greatest cranial-caudal dimension measuring about 13 cm in size.
      • A hepatic cyst 1 cm in S5/6 is suspected. Please correlate with sonography.
      • The gallbladder shows small contracted with diffuse symmetrical mild wall thickening that may be adenomyomatosis?
        • In addition, three gallstones in the neck are noted.
      • Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
      • There is nodular osteopenic defect in left lateral aspect of L3 vertebral body with fat density. Lipoma is highly suspected. please correlate with clinical condition and MRI.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5. There is end plate sclerotic change of L3-4.
      • Transitional vertebra of L5-S1, left side.
    • Impression:
      • Splenomegaly is noted. please correlate with clinical condition.
      • Lipoma in left lateral aspect of L3 vertebral body is suspected. please correlate with clinical condition and MRI.
  • 2023-05-03, 2022-11-07 MRI - nasopharynx
    • IMP: No neck LAP, stationary.
  • 2022-03-08 MRI - nasopharynx
    • Swollen change of hypopharyngeal space with mucosal thickening.
    • The bilateral parotid and submandibular glands enhance as before. It is consistent with post-radiation inflammation.
  • 2021-11-16 MRI - nasopharynx
    • History of NK lymphoma of nasopharynx
    • IMP: small LNs in bil. level I-II spaces, stationary.
  • 2021-07-02 MRI - nasopharynx
    • Indication: History of nasal NK T cell lymphoma, post chemotherapy and RT. For evaluate tumor status.
    • Impression:
      • Edematous change of bilateral aryepiglottic folds.
      • Regression of the Waldeyer’s ring masses.
      • No enlarged cervical lymphadenopathy.
  • 2021-03-29 CT - neck
    • History of NK-T cell lymphoma over oropharynx with mediastinal LN metastases. Follow up lymphoma status
    • IMP: no neck LAP
  • 2021-02-18 Neck Soft Tissue
    • Disc space narrowing with marginal osteophyte formation of C3-4 and C4-5.
  • 2020-12-24 CT - chest
    • Imp:
      • Regression of mediastinal lymphadenopathy
      • Consolidation over B6 of left lower lobe, previous infection
      • Gallstones and GB polyp(?) Suggest correlate with sonography.
  • 2020-10-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (71.7 - 16.6) / 71.7 = 76.85%
      • M-mode (Teichholz) = 76.8
    • Conclusion:
      • Concentric LVH.
      • Normal RV & LV systolic function. No regional wall motion abnormalities.
      • Impaired LV relaxation.
      • Aortic valve sclerosis, with mild aortic regurgitation.
      • Mild mitral regurgitation.
      • Mild tricuspid regurgitation.
      • Mild pulmonic regurgitation.
      • Small pericardial effusion.
  • 2020-09-24 CT - chest
    • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
    • Small lymph nodes are found at bilateral pulmonary hilar and paratracheal region is found.
    • There is bilateral minimal pleural effusion.
    • Diffuse interstitial change at both lungs is found.
    • Splenomegaly is found.
    • There is stone at dependent portion of GB. GB stone(s) are noted. The GB wall is not thickening
  • 2020-09-22 CXR
    • Tortuosity of thoracic aorta with Atherosclerotic change of aortic arch and Cardiomegaly
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process. The differential diagnosis include pulmonary edema?
  • 2020-09-22 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy
    • Sections show 30-40 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-9/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells. The immunohistochemical stains of CD3, CD20, and CD56 show no infiltrative lymphoma.
  • 2020-09-21 PET
    • Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension.
    • Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation.
    • Lymphoma, c-stage IIE (Lugano classification), by this F-18-FDG PET/CT scan.
  • 2020-09-14 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “Post. oropharyngeal wall grnulation tissue, r/o killer cell lymphoma?”, biopsy — Lymphoma.
    • Section shows bland squamous mucosa lined tissue with marked necrotic and diffusely infiltration of atypical round blue cells.
    • IHC stains: CD56 (strong +), CD3 and CD20: equivocal; CD4 and CD8 : more CD4 than CD8. CK (equivocal, probalby background). Features compatible with N/K T cell lymphoma.
  • 2020-09-04 CT - neck
    • IMP: Lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. D/D: multiple malignancies, infectious processes.

[MedRec]

  • 2023-06-18 ~ 2023-07-01 POMR Hemato-Oncology
    • Discharge diagnosis
      • Mature T/NK-cell lymphomas, unspecified, extranodal and solid organ sites stage IV post chemotherapy with relapse over spleen and bone marrow post splenectomy
      • Urinary tract infection, site not specified
    • CC
      • fever and weakness since 2 days ago.
    • Present illness
      • This 64 year old female who denied any systemic disease. Neck CT on 2020/09/03 revealed lesions at right nasopharynx, left palatine tonsil and right pyriform sinus with bilateral lymph nodes. Nasopharyngoscopy local biopsy was done on 2020/09/14, the pathological report proved N/K T cell lymphoma. PET was performed on 2020/09/21 which revealed 1. Glucose hypermetabolism in nasopharyngeal wall, Waldeyer’s ring, and right piriform sinus, and bilateral cervical lymph nodes, compatible with lymphoma involving lymphatic sites on the same side of diaphragm with extralymphatic extension. 2. Some glucose-hypermetabolic lesions of ground-glass opacity in upper lobe of left lung and middle lobe of right lung, pulmonary infection/inflammation may show such a picture but malignancy cannot be excluded. Please keep follow up with imaging modalities and, if feasible, correlate with histopathological studies for further evaluation. 3. Lymphoma, c-stage IIE (Lugano classification). Bone marrow done on 2020-09-21 which revealed Negative for malignancy. Port-A insertion was done on 20200922. CT of chest on 20200924 which revealed small lymph nodes are found in the mediastinum. Diffuse interstitial change at both lungs. Gallstones. Bronchoscopy was performed on 20200925 for distal airway sampling to r/o TB, lymphoma with lung involvement, PJP infection, aspergillosus or other pathogen, PFT test to evaluate small airway dysfunction. RT was started from 2020/10/02 at 1000cGy/5 fractions (6MV photon) of the pharyngeal tumor, peripheral, to bilateral neck nodal area. PJP DNA was reported positive on 2020/10/05, thus Infection was consulted. They suggest Baktar 2# Q8H for PJP infection control and augmented with Cravit 750mg IV QD for two week.
      • Under the diagnosis of Right oropharyngeal N/K T cell lymphoma, stage IIE
      • Chemotherapy as weekly Cisplatin (30) x 3 weeks, then followed by VIPD x3 (every 3 weeks)
      • She received CCRT with Cisplatin since 2020/09 - 2020/11.
      • C1 VIPD on 2020/11/27 to C4 VIPD on 2021/02/18.
      • Followed MRI was performed on 2023/05/03 and report showed no neck LAP.
      • Bone marrow was done for pancytopenia on 2023/05/25.
      • Bone marrow pathoolgy (2023/05/25) showed residual N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
      • PET showed glucose hypermetabolism in two focal areas in the spleen. GS was consulted for pancytopenia and splenomegaly surgical intervention assessment.
      • Spleen, laparoscopic splenectomy pahtology (2023/05/26) showed: N/K T cell lymphoma. IHC stains: CD3 > CD20; CD4 > CD8; CD56 (+).
      • Due to impression of splenic lesions and splenomegaly with progressed pancytopenia and leukopenia. She received Pneumococcal Vaccine 13 and GCF on 2023/05/25. She received laparoscopic splenectomy on 2023/05/26, and was transferred to GS service care on 2023/05/26.
      • 2023-05-17 ABD CT: Two renal stone 1 cm and 0.8 cm in left lower pole are noted.
      • This time, she has fever with chills and limbs soreness for 2 days, so she was brought to our ED for help pn 2023/06/18 afternoon. She denied abdominal pain or dysuria condition, but sometimes has dry cough. At ED, the lab data showed normal WBC, CRP just 2. No evidence of UTI or pneumonia. Under the impression of fever suspect virus or tumor related, so she was admitted.
    • Course of inpatient treatment
      • After admission, antibiotic was given. Tapimycin (06/18- ) > Sintrix (06/19- ) > Doripemem (06/21- ). Sintrix changed to doripenem was based on U/C. N/S: 500 BID + nako no.5 500 QD were given for hydration. Panadol was given for fever control.
      • Lab data showed WBC: 6.9 (06/18) > 4.4 (06/23), CRP: 2.2 > 1.9 (06/23). Abd echo: no hydronephrosis, Hyperechoic lesion was noted in the left kidney Size 0.9 cm. Blood culture showed no growth on 06/24.
      • On 06/26, U/A showed WBC: 0 (06/26), RBC: 0 (06/26).
      • On 06/27, fever up to 37.8c. WBC showed 6.9 (06/18) > 4.4 (06/23) > 5k (06/27). PCT showed 0.07.
      • We changed to brosym on 06/28. Urine culture on 06/26 showed no growth.
      • Under stable condtion, she was discharged with OPD follow up.
    • Prescription
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 0.5# HS
      • Axcel (acyclovir) QD TOPI for buttock herpes zoster

[chemotherapy]

  • 2023-07-19 - L-asparaginase 6000unit/m2 9540unit IM 1min

  • 2023-07-10 - methotrexate 4600mg NS 250mL 24hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-02-18

  • 2021-01-14

  • 2020-12-21

  • 2020-11-27

  • 2020-11-13

  • 2020-10-06

  • 2020-09-29

==========

2023-07-31

[deterioration in liver function; acetaminophen, Stronger Neo Minophagen C Injection]

In recent days, the patient has shown a significant increase in bilirubin and liver enzymes. After reviewing the drugs listed in the active medication, entecavir, furosemide, and acetaminophen are found to be associated with these symptoms according to the medication database. Since the VAS (visual analogue scale) has been recorded as 0 since 2023-07-29, it might be worth considering discontinuing acetaminophen. Additionally, please note that the Stronger Neo Minophagen C Injection will expire by the morning of 2023-08-01. If it is still required, please extend its use accordingly.

2023-07-31 Bilirubin total 14.51 mg/dL ** 2023-07-27 Bilirubin total 2.44 mg/dL *
2023-07-26 Bilirubin total 1.02 mg/dL
2023-07-24 Bilirubin total 0.70 mg/dL
2023-07-21 Bilirubin total 0.49 mg/dL
2023-07-19 Bilirubin total 0.51 mg/dL
2023-07-17 Bilirubin total 0.52 mg/dL
2023-07-15 Bilirubin total 0.59 mg/dL
2023-07-14 Bilirubin total 0.68 mg/dL
2023-06-27 Bilirubin total 0.31 mg/dL

2023-07-31 S-GPT/ALT 655 U/L 2023-07-27 S-GPT/ALT 309 U/L 2023-07-26 S-GPT/ALT 219 U/L 2023-07-24 S-GPT/ALT 161 U/L 2023-07-21 S-GPT/ALT 180 U/L 2023-07-19 S-GPT/ALT 162 U/L 2023-07-17 S-GPT/ALT 278 U/L 2023-07-15 S-GPT/ALT 541 U/L 2023-07-14 S-GPT/ALT 638 U/L 2023-07-13 S-GPT/ALT 412 U/L 2023-07-09 S-GPT/ALT 137 U/L 2023-06-27 S-GPT/ALT 63 U/L 2023-06-23 S-GPT/ALT 62 U/L 2023-06-18 S-GPT/ALT 46 U/L 2023-06-05 S-GPT/ALT 31 U/L 2023-06-03 S-GPT/ALT 26 U/L

2023-07-27

[No specific preparation is described for Stronger Neo-Minophagen C Injection]

to primary nurse: After checking the Micromedex database, there is no available data on the compatibility of glycyrrhizinate monoammonium, the main ingredient in Stronger Neo-Minophagen C Injection. Additionally, the package insert for this medication does not provide specific instructions regarding the preparation prior to injection administration.

2023-07-19

[teicoplanin 600mg from Q3D to QOD]

2023-07-19 Cre 1.47mg/dL, 57.5kg => CrCl 35mL/min. According to the Sanford Guide, teicoplanin in patients with CrCl 30 to 80, for complicated skin/soft tissue, pneumonia, complicated UTI: 6mg/kg QOD and for bone and joint infections, endocarditis: 12mg/kg QOD. It is recommended to increase the frequency from Q3D to QOD.

[leukopenia]

An episode of leukopenia was observed on 2023-07-19, 9 days after administration of 4600 mg MTX on 2023-07-10. The label for MTX includes a boxed warning regarding potential bone marrow, liver, lung, skin, and kidney toxicity, and patients should be monitored closely for such effects. Given the timing and characteristics of MTX, it cannot be ruled out that the leukopenia episode was due to MTX.

  • 2023-07-19 WBC 1.47 x10^3/uL
  • 2023-07-17 WBC 4.58 x10^3/uL
  • 2023-07-15 WBC 11.08 x10^3/uL
  • 2023-07-14 WBC 14.72 x10^3/uL
  • 2023-07-13 WBC 16.11 x10^3/uL
  • 2023-07-09 WBC 11.29 x10^3/uL

According to NHI reimbursement guidelines, short-acting G-CSF (e.g., filgrastim, lenograstim) may be used for patients with hematologic malignancies receiving intravenous chemotherapy, provided the patient meets this condition.

2023-07-14

[MTX level follow-up. Leucovorin might begin 24 hr after the start of MTX]

Methotrexate 4600mg was administered on 2023-07-10, and leucovorin 150mg Q3H has been started since 2023-07-13. Follow-up methotrexate level has shown significant decrease and is now less than 10 umol/L.

  • 2023-07-14 Methotrexate 9.927 umol/L
  • 2023-07-13 Methotrexate 39.609 umol/L
  • 2023-07-13 Methotrexate 65.124 umol/L

It is recommended that rescue treatment following high-dose methotrexate starts with an initial dosage of around 15 mg (~10 mg/m2). This should begin 24 hours after the start of the methotrexate infusion and the treatment should continue Q6H for doses, until the MTX level drops below 0.05 micromolar.

The patient is adequately hydrated with normal saline and the urine is alkalinized with Rolikan (sodium bicarbonate).

[bedside visit]

I visited the patient at around 16:00 today. She mentioned that her throat was a bit sore, which could be due to mucositis. The addition of Nincort Oral Gel (triamcinolone acetonide) might help in relieving her symptoms.

[Covorin demand confirmation]

Today, during the UD (Unit Dose) vehicle preparing, it was discovered that the demand for Covorin (leucovorin 50mg) is 72 amps. At 13:25, I made a call to Dr. Wang QiQi to confirm the chief resident physician’s decision on the medication quantity.

701432045

230727

[diagnosis] - 2023-03-13 admission note

  • Malignant neoplasm of stomach, unspecified
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Type 2 diabetes mellitus without complications
  • Thyrotoxicosis, unspecified without thyrotoxic crisis or storm
  • Insomnia, unspecified

[past history]

  • The patient had type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control.
  • history of operation: nil
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Regular medications:
    • Amepiride 2mg/tab (Glimepiride) 0.5 tab QDAC
    • Cardiolol 10mg/tab (Propranolol) 1 tab TID
    • Methimazole 5 mg/tab (Methimazole) 1 tab TID
    • Uformin 500mg/tab (Metformin) 1 tab BIDCC             

[family history]

  • Mother: type 2 diabetes hypertension
  • Sisiters: breast cancer and skin cancer

[lab data]

  • 2022-08-11 TSH receptor Ab 40 %
  • 2022-08-11 Free T4 (nuclear medicine) 1.926 ng/dl
  • 2022-08-11 TSH (nuclear medicine) <0.04 uIU/ml
  • 2022-07-08 RPR/VDRL Nonreactive
  • 2022-07-08 T3 3.85 ng/mL
  • 2022-07-08 TSH <0.005 uIU/mL
  • 2022-07-08 Free-T4 4.60 ng/dL
  • 2022-07-08 Free PSA 0.655 ng/mL
  • 2022-07-08 free PSA/PSA 45.631 %
  • 2022-07-08 Anti-HAV IgG Nonreactive
  • 2022-07-08 Anti-HAV IgG Value 0.20 S/CO
  • 2022-07-08 Anti-HBc Reactive
  • 2022-07-08 Anti-HBc-Value 7.80 S/CO
  • 2022-07-08 Anti-HBs 0.99 mIU/mL
  • 2022-07-08 HBsAg Reactive
  • 2022-07-08 HBsAg (Value) 4.68 S/CO
  • 2022-07-08 HIV Ab-EIA Nonreactive
  • 2022-07-08 Anti-HIV Value 0.09 S/CO
  • 2022-07-08 Anti-HCV Nonreactive
  • 2022-07-08 Anti-HCV Value 0.31 S/CO
  • 2022-07-08 HbA1c 8.4 %

[exam findings]

  • 2023-05-12 CT - abdomen
    • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • Findings: Comparison prior CT dated 2021/09/23. There is no significant interval change.
      • Prior CT identified four metastases on both hepatic lobes are noted again, mild increasing in size that is c/w liver metastases S/P C/T with stable disease.
        • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
      • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
      • S/P subtotal gastrectomy and S/P cholecystectomy.
      • Prior CT identified focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail is noted again, mild decreasing in size to 3.2 cm.
    • Impression:
      • Four metastases on both hepatic lobe S/P C/T show stable disease.
      • There are few enlarged nodes in hepatoduodenal ligament and celiac trunk area. Metastatic nodes are highly suspected.
  • 2023-02-25 CT - chest
    • Indication: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • IMP
      • No evidence of pulmonary meta in the study.
      • s/p nearly total gastrectomy.
      • Loculated fluid like accumulation anterior to the pancreatic tail is found measuring 3.5cm in largest dimension. Meta? Post op. change?
  • 2023-02-24 CT - abdomen
    • History: gastric cancer, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC
    • Findings:
      • There are four well-defined poor enhancing lesions 1.7 cm in S2, 0.8 cm in S8 (near IVC), 0.4 cm in S5, and 1 cm in S6 of the liver that may be metastases. Please correlate with MRI.
      • A hepatic cyst measuring 0.9 cm in S2/3 is noted.
      • S/P subtotal gastrectomy
      • There is focal cystic lesion 3.6 cm (the largest dimension) in between the residual stomach and pancreatic tail that may be focal seroma or abscess?
    • Impression:
      • Four metastases on both hepatic lobes are highly suspected.
  • 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some hot or faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the lower L-spines, left humeral shaft, bilateral shoulders, left sternoclavicular junction and bilateral hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some hot or faint hot spots in the anterior aspect of bilateral rib cages and mildly increased activity in the left humeral shaft. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, left sternoclavicular junction and bilateral hips, compatible with benign joint lesions.
  • 2022-08-12 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, subtotal gastrectomy — Adenocarcinoma
      • Margin, frozen section — Free of tumor invasion
      • Margins, subtotal gastrectomy — Free of tumor invasion
      • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/3)
      • Lymph nodes, LN 3, ditto — Tumor metastasis (3/9) with extracapsular extension (3/3)
      • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/11)
      • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, LN 6, ditto — Fat tissue only
      • Lymph nodes, LN 12c, ditto — Free of tumor metastasis (0/1)
      • Lymph nodes, LN 14, ditto — Free of tumor metastasis (0/8)
      • Lymph nodes, LN 7,8,9,11p,12a, ditto — Tumor metastasis (1/7) with extracapsular extension (0/1)
      • Omentum, omentectomy — Free of tumor invasion
      • Gallbladder, cholecystectomy — Free, chronic cholecystitis
      • AJCC Pathologic staging — pT4aN2, if cM0, stage IIIA
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, gallbladder and omentum
      • Specimen size: (a) Stomach: GC: 20.5 cm; LC: 6.8 cm, (b) Omentum: 35 x 19 x 4 cm
      • Number of lesions: Solitary
      • Tumor site: angle
      • Tumor size: 3.6 cm
      • Tumor configuration: ulcerative mass
      • Gallbladder: 5.6 x 3.3 x 1.6 cm
      • Representative sections as follows: A: LN 1, B1-B3: LN 3, C: LN 4, D: LN 5, E: LN 6, F: LN 12c, G1-G2: LN 14, H1-H2: LN 7,8,9,11p,12a, I1-I2: bilateral resection margins, I3-I8: tumor + serosa, I9: non-tumor stomach, J1-J2: omentum, K: gallbladder [Reference: F2022-00375 FS: cutting end, one small piece measured 9.7 x 0.5 cm with staples]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma
      • Histologic grade: Grade 3, poorly differentiated
      • Depth of tumor invasion: serosa layer
      • Lymph nodes: Tumor metastasis (4/40) with extracapsular extension (3/4) in total number
      • Omentum: free of tumor invasion
      • AJCC Pathologic Staging: pT4aN2, stage IIIA
      • Bilateral Margins: Free, 2.8 and 3.6 cm away from bilateral margins
      • Additional pathologic findings: focal tumor necrosis, focal micropapillary pattern and mild intestinal metaplasia
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Immunohistochemical stains: CK(+) and HER2(equivocal, Dako score 2+)
      • Gallbladder: chronic cholecystitis with one reactive lymph node. No stone
  • 2022-08-09 CT - abdomen
    • History and indication: gastric cancer
    • Findings
      • A tumor (3.6cm) at gastric body, LC, with reginal LAP.
      • Left liver cyst (0.9cm).
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP: Gastric body cancer (3.6cm, LC) with regional LAP.
  • 2022-08-08 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Borderline ECG
  • 2022-08-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 41) / 132 = 68.94%
      • M-mode (Teichholz) = 69
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis
  • 2022-07-21 Thyroid Ultrasound
    • Autoimmune thyroid disease
  • 2022-07-19 CT - abdomen
    • Clinical history: 56 y/o male patient with An big A2 ulcer was noted at angle. Biopsy x4 was done. DIAGNOSIS: Stomach, antgle, biopsy — Adenocarcinoma.
    • Findings
      • Thickening wall at gastric body, c/w gastric malignancy.
      • There are enlarged lymph nodes in perigastric region, could be due to metastatic lymph nodes.
      • Suspected liver cyst, 0.9cm in S2.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • Bilateral lower lung cysts.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: III (Stage_value)
  • 2022-07-08 Patho - colorectal polyp
    • Colon, 10 cm above anal verge, cold snare polypectomy (B) — Hyperplastic polyp
    • Section shows fragment(s) of polypoid colonic mucosal tissue with crowded benign hyperplastic mucinous glands.
  • 2022-07-08 Patho - colorectal polyp
    • Colon, 25 cm above anal verge, polypectomy (A) — Tubular adenoma with low grade dysplasia
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with low grade dysplasia.
  • 2022-07-08 Patho - stomach biopsy
    • Stomach, antgle, biopsy — Adenocarcinoma.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
  • 2022-07-08 CT - chest
    • Low dose spiral CT of the chest without contrast enhancement for screening of lung tumor showed:
      • Lungs:Pneumatocele at both lungs up to 1.75cm in largest dimension.
      • Unremarkable in the mediastinum and hilars.
      • Unremarkable of the pleura.
      • Unremarkable of the chest wall.
      • Unremarkable of the supraclavicular fossa.
      • Visible bones: Unremarkable.
      • Calcified coronary arteries is found.
      • Enlarged lymph nodes are found at gastric pericardial region. r/o gastric tumor related.
    • IMP:
      • No definite nodular lesion at both lungs.
      • Calcified coronary arteries is found.
      • Perigastric lymphadenopathy, suspected gastric tumor related.
  • 2022-07-08 Panendoscopy
    • Superficial gastritis, antrum s/p CLO test
    • GU, large, angle s/p biopsy suspected malignancy

[consultation]

  • 2022-12-13 Dermatology
    • Q
      • for skin itchy, skin rash at back and upper limbs after chemotherapy.
      • This 56-year-old male, a pt of gastric CA, pT4aN2 (4/40), cM0, stage IIIA, s/p subtotal gastrectomy & HIPEC on 20220812 by Dr Wu, suffered from initial presentation of progressive weight loss of 80kg to 65kg in 3 months & CEG in July 2022 showed a big A2 ulcer at angle. Biopsy proved CA.
      • Today, he was admitted for #2 post-Op adjuvant C/T with mFOLFOX IV Q2W x 12 on 20221213. He complatins skin itchy, skin rash at back and upper limbs after chemotherapy, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from cancer s/p chemotherapy. diffuse ithcy red papules with keratosis and fine pusutles was noted.
      • Under the impression of xerotic dermatitis and lichen pilaris et secondary inflammation episode.
      • The following sugeetion:
        • for itchy reddish papules and fine pustules lesion, Mycomb cream 2 tube topical PRN bid use.
        • for follculiar kertosis and xerosis, Sinphraderm cream 1 tube topical QN use.
  • 2022-08-19 Radiation Oncology
    • Q
      • For CCRT
      • This 56-year-old male is a case of type 2 diabetes mellitus and thyrotoxicosis under medicatiosn control. According for his statement, he noted of weight loss for 20 kg and mild poor appetite in 2 months. Then he came to our hospital for health examination on 2022/07/08. UGI scope was showed erythmatus change of gastric mucosa was found at antrum. An big A2 ulcer was noted at angle. Biopsy was done. Final pathology showed adenocarcinoma. Abdomen CT also revealed gastric malignancy with lymph nodes metastasis, cstage T3N2M0. On the same health examination, type 2 diabetes mellitus and thyrotoxicosis was also noted. So medications was keep control first. Due to gastric cancer, he referred to GS OPD for further management. Tumor marker of CEA:2.095 ng/ml; CA-199:173.175 U/ml on 20220711. After diabetes and thyrotoxicosis under medications control, his body wight was improved and stable in 65kg. He denied fever, chills dizzness, poor appetite, nausea, vomiting, or tarry stool passage in recently.
      • This time, he was admitted to our ward for further evaluate and management. He underwent subtotal gastrectomy + HIPEC on 20220811. Post operative course smoothly, fair oral intake. The pathology showed adenocarcinoma, pT4aN2M0, stage IIIA. We need your expertise for further radiotherapy evaluation. Thanks for your times.
    • A
      • A: Adenocarcinoma of the stomach, AJCC Pathologic staging — pT4aN2(cM0), stage IIIA, s/p distal subtotal gastrectomy with D2 LN dissection. HIPEC with Oxaliplatinum, laparoscope staging, and small bowel serosa repair; laparoscope.
      • P: Postoperative CCRT is indicated for this patient with the following indicators: stage pT4aN2(cM0).
        • Goal: curative
        • Treatment target and volume: gastric to regional lymphatic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gastric to regional lymphatic area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his girl friend. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-09-15.

[MedRec]

  • 2023-03-08 SOAP Hemato-Oncology
    • O: 2023/02/24 CT ABD: Four metastases on both hepatic lobes are highly suspected.
    • P: Suggest to change regimens to Doctaxel + 5-FU and pembo (100 mg) q2w
  • 2022-09-06 SOAP Hemato-Oncology
    • S: Will give post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX IV Q2W x 6.

[surgical operation]

  • 2022-08-20
    • Surgery
      • small bowel serosa repair
      • laparoscope
    • Finding
      • small bowel serosa tear with bleeding+
      • intraabd blood 450cc
      • left inguinal hernia indirect type
  • 2022-08-11
    • Surgery
      • distal subtotal gastrectomy with D2 LN dissection
      • HIPEC with Oxaliplatinum 300 mg for 60 mins at 42 C
      • laparoscope staging
    • Finding
      • laparoscope staging: distal gastric tumor with serosa involve
      • no peritoneal seeding
      • obvious LN at lesser curvature

[radiotherapy]

  • 2022-09-28 ~ 2022-11-02 - 4500cGy/25 fractions of the gastric to regional lymphatic area.

[chemoimmunotherapy]

  • 2023-07-26 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-30 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 400mg/m2 670mg NS 100mL 10min + fluorouracil 1000mg/m2 1650mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 65mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-06-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 65mg NS 200mL 4hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 400mg/m2 675mg NS 100mL 10min + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr He JingLiang)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-05-08 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-04-06 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 400mg/m2 680mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-03-13 - pembrolizumab 100mg NS 100mL 30min + docetaxel 40mg/m2 60mg NS 200mL 4hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 100mL 10min + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-2 + NS 500mL 2hr D3 (before cisplatin) + cisplatin 40mg/m2 60mg NS 500mL 2hr D3 + NS 500mL 2hr (after cisplatin) D3 (Dr Wan XiangLin)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2023-02-22 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 685mg NS 250mL 2hr + fluorouracil 2800mg/m2 4825mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-29 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4720mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-24 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr (adjuvant FOLFOX, Dr. Zhang ShouYi)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-31 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D3 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-24 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-17 - fluorouracil 225mg/m2 360mg NS 500mL 24hr D1-D5 (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-14 - fluorouracil 225mg/m2 360mg NS 500mL 24hr (adjuvant CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-08-11 - oxaliplatin 300mg/m2 525mg IP 1hr (HIPEC)

[note]

Chemotherapy regimens for advanced esophagogastric cancer: Docetaxel, cisplatin, and fluorouracil (DCF) 2023-07-27 https://www.uptodate.com/contents/image?imageKey=ONC%2F73324

  • Cycle length: 21 days.
  • Drug
    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 75 mg/m2 IV
      • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 750 mg/m2 per day IV
      • Dilute in 500 to 1000 mL D5W and administer as a continuous infusion over 24 hours. For use in an ambulatory infusion pump. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS.
      • Days 1 through 5

Chemotherapy regimens for locally advanced, potentially resectable gastric or gastro-esophageal junction adenocarcinoma: Perioperative docetaxel, oxaliplatin, fluorouracil, and leucovorin (FLOT4) 2023-03-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F120512

  • Cycle length: 14 days.
  • Duration of therapy: In the original trial, preoperative FLOT was given every 14 days for 4 cycles. Following surgery, postoperative FLOT was given every 14 days for 4 cycles.
  • Drug
    • Docetaxel
      • 50 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (oxaliplatin and leucovorin can be administered concurrently in separate bags using a Y-connector).
      • Day 1
    • Leucovorin
      • 200 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2600 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 24 hours (begin immediately after completion of leucovorin infusion). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose can be diluted in 100 to 150 mL NS or D5W.
      • Day 1

ref: Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastro-oesophageal junction adenocarcinoma (FLOT4): a randomised, phase 2/3 trial. Lancet. 2019;393(10184):1948-1957. doi:10.1016/S0140-6736(18)32557-1

==========

2023-07-27

This patient receives all medical care exclusively at our hospital and has appointments with both the hematology-oncology and endocrinology and metabolism departments. Medications prescribed by the endocrinology and metabolism department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were correctly documented on the active medication list. As a result, no medication reconciliation issues were identified.

2023-07-03

  • This patient is treated exclusively at our hospital and has appointments with both the Hematology-oncology and Endocrinology and Metabolism departments. The medications prescribed by the endocrinology and metabolism department, which include Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, were all accurately entered into the active medication list. As a result, no discrepancies were found during the medication reconciliation process.

2023-06-07

  • This patient is treated only at our hospital. In addition to visits to the hematology-oncology service, he also visits the endocrinology and metabolism service. Medications prescribed by the latter department, including Cardiolol (propranolol), Galvus Met (vildagliptin, metformin), and methimazole, are all appropriately included in the active medication list, with no medication reconciliation issues identified.

2023-05-09

  • Given that the most recent CT scan was conducted in February 2023 and three months have since elapsed, it may be prudent to schedule a new CT scan to obtain updated imaging.
  • The patient’s fasting blood glucose levels during this hospital stay were recorded approximately 150mg/dL. Including Dibose (acarbose 100mg/tab) 1# TIDCC could potentially improve glucose regulation.

2023-03-14

  • CT scans conducted in late Feb indicated the possible presence of metastases in the liver as well as loculated fluid-like accumulation near the pancreatic tail. As a result, the FOLFOX regimen was replaced by a new treatment regimen consisting of pembrolizumab, docetaxel, leucovorin, fluorouracil, and cisplatin. This new regimen was first administered during the patient’s current hospital stay.
  • The patient’s vital signs in the TPR panel have remained stable, and the lab data from 2023-03-14 showed grossly normal results. The patient’s underlying conditions of hyperglycemia and thyrotoxicosis are being managed with corresponding medications, and hydroxocobalamin is being administered to prevent vitamin B12 deficiency after gastrectomy. No medication reconciliation issues were found.

2022-12-14

  • The IHC HER2 result was equivocal (Dako score 2+), and there was no HER2 FISH or PD-L1 result available yet. Trastuzumab or its biosimilar should be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma.
  • The underlying conditions are treated with corresponding medications without an issue.

700185130

230725

{not completed}

[exam findings]

  • 2023-07-05 CT - abdomen
    • History:
      • Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11 s/p EP from 2023/04/27
      • 20230411 US-guided biopsy: Neuroendocrine carcinoma, large cell type
    • Findings:
      • Prior CT identified a large heterogeneous poor enhancing tumor with central tumor necrosis (10.0cm in the largest dimension) at the pancreatic body and tail is noted again, stationary that is c/w neuro-endocrine carcinoma of the pancreas S/P C/T with stable disease.
        • Prior CT identified tumor thrombosis in the trifurcation of the splenic vein, superior mesenteric vein, and portal vein is noted again, stationary.
        • In addition, there is small size of the splenic artery and non-visualization of the splenic vein that is c/w tumor encasement.
      • There is splenomegaly (the greatest cranial-caudal dimension measuring 13 cm in size).
      • There is ascites in the pelvis.
    • Impression:
      • Neuro-endocrine carcinoma of the pancreatic body and tail S/P C/T shows stable disease.
  • 2023-07-02 CT - brain
    • Indication: con’s change
    • Impression: No definite abnormality in this study
  • 2023-07-01 ECG
    • Sinus bradycardia
    • Lateral infarct, age undetermined
  • 2023-06-13 ECG
    • Sinus rhythm with short PR
  • 2023-06-09 All-RAS + BRAF mutation
    • Tissue Block No: S2023-06855
    • RESULTS:
    • ALL-RAS: There was no variant detect in the KRAS/NRAS gene
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-04-26 ENT Hearing Test
    • Reliabilty Fair
    • PTA
    • R’t : >120 dB HL, profound HL
    • L’t : 93 dB HL, severe to profound SNHL.
  • 2023-04-12 Patho - pancreas biopsy
    • Pancreas, sono-guided biopsy — Neuroendocrine carcinoma, large cell type
    • The sections show neuroendocrine carcinoma, large cell type, composed of large pleomorphic neoplastic cells with moderate amount eosinophilic cytoplasm, arranged in solid pattern. Tumor necrosis is present.
    • IHC, tumor cells reveal: CK(+), CK7(+), CD56(focal +), Synaptophysin(+), Trypsin(-/+) and Ki67=70%.
  • 2023-04-11 Sono-guided pancreatic tumor biopsy
    • Findings: A large heterogeneous isoechoic tumor with anechoic component at pancreatic neck and body.
  • 2023-04-08 MRI - pancreas
    • History and indication: abdominal pain
    • With and without contrast MRI of abdomen with MRCP reconstruction revealed:
      • A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.
      • Normal appearance of liver and kidneys.
      • No ascites, nor enlarged lymph node.
      • No abnormal signal intensity in bilateral basal lungs.
    • IMP:
      • In favor of pancreatic tumor as described.
  • 2023-04-07 SONO - abdomen
    • Diagnosis
      • Pancreatic tumor, with tumor necrosis, PVT, invasion to left kidney.
      • Splenomegaly, mild
    • Suggestion
      • consider trans-abdominal biopsy.
  • 2023-03-25 CT - abdomen
    • History and indication: Hematochezia / Melena
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large poor enhancing tumor (8.1x10.0cm) at LUQ r/o pancreatic tumor. Splenic artery and vein invasion and proximal portal vein thrombosis with collateral circulation was noted. Stomach, left adrenal, adjacent bowel and spleen invasion should be ruled out.
      • Small amout ascites. Some LNs at upper abdomen.
    • IMP:
      • Suspected pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion.

[consultation]

  • 2023-06-09 Obstetrics and Gynecology
    • Q
      • This is a 43-year-old female with history of Pancreatic cancer with tumor necrosis, portal vein thrombosis, invasion to left kidney, T4NxM1, stage IV, status post transabdominal pancreatic biopsy on 2023/04/11, s/p Etoposide plus Cisplatin form 2023/04/27, this time, she was admitted for chemotherapy.  
      • For menstrual pain was noted, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • We consulted for menstrual pain
      • OBGYN:
        • P2 (NSD*2)
        • LMP 06/06
      • Lab:
        • WBC 3660, Hb 10.7, PLT 178000, BCS WNL
        • CEA 2.09, CA199 9.14, CA125 49.3
      • PV:
        • moderate amount of red discharge
        • no lifting pain
        • smooth cervix
      • TVUS and TAS:
        • Uterus 108*40mm, EM 14.8mm
        • ROV 2418mm, LOV 2317mm
        • ascites+
      • Impression:
        • EM 14.8mm
      • Suggestion:
        • current no GYN lesion noted
        • NSAID for pain control
        • GYN OPD f/u for menstrual cycle
  • 2023-04-13 Hemato-Oncology
    • A -This 43 year old woman is a case of pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion s/p Transabdominal pancreatic biopsy was done on 20230411. We are consulted for further evaluation.
      • May check LDH, HBsAg, Anti-HBc, Anti-HBs, Anti-HCV. Pending pathology result. Arrange our OPD after discharge.
  • 2023-04-12 General and Gastroenterological Surgery
    • Q
      • This 43 years old woman denied any systmic underlying disease, hearing-impaired person.
      • This time, she has abdominal pain since 2023-03-15 (thought it was menstrual pain) but pain sensation no improve so she came to our ED for hlep on 2023-03-19, ecchymosis around the navel was also noted, suggest abdominal CT examination but reufsed and AAD. Still intermittent abdominal pain and mass lesion over left abdominal, back stool passage for one weeks, so she came to ED and arrange PES was done on 2023-03-24, report showed Gastric huge mass lesion, upper body, suspect external compression, no ulcer or active bleeding noted. The Abdominal CT was done on 2023-03-25 and revealeding R/O pancreatic tumor with splenic artery/ vein/ portal vein/ stomach/ left adrenal gland/ adjacent bowel loop and splenic invasion. There was no fever, productive cough, abdominal pain is intermittent, The tarry stool was improved after medication, but syncope while riding a motorcycle yesterday. TOCC history was unremarkable. Thus, she was admitted to our GI ward for MRCP examination on 2023-04-05.
      • Pancreatic MRI plus MRCP was performed on 2023/04/08 and reported A large poor enhancing tumor (8.8x10.0cm) at LUQ with splenic artery, vein, stomach, left adrenal, adjacent bowel and spleen invasion. Proximal portal vein thrombosis with collateral circulation.Transabdominal pancreatic biopsy was done on 2023-04-11 ,the pathology was pending. We will need your surgical evaluation, thank you
    • A
      • Please pending pathology report
      • Poor operation due to r/o pertoneal seeding and proximal portal vein thrombosis was noted.

[MedRec]

  • 2023-07-03 Multi-disciplinary Team Recommendations - Social Services
    • Referral Date: 2023-07-03
    • Reason for Referral: The patient lacks self-care ability during hospitalization, and family members are unable to come to the hospital to take care of her.
    • Status: Case opened
    • Family Situation: According to past service records and the visit to the patient on 2023-06-30, and after having a conversation with the patient, the following family situation was obtained:
      • The patient is 43 years old, unmarried, and has a hearing impairment. She works as an administrative assistant with a monthly income of 24,000 NTD. She used to live with her two children on the 8th floor with an elevator in a rented apartment, with a monthly rent of 29,000 NTD. Since June 2023, she has moved in to live with her mother, and her two children are taken care of by her eldest younger sister.
      • The patient has had two intimate relationships, and each relationship has resulted in one son. The elder son is in the fourth grade of Muzha Elementary School, and the younger son is in the middle class of Renmei Kindergarten. According to the patient’s aunt, the elder son maintains contact with his biological father, while the younger son has no contact with his biological father, and both sons have not undergone paternity acknowledgment.
      • The patient’s mother is 64 years old and works in a fruit shop. She has been married twice and has three daughters and one son (female, female, female, male). The patient is the eldest daughter, and her father has passed away. Her two younger sisters are married, and her brother lives abroad. According to the patient’s aunt, due to past family issues, the relationship between the patient and her mother and siblings is somewhat distant. The patient was raised by her maternal grandmother since childhood and is closer to her aunt, who is of a similar age, and thus trusts her aunt more.
      • The patient was diagnosed with malignant sebaceous gland tumor around 2017 years ago and received treatment at the Postal Hospital. After completing the treatment, the patient did not continue to follow up with regular visits.
      • The patient is classified as a fourth-class low-income household in Taipei City and holds a second-class severe disability certificate due to her hearing impairment. She receives a total of 17,576 NTD in disability and low-income living allowances each month.
      • Contact persons: Patient’s mother (Deng XiuZhu), patient’s aunt (Deng YuZhu).
    • Main Problem: Economic issue
    • Problem Details: Issue with hiring caregiver costs
    • Disposition: Referral for economic assistance
    • Responder: Liu SiLing
    • Reply Date: 2023-07-03
    • Physician Response:
      • 2023/07/04 10:48 Dr. Xia Hexiong: Will follow the recommendations, the family relationship in this case is very complicated. The patient’s children are taken care of by her younger sister, but the patient has a poor relationship with her sisters. The patient interacts more with her aunt. The patient now lives with her mother, but during the conversation with her aunt regarding the patient’s condition, it was discovered that even the relationship between the aunt and the patient’s mother is not good. The attending physician hopes to have a complete discussion and explanation of the patient’s condition with all the family members concerned about the patient. A family meeting is scheduled to be held on Friday, 2023/07/07. The aunt has left the mother’s phone number, and the hospital is expected to contact the mother directly. Attempts were made to contact the mother on 2023/07/03 and 2023/07/04, but the calls were not answered.
  • 2023-07-02 Multi-disciplinary Team Recommendations - Psychological Oncology
    • Referral Date: 2023-07-02
    • Reason for Referral: Stressful illness event: Psychological response due to physical illness or decision-making regarding treatment options; Emotional distress: Anxiety, fear, depression, anger; shyness, shock, and other emotional categories.
    • Conclusion: (Social) Visit on 7/4, the patient was using a smartphone and responded with gestures that the treatment has not started yet. The first two treatments were okay, and they have been doing well at home and with their eating. Thank you for the concern. (Objective) Diagnosed with pancreatic cancer and renal metastasis on 12/3, previously visited on 4/27 (emotional distress, chronic stress; hearing impairment; unmarried, two children); admitted for the third round of chemotherapy on 6/30, nursing consultation on 7/2 reported psychological stress response. (Intervention) Providing support for the treatment burden of the patient. (Action Plan) The patient remains unwilling to talk; it is advised to consider prognosis, physical condition, family support, and financial burden, and continue discussing the treatment direction with the family. Counseling Psychologist Huang Xiaofang 65628
    • Responder: Huang XiaoFang
    • Reply Date: 2023-07-05 17:42
    • Physician Response:
      • 2023/07/06 07:49 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
  • 2023-06-30 Multi-disciplinary Team Recommendations - Social Services
    • Referral Date: 2023-06-30
    • Reason for Referral: Other: Low-income household
    • Status: Not opened
    • Reason for Not Opening: The social services department has dealt with the case previously and is still in the process.
    • Family Situation: The same as previously mentioned.
    • Social Worker Evaluation and Handling:
      • The patient is undergoing routine chemotherapy during this hospitalization. As a low-income individual, she is exempt from hospitalization fees and has not used any self-paid items. The patient can take care of herself during hospitalization, so there are no economic and care issues assessed.
      • The social worker has provided the above handling, and there are no further derivative problems at this time. If there are any other needs, please refer again. Thank you.
    • Responder: Liu Si-ling
    • Reply Date: 2023-06-30
    • Physician Response:
      • 2023/07/03 08:00 Dr. Xia Hexiong: Will follow the recommendations and continue to monitor and observe the patient’s condition. Will also arrange a family meeting to help the patient and family better understand the current situation. Thank you for the team’s response.
  • 2023-04-19 SOAP Hemato-Oncology
    • Assessment and Plan
      • pancrease neuroendocrine carcinoma, large cell type
      • transfer to ER due to anemia with dizzines (blood transfusion and admission)
      • admiited for port A insertion, check 24 urine CCR, audiometry and then C/T with EP
        • etoposide + carboplatin (hearing impairment)

[chemotherapy]

  • 2023-06-30 - etoposide 100mg/m2 120mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 30mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-06-07 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL
  • 2023-04-27 - etoposide 100mg/m2 130mg NS 500mL 1hr D1-3 + cisplatin 25mg/m2 35mg NS 500mL D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO D1-3 + NS 250mL

==========

2023-07-25

Episodes of anemia were evident according to the most recent lab results.

  • 2023-07-24 HGB 9.1 g/dL
  • 2023-07-19 HGB 6.4 g/dL **
  • 2023-07-10 HGB 10.4 g/dL
  • 2023-07-07 HGB 8.7 g/dL *
  • 2023-07-05 HGB 10.9 g/dL
  • 2023-07-03 HGB 10.8 g/dL
  • 2023-07-01 HGB 9.0 g/dL
  • 2023-06-30 HGB 9.1 g/dL

The most recent chemotherapy administration was initiated on 2023-06-30. Additionally, the patient experienced several GI tumor bleeding events since 2023-03 and received blood transfusions on the following dates: 2023-03-24, 2023-03-25, 2023-04-05, 2023-04-12, 2023-04-19, 2023-04-23, 2023-06-30, 2023-07-07, 2023-07-19, and 2023-07-24. Considering that both tumor bleeding and blood transfusions can affect HGB levels, it is difficult to conclusively attribute anemia solely to chemotherapy, and the potential impact of chemotherapy cannot be completely ruled out.

2023-07-10

Studies indicate that patients with gastroenteropancreatic neuroendocrine carcinoma who receive cisplatin/etoposide treatment can have an Objective Response Rate (ORR) ranging from 14% to 67%, as stated in “Systemic Treatment of Gastroenteropancreatic Neuroendocrine Carcinoma. Curr. Treat. Options in Oncol. 22, 68 (2021).”

The CT scan on 2023-07-05 demonstrated stable disease for the neuroendocrine carcinoma of the pancreatic body and tail, following 3 cycles of the cisplatin/etoposide regimen. This might suggest that the disease could be developing some degree of resistance to the treatment.

2023-07-03

After reviewing the PharmaCloud database and in-hospital HIS5 records, no medication reconciliation issues were identified.

2023-06-08

The patient sought treatment for unspecified dermatitis at Huang ZhenXian Dermatology Clinic on 2023-05-08 and was prescribed tranexamic acid, betamethasone, prednisolone, and loratadine for a short duration of 3 days. Currently, no dermatitis-related symptoms are observed in the admission note or the active medical problem list. Therefore, no medication reconciliation issues are identified.

700337848

230725

[exam findings]

  • 2023-06-26 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-06-05 Patho - colon biopsy
    • Large intestine, rectum, 6-7 cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-06-05 Colonoscopy
    • An ulcerative tumor lesion is located at rectum (6-7cm AAV) with obstruction.
  • 2023-06-02 MRI - pelvis
    • Indicaiton
      • 20230528 CC: bloody stool on and off for months
      • 20230530 colonoscopy: circumferential rectal tumor with lumen narrowing, scope cannot pass through since 10cm, 1st fold of rectum.
      • 20230601 CT: upper rectal cancer & obstruction, T4bN2aM0, STAGE: IIIC
    • Findings
      • There is a lobulated soft tissue mass in the upper rectum, measuring 8 cm (the largest dimension), showing hypointensity on T1WI and mild hyperintensity on both T2WI and DWI. During dynamic study, this tumor shows poor enhancement that is c/w adenocarcinoma of the upper rectum.
        • In addition, there is fat plane obliteration between this rectal mass and the urinary bladder and prostate that may be urinary bladder and prostate invasion (T4b).
        • There is fat plane obliteration between this rectal mass and the mesorectal fascia that is c/w mesorectal fascia invasion.
      • There are four enlarged nodes in the perirectal space that are c/w metastatic nodes (N2a).
      • There are enlarged nodes in right and left inguinal area that may be non-regional metastatic nodes (M1a).
        • Please correlate with PET scan.
      • There is a vesical stone 1 cm.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M1a(M_value) STAGE:IVA(Stage_value)
  • 2023-06-01 CT - abdomen
    • History and indication:
      • rectal cancer with obstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat, prostate, seminal vesicles invasion and regional LAP.
      • Bil. pleural effusions.
      • A stone (1.0cm) in urinary bladder. Left renal staghorn stone. Renal cysts (up to 1.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-06-01 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 73) / 122 = 40.16%
      • M-mode (Teichholz) = 40
    • Conclusion:
      • Dilated LA
      • Impaired LV systolic function, generalized hypokinesis
      • LV hypertrophy, Impaired LV relaxation
      • Mild MR, TR, AR, PR
  • 2023-06-01 Flow Volume Loop
    • Normal spirometry
  • 2023-05-31 KUB
    • Radiopaque spot(s) at left renal region r/o renal stone(s).
    • Presence of ileus.
    • A calcification at right pelvic cavity.
  • 2023-05-30 Sigmoidoscopy
    • Finding: circumferential rectal tumor with lumen narrowing, scope can not pass through since 10cm, 1st fold of rectum.
    • Diagnosis: Highly suspect rectal cancer with osbtruction, due to PLVIX only 3 days stopping, no biopsy
    • Suggestion:
      • repeat sigmoidoscopy with biopsy after plavix 6~7 days
      • T colostomy or stenting for rectal cancer obstruction
      • A + P and Chest CT, CEA.
  • 2023-05-29 SONO - abdomen
    • Hepatic calcification, right lobe
    • Parenchymal renal disease
    • Renal cyst, RK
    • Renal stone, LK
  • 2023-05-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia
      • Gastric polypoid lesion, prepyloric antrum, LC, s/p biopsy
      • Gastric erosions, pylorus
      • Duodenal ulcer scar with pseudodiverticulum, bulb
    • Suggestion:
      • Pursue pathology report
      • PPI therapy
  • 2023-05-27 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
    • Left axis deviation
    • Moderate voltage criteria for LVH, may be normal variant
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2023-05-27 CXR
    • Cardiomegaly and tortuosity of the thoracic aorta.
    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-05-27 ECG
    • Sinus rhythm with frequent Premature ventricular complexes
    • Left axis deviation
    • Voltage criteria for left ventricular hypertrophy
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG

[MedRec]

  • 2023-07-10 SOAP Radiation Oncology
    • A/P
      • RT dose: 2700cGy/15 fractions (15 MV photon) to rectal tumor and lymphatics, 2023/6/16 to 7/07.
        • 5FU: 6/25-30.
      • RT Side effect evaluation, 7/07: Radiation dermatitis, grade 0; N/V, grade 0; enteritis, grade 0; cystitis, grade 0; proctitis, grade 0.
  • 2023-07-04 SOAP Dermatology
    • S
      • multiple painful erythematous papule-nodules on face,trunk and 4-limbs
      • multiple erythematous scars and keloids on scalp for months, progressive enlarged recently, itching(+), keloid (+)
    • O
      • Imp: acne on face and trunk for months, multiple pustule (+),inflammation(+), painful(+)
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • triamcinolone suspended 10mg ST IS
      • fusidic acid BID EXT
      • doxycycline 100mg 1# BID PO

[consulation]

  • 2023-07-11 Cardiology
    • Q
      • The patient is an 76-year-old male with a history of
        • Hypertension for 20+ years with medication control,
        • Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023),
        • Type II diabetes mellitus for 10+ years with medication control,
        • Rectal cancer with impending obstruction s/p loop colostomy on 2023/06/02 with perirectal and bilateral inquinal LAP metastasis, stage cT4bN2aM1a, stage IVA
      • He presented with Coronary artery disease for 10+ years s/p stent x6 (last one in early of 2023) and Hypertension for 20+ years with medication control Hx, for CV drug adujst, we need your further evaluation and management.
    • A
      • He is admitted for evaluation of chemotherapy and we are consulted for CV meds adjust
        • ECG shows sinus rhythm with PVCs, LAD
        • CXR shows cardiomegaly
        • echocardiography shows dilated LA, LVH, global LV hypokinesis with impaired LV systolic function
      • CV meds with plavix 1 # qd, concor 2.5 mg qd, diovan 40 mg qd forxiga 1 # qd
      • suggest
        • to keep present CV meds
        • monitor I/O and BW
        • to avoid overhydration

[radiotherapy]

[chemotherapy]

  • 2023-07-14 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1,4-7 (for CCRT, QW)
  • 2023-06-26 - [fluorouracil 400mg/m2 650mg NS 100mL 10min + leucovorin 20mg/m2 30mg NS 100mL 10min] D1-5 (for CCRT, QW)

==========

2023-07-25

[tube feeding - Concor]

According to the manufacturer’s instructions for Concor (bisoprolol 5 mg tablets), it should be swallowed with a drink of water and not chewed. However, if the patient is receiving tube feeding, the Simple Suspension Method (SSM) can be used. This method involves dissolving the tablets in warm water for 5-10 minutes and then passing the solution through a feeding tube for administration. The Simple Suspension Method may be appropriate for administration of Concor tablets through a feeding tube.

[renal dosing Tapimycin from Q6H to Q8H]

Kidney function appears to be deteriorating in this patient. 2023-07-25 CrCl 27 mL/min.

  • 2023-07-25 Creatinine 2.00 mg/dL
  • 2023-07-14 Creatinine 1.50 mg/dL
  • 2023-07-25 eGFR 34.70
  • 2023-07-14 eGFR 48.36
  • 2023-07-25 BUN 38 mg/dL
  • 2023-07-14 BUN 22 mg/dL

When using Tapimycin (piperacillin 4g, tazobactam 0.5g) in patients with a CrCl between 20 and 40, if the intended dose is 4.5g Q6H infused over 30 minutes, then the recommended doses are either 4.5g Q8H or 3.375g Q6H, with the former being preferred.

A dose of 4 mg once daily is recommended when using Urief (silodosin 8 mg) in patients with a CrCl between 30 and 50.

[leukopenia and thrombocytopenia]

Bicytopenia (leukopenia and thrombocytopenia) is evident based on recent lab results after consecutive 5-day fluorouracil administration (for CCRT), which started on 2023-06-26 and 2023-07-14.

  • 2023-07-25 WBC 0.16 x10^3/uL

  • 2023-07-14 WBC 2.82 x10^3/uL

  • 2023-07-05 WBC 6.47 x10^3/uL

  • 2023-06-26 WBC 8.28 x10^3/uL

  • 2023-06-13 WBC 9.43 x10^3/uL

  • 2023-07-25 HGB 9.0 g/dL

  • 2023-07-14 HGB 9.1 g/dL

  • 2023-07-05 HGB 9.5 g/dL

  • 2023-06-26 HGB 8.3 g/dL

  • 2023-06-13 HGB 10.0 g/dL

  • 2023-07-25 PLT 80 *10^3/uL

  • 2023-07-14 PLT 301 *10^3/uL

  • 2023-07-05 PLT 299 *10^3/uL

  • 2023-06-26 PLT 340 *10^3/uL

  • 2023-06-13 PLT 459 *10^3/uL

Blood transfusions are performed on 2023-05-27, 2023-06-01, 2023-06-26, 2023-07-14, 2023-07-25 and Granocyte (lenograstim 250ug) is to be administered since 2023-07-25 for consecutive 6 days. No issue with the use of G-CSF.

2023-07-18

[ARBs Equivalent Dose Conversion]

This patient is currently self-administering Diovan (valsartan 40mg) once daily and the supply is almost exhausted. Upon checking, our hospital only carries a 160mg dosage, which is inconvenient to divide into quarters. However, Olmetec (olmesartan 20mg) or Blopress (candesartan 8mg) is an option, as it belongs to the class of angiotensin II receptor blockers (ARBs) just like valsartan. Considering that approximately 40 mg of valsartan is equivalent to 10 mg of olmesartan or 4 mg of candesartan, it may be advisable to prescribe Olmetec at a dose of 0.5 tablets or Blopress at a dose of 0.5 tablets per day as a suitable alternative.

2023-07-11

Our dermatologist prescribed fusidic acid and doxycycline on 2023-07-04 and these drugs are integrated into the active medication list without reconciliation issues found

2023-06-29

[to replace Forxiga with Jardiance]

  • Based on the HIS5 database records, the patient’s eGFR has remained within a range of approximately 40 to 50 mL/min/1.73 m2 for the past 30 days. 2023-06-26 eGFR 43, Cre 1.64mg/dL, age 75 male => CrCl 34mL/min.
  • Considering the patient’s type 2 DM and an eGFR below 45, the package insert advises against the use of dapagliflozin. However, empagliflozin can still be used for patients with an eGFR greater than or equal to 30. Therefore, it would be beneficial to switch from Forxiga (dapagliflozin 10mg) 1# QDAC to Jardiance (empagliflozin 10mg) 1# QD.

[patient education: 5-FU]

  • I visited the patient on 2023-06-29 at 13:30. The patient was lying in bed while his wife sat on the bench next to the bed. I brought an information sheet about fluorouracil and explained to both of them the precautions and possible side effects of the drug. I emphasized that because of the potential impact on his immune system, he should avoid raw foods and practice good food preparation hygiene. Since the patient’s renal function is relatively poor, I also reminded him to maintain adequate hydration.
  • During my visit, the patient seemed somewhat frail, even though he was capable of communicating without any difficulties. He seemed to lack energy and spirit. At the time of the visit, the patient did not express any specific concerns or complaints.

2023-06-26

[reconciliation]

  • The patient has had multiple medical appointments at different hospitals over the past few weeks. On 2023-05-23, the patient was seen at JingMei Hospital for hemorrhoids. Additional visits to JingMei Hospital include a visit on 2023-05-08 for contact dermatitis, and another one on 2023-05-01 for tinea corporis.
  • The patient also visited WanFang Hospital for various conditions. On 2023-04-30, he was treated for pneumonia; on 2023-04-29, for a gastric ulcer; and on 2023-04-24, for anemia.
  • The prescriptions from these visits seem to be mostly short-term, with the exception of a 28-day prescription for lansoprazole 30mg QDAC, which could possibly be refilled. Currently, this medication is included in the patient’s active medication list, therefore no reconciliation issues have been identified.

700787697

230725

[MedRec]

  • 2023-07-24 DutyNote Hemato-Oncology
    • The 82 y/o pateint 1) Hypertension, heart disease under control; 2) Diabetes mellitus, type 2 under control; 3) right renal stone; 4) L spine HIVD s/p op had admitted to our ward due to leukocytosis (WBC > 16K) at ER on 7/8. In order to rule out the possibility of multiple myeloma, the patient was admitted to our ward for bone marrow survey and further management. According to himself, he denied fever, chillness, dizziness, or other discomfort but bilateral leg edema with tenderness and slightly short of breathe but with fair saturation under nasal cannula 3L/min given.
  • 2023-06-13 SOAP Ophthalmology
    • Prescription (multiple)
      • Combigan Eye Drops (brimonidine 2mg, timolol 5mg) 1# Q12H OS
      • Vidisic Gel (carbomer 10gm) QID OU
      • Tears Naturale (hydroxypropyl methylcellulose 3mg, dextran 70) QID OU
  • 2023-06-06 SOAP Neurology
    • Prescription (multiple)
      • dipydidamole 25mg 1# BID
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# PRNQD
      • Rivotril (clonazepam 0.5mg) 0.5# PRNHS
      • Neurontin (gabapentin 100mg) 1# PRNHS
  • 2023-05-03 SOAP Metabolism and Endocrinology
    • Prescription (multiple)
      • NovoRapid (insulin aspart, recombinant) 15unit TIDAC
      • Toujeo (insulin glargine) 15unit HS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Lipanthyl Supra (fenofibrate 160mg) 1# QW1357
      • Through (sennoside 12mg) 2# HS
      • Tulip (atorvastatin 20mg) 1# QD
  • 2023-04-06 SOAP Cardiology
    • Prescription (multiple)
      • Norvasc (amlodipine 5mg) 1# BID
      • Syntrend (carvedilol 25mg) 0.5# BID
      • Meletin (mexiletine 100mg) 1# BID
      • Ulstop (famotidine 20mg) 1# QD
      • Plavix (clopidogrel 75mg) 1# QOD
      • Urief (silodosin 8mg) 1# QD

==========

2023-07-25

This patient has been regularly visiting multiple departments at our hospital and receiving several repeat prescriptions.

Cardiology prescribed the following medications: - Norvasc (amlodipine) - Syntrend (carvedilol) - Meletin (mexiletine) - Ulstop (famotidine) - Plavix (clopidogrel) - Urief (silodosin)

Endocrinology prescribed the following medications: - NovoRapid (recombinant insulin aspart) - Toujeo (insulin glargine) - Kentamin (vitamin B1, B6, B12) - Lipanthyl (fenofibrate) - Through (sennoside) - Tulip (atorvastatin)

Neurology prescribed the following medications: - Dipydidamole - Sketa (acetaminophen, chlorzoxazone) - Rivotril (clonazepam) - Neurontin (gabapentin)

Ophthalmology prescribed the following eye medications: - Combigan Eye Drops (brimonidine, timolol) - Vidisic Gel (carbomer) - Tears Naturale (hydroxypropyl methylcellulose, dextran 70)

All the oral drugs have been included in the active medication list, except for the eye medications. Please check if the patient still needs these eye medications.

700385796

230724

[exam findings]

  • 2023-07-15 MRI - brain
    • Indication: Esophageal cancer with regional lymph nodes are favored.
    • IMP: no evidence of brain metastasis.
  • 2023-07-14 SONO - abdomen
    • Suspected liver cyst,left
    • Suspected GB polyps
  • 2023-07-13 PET
    • A glucose hypermetabolic lesion involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in two upper left paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
    • A glucose hypermetabolic lesion in the posterior aspect of right acetabulum. The nature is to be determined. Please correlate with other imaging modalities such as MRI to rule out the possibility of bone metastasis.
    • Mild glucose hypermetabolism in a focal area in the anterior aspect of right 4th rib, possibly more benign in nature. However, please follow up bone scan for further evaluation.
  • 2023-07-13 Pure Tone Audiometry
    • Reliability FAIR
    • Average RE 33 dB HL; LE 34 dB HL.
    • Bil normal to moderately severe SNHL.
  • 2023-07-12 Treadmill Exercise Test
    • Conclusion
      • maximal exercise by RER>1.10
      • low exercise capacity ( VO2 48%, WR 65%) ( normal value >85%)
      • spirometry: normal (FVC 101%, FEV1 98%)
      • respiratory muscle strength: low ( MIP 59%, MEP 51%)
      • Breathing reserve normal
      • desaturation below 90%: nil
      • cardiac response during exercise normal
      • HR response during exercise: normal slope
      • work efficiency low
      • anaerobic threshold low
      • oxygen pulse low
      • BP response: normal
      • EKG: nonspecific findings
      • Health-related quality of life, CAT= 8, poor sleep 3
    • Impression:
      • low exercise capacity
      • low respiratory muscle strength
    • suggestion:
      • Treat underlying disease
      • Exercise training for low exercise capacity
      • Breathing exercise
      • low work efficiency, low AT, low O2p but normal cardiac response, suggest to arrange lower limbs doppler to survey PAOD
  • 2023-07-10 Tc-99m MDP bone scan
    • Two hot spots in the ant. aspect of the left 5th rib, and the right 4th rib, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-07-03 CT - chest
    • Indication: EGD today: favor esophageal cancer. s/p biopsy. arranged chest CT scan. refer to CS OPD on 2023-07-06 for further management.
    • Findings
      • Soft tissue mass at middle third esophagus up to 4.32cm is found.
      • Lymphadenopathy at paratracheal region is found.
      • Minimal tree in bud appearance at both lungs are found. Previous aspiration is suspected.
    • Imp: Esophageal cancer with regional lymph nodes are favored.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-06-30 Patho - esophageal biopsy
    • Esophagus, 25-30 cm below incisor, biopsy — Poorly differentiated squamous cell carcinoma
    • Microscopically, it shows poorly differentiated squamous cell carcinoma composed of a proliferation of non-keratinizing squamous tumor cells with invasive growth pattern, arranged in solid architecture and foci of c debris. The tumor shows nuclear hyperchromasia, pleomorphism and mitotic activity.
    • Immunohistochemical stain reveals P40(+), p63(+), CD56(focal +, 5%), CEA(-) and CDX-2(-).
  • 2023-06-30 Esophagogastroduodenoscopy, EGD
    • Highly suspected advanced esophageal malignancy, M/3
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis

[chemotherapy]

  • 2023-07-21 - cisplatin 30mg/2 47mg NS 500mL + fluorouracil 1000mg/m2 1580mg NS 500mL 24hr (PF CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701475030

230724

[exam findings]

  • 2023-03-30 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Hepatocellular carcinoma, moderately differentiated
    • The sections show a picture of hepatocellular carcinoma, moderately differentiated, composed of nests of polygonal neoplastic hepatocytes with moderate amount basophilic cytoplasm, arranged in trabecular pattern.
  • 2023-03-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, middle C-spine, L4, bilateral shoulders and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in the middle C-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-03-28 CT - abdomen
    • CC: left arm weakness for 3 weeks
      • 20230325 MRI: a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encasement of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted.
      • 20230325 AFP:70867 ng/mL (< 9). CEA, CA199, CA125, PSA, & SCC: normal Indication: R/O metastasis
    • Findings:
      • There are several kissing masses on right lobe of the liver, measuring 10 cm in size (the largest dimension), and showing contrast washout in delayed phase images.
        • HCCs on right lobe of the liver (T3) are highly suspected.
        • In addition, right superior segment portal vein is not visualized that is c/w tumor compression.
        • In addition, there is no enlarged node in the hepatic hilum (N0).
      • There is osteolytic lesion in left lateral aspect of C4 vertebral body and left transverse process that is c/w bony metastasis (M1).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Hepatocellular Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
  • 2023-03-25 MRI - C-spine
    • Indication: cervical 4-5 and 5-6 herniated interverteb disc disease, r/o tumor formation need enhancement for exclusion.
    • Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
      • normal bone alignment of the spine
      • a heterogeneous enhancing tumor, about 35mm, along the left cervical VA from the level of the C3 to C4 vertebral body. Tumor encaenment of the left cervical CA was noted. Tumor invasion to the C4 vertebral body and left prevertebral muscles was noted. Signal-void curvilinear structures in the lesion was noted.
      • unremarkable change in the visible cord.
      • degenerative change at the middle and lower C-spine disc spaces. Herniated disc in the C4/5 disc cuased moderate anterior indentation on the right C405 cord.
      • unremarkable change in the bone marrow signal intensity.
    • IMP:
      • a tumor in the left paravertebral and perivertebral spaces along the left VA at the levels of the C3 and C4 vertebral bodies.
      • herniated disc in the C4/5.

[chemoimmunotherapy]

  • 2023-05-09 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL

atezolizumab 2023-05-15 https://www.uptodate.com/contents/atezolizumab-drug-information

  • Brand Names: Tecentriq

  • Pharmacologic Category

    • Antineoplastic Agent, Anti-PD-L1 Monoclonal Antibody; Antineoplastic Agent, Immune Checkpoint Inhibitor; Antineoplastic Agent, Monoclonal Antibody
  • Dosing: Adult

    • Note: Per the manufacturer’s labeling, atezolizumab may be dosed at 840 mg IV once every 2 weeks or 1,200 mg IV once every 3 weeks or 1,680 mg IV once every 4 weeks. Indication, combination, and/or trial-specific dosing is listed below; refer to protocols for further information.
    • Alveolar soft part sarcoma, unresectable or metastatic
      • IV: 1,200 mg once every 3 weeks (as a single agent); continue until disease progression or unacceptable toxicity.
    • Hepatocellular carcinoma, unresectable or metastatic
      • IV: 1,200 mg once every 3 weeks (in combination with bevacizumab); continue until disease progression or unacceptable toxicity; may continue beyond disease progression if clinical benefit demonstrated
        • If bevacizumab is discontinued due to unacceptable toxicity, may continue atezolizumab monotherapy (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Melanoma, unresectable or metastatic (BRAF V600 mutation-positive)
      • IV: 840 mg once every 2 weeks (in combination with cobimetinib and vemurafenib); continue until disease progression or unacceptable toxicity; prior to initiating atezolizumab, patients should receive a 28-day treatment cycle of cobimetinib and vemurafenib. Refer to protocol for further information.
    • Non–small cell lung cancer, adjuvant treatment:
      • IV: 1,200 mg once every 3 weeks (as a single agent; after up to 4 cycles of adjuvant platinum-based chemotherapy); continue atezolizumab for up to 1 year, unless disease recurrence or unacceptable toxicity occurs.
        • Note: Select patients for atezolizumab therapy based on the programmed death-ligand 1 (PD-L1) expression on tumor cells.
    • Non–small cell lung cancer (NSCLC), metastatic:
      • Single-agent atezolizumab:
        • First-line treatment NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
          • Note: Select patients for atezolizumab therapy based on the PD-L1 expression on tumor cells or on tumor-infiltrating immune cells.
        • Previously treated NSCLC: IV: 1,200 mg once every 3 weeks; continue until disease progression or unacceptable toxicity.
      • Combination therapy:
    • First-line treatment, nonsquamous NSCLC:
      • IV: 1,200 mg on day 1 every 3 weeks (in combination with bevacizumab, paclitaxel, and carboplatin) for 4 to 6 cycles, followed by atezolizumab 1,200 mg on day 1 (followed by bevacizumab) every 3 weeks until disease progression or unacceptable toxicity; if bevacizumab is discontinued after the 4 to 6 cycles of combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
      • IV: 1,200 mg on day 1 every 3 weeks (in combination with paclitaxel [protein bound] and carboplatin) for 4 to 6 cycles; after the 4 to 6 cycles of induction combination chemotherapy, atezolizumab may be continued as a single agent (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Small cell lung cancer (extensive stage), first-line treatment:
      • IV: 1,200 mg once every 3 weeks (in combination with carboplatin and etoposide for 4 cycles), followed by maintenance therapy of single-agent atezolizumab (at any of the approved doses/intervals) until disease progression or unacceptable toxicity.
    • Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

==========

2023-07-24

[De-escalation of Cefepime]

Based on in-hospital stock, the only available third-generation oral cephalosporin is Ceficin (cefixime 100mg) at a recommended dosing frequency of 2# Q12H. As the patient’s laboratory data on 2023-07-24 showed normal values for creatinine and blood urea nitrogen (BUN), there is no need to adjust the dosage of Ceficin.

2023-05-15

  • This is the patient’s first dose of the immune checkpoint inhibitor atezolizumab during this hospiatalization. While this therapy is designed to boost the immune response against cancer cells, it can sometimes cause the immune system to attack normal organs and tissues in the body. These side effects are commonly referred to as immune-related adverse events (irAEs).
  • It’s important to closely monitor the patient for potential irAEs such as dermatologic symptoms (e.g., rash), endocrine and metabolic symptoms (e.g., hypothyroidism), and gastrointestinal symptoms (e.g., constipation, diarrhea, nausea, decreased appetite). Prompt recognition and treatment of these irAEs may help reduce their severity and prevent serious complications.
  • Atezolizumab is currently being administered in combination with bevacizumab. It is supposed to continue this combination until there is evidence of disease progression or the occurrence of unacceptable toxicity. If the patient continues to demonstrate clinical benefit, treatment may persist even beyond disease progression.
  • In case bevacizumab has to be discontinued due to severe side effects, atezolizumab monotherapy can be maintained until the disease progresses or until there are intolerable side effects.

701468195

230720

[diagnosis] - 2023-04-12 admission note

  • Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Cachexia

[past history]

  • DM(-), HTN(-)    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-05-26 CT - neck
    • With and Without contrast Neck CT showed
      • an extensive tumors in the nasopharynx with invasion to the posterior cranial fossa, upper C-spine spinal canal, bilateral parapharyngeal space, bilateral prevertebral fascia and left perevertebral space.
      • multiple enlarged heterogeneous enhancing lymph nodes in the bilateral neck, esp. left neck.
      • The major salivary glands were unremarkable.
      • skull bone invasion and bone metastasis at the upper C-spine and upper T-spine.
    • IMP: extensive tumors in the upper neck with LAP and bone metastasis. As compared with previous study on 20230131, the sizes were mildly decreased.
  • 2023-02-04 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 60 dB HL, LE 44 dB HL
    • R’t moderate to profound mixed type HL
    • L’t mild to severe HL.
    • (BC masking dilemma) ChatGPT: “BC masking dilemma” refers to a situation that can occur during pure tone audiometry when a sound presented to one ear through bone conduction (BC) also stimulates the opposite ear, making it difficult to determine the true threshold of the stimulated ear.
  • 2023-02-01 bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot spots in the right frontal region of the skull, some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet, in whole body survey.
    • IMPRESSION:
      • Hot spots in some C- and upper T-spine, faint hot spots in both rib cages, and increased activity in the sternum, malignancy with bone mets may be considered, suggesting further investigation and follow-up with bone scan in 3 months.
      • A hot spot in the the right frontal region of the skull, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in the maxilla, some L-spine, bilateral shoulders, elbows, S-I joints, hips, and feet.
  • 2023-01-31 MRI - nasopharynx
    • Indication: nasopharyngeal cancer, for cancer workup
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries.
      • Invasion of right Foramen of Ovale, but No definte intracranial invasion.
      • Invasion of right parotid gland (T4).
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage.
      • Destructions of left T1 boy and right T3 body were noted.
    • IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
  • 2023-01-31 SONO - abdomen
    • Diagnosis: negative
  • 2023-01-16 Patho - nasopharyngeal / oropharyngeal biopsy
    • Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B);
    • IHC stain: CK (+).
  • 2023-01-16 Nasopharyngoscopy
    • NP tumor(+), suspected NPC

[MedRec]

  • 2023-02-07 SOAP Radiation Oncology
    • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
    • He requests CCRT first.
    • Plan: CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered.
  • 2023-02-07 SOAP Hemato-Oncology
    • Arrange weekly CDDP for CCRT then followed by palliative PF
    • C/T will be given next week
    • RTC on 2023-02-16 for 2023-02-17 C/T

[consultation]

  • 2023-05-29 Thoracic Surgery
    • Q
      • This 47-year-old man patient had Nasopahryngeal Non-keratinizing carcinoma, undifferentiated, with bilateral neck LAPs metastasis, T4N3M1, stage IVB s/p chemotherapy with TPF (Taxotere 60mg/m2, CDDP 75mg/m2, 5FU 1000mg/m2x4days) from 2023/02/17.
      • This time, he suffered from poor appetite, easy choking for one weeks.
      • For unable to eat, hope ostomy implantation for intake, we need your further evaluation and management.
      • Thanks a lot!!!
    • A
      • I will arrange interview with his family and himself at my OPD. I will explain risk factor of jejunostomy and maybe tracheostomy if ETT (endotracheal tube) can not be weaning. I will arrange operation this week. Thanks for your consultation!!
  • 2023-02-11 Hemato-Oncology
    • A
      • For metastasis NPC, systemic therapy is indicated. Consider cisplatin-based regimens (Gemcitabine plus cisplatin may considered a preferred front-line option). Please arrange port A insertion.
      • Check EBV DNA, 24 urine CCR, HbsAg, Anti Hbc, Anti HCV, auditory test. Thanks for your consultation.
  • 2023-02-02 Radiation Oncology
    • Q
      • For CCRT for NPC, T4N3M1, stage IVB
      • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma work-up. Nasopharynx MRI arranged and showed NPC, bilateral neck LAPs, T4N3M1, stage IVB. Abd echo showed negative. Bone scan was done, and pending result. Concurrent chemoradiotherapy will be arranged after staging. We need your expertise for CCRT evaluation. Thanks a lot!
    • A
      • Subjective:
        • History: This is a 47-year-old man with no known underlying disease. He has suffered from painful left neck mass for 3 months. BW loss of 15 kg in 6 months, nasal obstruction, left hearing impairment, mild dysphagia and mild dyspnea during meal was noticed. He denied epistaxis, diplopia, otalgia, blurred vision or facial numbness. Therefore, the patient came to our OPD for help. Physical exam showed a 75 cm hard mass over left neck level II-III region and a 32 cm firm mass over right level V region. Fiberscopic exam showed nasopharyngeal tumor. Nasopharynx MRI showed NPC, bilateral neck LAPs, T4N3M1, stage IVB with bone metastasis. Abdomen echo showed negative. Bone scan showed multiple spines, ribs, pelvic bone metastasis (pending formal report).
          • Previous RT: denied.
          • Other disease: denied.
          • Family history: denied.
        • Habit: Alcohol: quitted; Smoking: 1 PPD for 20 yr, just quitted.; betel nut: quitted.
        • Single. Caregiver: his mother. Job: car wire. Mild economic stress.
        • Language: Mandarin. Taiwanese.
        • Religion: Buddism.
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 2023/02/02: Extensive LAPs over left and right neck, left SCF.
        • Pathology:
          • Nasopharyngeal Biopsy, 2023/01/16: Nasopahrynx, left, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B); IHC stain: CK (+).
          • left neck mass biopsy, 2023/01/16: Malignancy.
        • Images:
          • Nasopharynx MRI, 2023/01/31: Large nasopharynx tumor, bilateral, up to 11 cm, with skull base invasion, extension to bil. parapharyngeal spaces, encasing bil. carotid arteries. Invasion of right Foramen of Ovale, but No definite intracranial invasion. Invasion of right parotid gland (T4). Multiple bil. neck LAPs, especially at left, below the low border of cricoid cartilage. Destructions of left T1 bony and right T3 body, spinous process of C5-6 were noted. IMP: NPC, bilateral neck LAPs, T4N3M1, stage IVB
          • Bone scan, 2023/02/01: multiple spines, ribs, pelvic bone metastasis (report pending).
          • CXR, liver echo, 2023/01: negative for metastasis.
          • EBV DNA titer: pending.
      • Diagnosis: Nasopharyngeal carcinoma, non-keratinizing carcinoma, undifferentiated, with extensive LN metastasis and bone metastasis, cT4N3M1, stage IVB; BW loss of 15 kg in 6 months; ECOG =1.
      • Plan: Systemic chemotherapy with standard regimen is suggested for systemic control. CCRT to NPX tumor and LAPs, C spine metastasis for 7140cGy/34 fx may also be considered. Possible treatment toxicity of chemotherapy and radiotherapy is told. Diet education is given but nutrition consultation is also recommended.
  • 2023-01-30 Oral and Maxillofacial Surgery
    • Q
      • This is a 47-year-old man with no known underlying disease. This time, he was admitted to our ward for nasopharyngeal carcinoma cancer workup. Concurrent chemoradiotherapy will be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
    • A
      • This is a 47-year-old man suffering from nasopharyngeal carcinoma and is scheduled for further CCRT treatment. This time, we were consulted for dental evaluation before radiotherapy.
      • S: No specific discomfort over full mouth
      • O:
        • Panoramic findings:
          • Missing: Nil
          • Impaction: 48
          • Caries: Nil
          • Crown and bridges: Nil
        • Periodontal condition: Full mouth chronic periodontitis
        • Trismus due to large tumor compression over left neck was noted.
        • No specific intraoral lesion
      • P:
        • Explained the findings to the patient and his family.
        • Suggest keep good oral hygiene
        • No tooth extraction or treatment is needed at this moment. Suggest OPD follow up every 6 months

[surgical operation]

  • 2023-05-30
    • Surgery
      • Feeding jejunostomy + tracheostomy
    • Finding
      • 18 Fr. silicon Foley catheter as feeding jejunostomy.
      • 8.0 mm tracheostomy tube.

[chemotherapy]

  • 2023-04-12 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-14 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-17 - docetaxel 60mg/m2 100mg NS 250mL 1hr D1 + cisplatin 75mg/m2 115mg NS 500mL 24hr D1 (with 5-FU) + [furosemide 20mg NS 30mL (30min after cisplatin) + MgSO4 10% 20mL NS 100mL (1hr after cisplatin)] D2 + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (TPF)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[note]

TPF regimens for Neoadjuvant Chemotherapy (in-hospital Chemotherapy Regimens for Head and Neck Cancer: Collection as of 2022-02-11) - see No.701240721, with docetaxel 40mg/m2 and cisplatin 40mg/m2

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-04-13 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438

  • Cycle length: Every 21 days for three cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 100 mg/m2 IV
      • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 1000 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 4

In search for optimal induction chemotherapy for advanced nasopharyngeal cancer: Standard dosing of Docetaxel, Platinum, and 5-Fluorouracil (TPF) followed by chemoradiation. Published: 2023-02-02. https://doi.org/10.1371/journal.pone.0276651

  • induction standard dose T (75 mg/m2) P (75 mg/m2) F (750 mg/m2 IVCI x 5days) x 3 followed by weekly cisplatin (40 mg/m2) or carboplatin (AUC 1.5) x 6 concurrent with radiation therapy of 70 Gy over 6.5 to 7 weeks.
  • The 2-year progression free survival (PFS) rate for the M0 cohort was 90% (95% CI: 77.8%-100%), and was sustained at 5 years. The 2-year PFS rate for the M1 cohort was 66.7% (95% CI: 37.9%-00%). The 2-year overall survival (OS) rates for the M0 and M1 cohorts were 100% and 83.3% (95% CI: 58.3%-100%), respectively. At five years, OS was 94.4% for the M0 cohort.
  • Conclusion: Administration of standard-dose TPF as induction chemotherapy in this NPC patient population is both feasible and effective when coupled with definitive concurrent chemoradiation.

==========

2023-07-20

[duplicated H2RA]

The concomitant use of histamine H2-receptor antagonists such as Stogamet (cimetidine 300mg) and Ulstop (famotidine 20mg) is generally not recommended. Both drugs work by reducing the production of stomach acid, and using them together may increase the risk of side effects. It is advisable to evaluate the need to use these two drugs together to ensure drug safety.

2023-03-15

  • On 2023-02-25, a leukopenia event was observed in the patient with a WBC level of 2.88K/uL. This occurred approximately 1 week after the patient’s first TPF treatment, and will need to be closely monitored.
  • No medication reconciliation issues have been identified for the patient.

700132489

230717

[diagnosis] - 2023-04-06 admission note

  • Malignant neoplasm of unspecified site of unspecified female breast

  • 2023-03-17 discharged note

    • Malignant neoplasm of unspecified site of unspecified female breast
    • Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease
    • Insomnia, unspecified
    • Left breast cancer, 11/2.5 cm s/p SM + SLNB in 2018/07, ER(95%) PR(60%) Her2/neu(+) Ki-67: 60%, with left lower lobe lung metastasis, and bone metastasis - post anastrozole since 2022/03/23, shifted to Kisquali (ribociclib) on 2022/04/20, added Anazo on 2022/04/27, with multiple bilateral lung metastases with pleural involvements, multiple liver metastases, and multiple bony metastases according to the Positron Emission Tomography and computed tomography on 2023/03

[past history] - 2023-03-15 admission note

  • old CVA (20100402)
  • chronic left leg DVT (2017601)
  • HTN,
  • HCVD,
  • GERD,
  • hyperlipidemia,
  • cataract, insomnia,
  • left metastatic breast carcinoma /p operation and post treated at Taipei Medical University Hospital.

  [allergy]

  • NKDA

[family history]

  • Unknown of DM, CVA, cancer or CAD in her family

[exam findings]

  • 2023-07-06 SONO - abdomen
    • Hepatic tumors R/O metastasis
    • Focal fatty liver, mild
    • Prob. Parenchymal liver disease
    • Cholecystopathy
    • Rt renal cyst
    • Minimal ascites
  • 2023-07-05, 2023-06-21 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • There are several nodular opacity projecting in both lower lung that are c/w metastases after correlate with CT.
  • 2023-07-05, -06-28 KUB
    • Osteoblastic change of right sacrum is highly suspected. Please correlate with CT.
  • 2023-05-31 CT - chest
    • Indication: Breast cancer with lung and liver mets
    • Comparison was made with CT on 2023/02/25
      • Lungs: multiple nodules of variable sizes in both lungs upper to 22mm at LLL due to metastases.
      • Vessels: mild calcified plaques of the LAD coronary artery.
      • Thoracic aorta: dilated ascending aorta (4.3cm). mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: dilated LA, conventric LVH, mild calcified aortic valves
      • Chest wall and visible lower neck: s/p Rt MRM.
      • Visible abdominal-pelvic contents: diffuse heterogeneous enhancement of Lt hepatic lobe, in regression.
      • Extensive atherosclerotic change of the abdominal aorta and bilateral iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • IMP: breast ca with progression of lung metastasis and regression of hepatic metastasis compared with CT on 2023/02/25
  • 2023-04-07 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Patchy opacity projecting at right upper lung zone was suspected.
    • Please correlate with CT.
  • 2023-03-23 MRI - brain
    • Findings:
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • MR angiography of the brain shows atherosclerotic change of intracranial and carotid vessels.
      • Left mastoiditis.
    • Impression:
      • Aging brain appearance.
  • 2023-03-16 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (114 - 25) / 114 = 78.07%
      • M-mode (Teichholz) = 78
    • Dilated LA
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild AR
  • 2023-02-25 CT - abdomen
    • History and indication: left abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Poor enhancement of left hepatic lobe r/o malignancy. Poor enhancing nodules at S1 and right hepatic lobe.
      • Multiple nodules at bil. lungs.
      • Renal cysts (up to 1.8cm).
      • Normal appearance of spleen, pancreas, adrenals.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Suspected liver malignancy with lung metastases.
  • 2023-02-25 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-02-22 Nasopharyngoscopy
    • erosion on bil nasal septum, smooth NPx, OPx, a cyst over R AE fold
  • 2022-12-30 CT (Taipei Medical University Hospital)
    • Findings
      • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
      • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
      • No significant pleural effusion.
      • Calcifications of the aorta and coronary arteries are present.
      • S/P left mastectomy
      • No evidence of local recurrence or axillary lymphadenopathy is noted.
      • There is no evidence of masses in the anterior, middle and posterior compartment.
      • No significant enlarged lymphadenopathy is noted in the mediastinum.
      • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation.
      • No significant bone destruction is noted.
    • IMPRESSION:
      • Progressive change of the metastatic nodules at both lung fields, the largest one is 2.1 cm at superior segment of LLL.
      • Still mild radiation pneumonitis at anterior portion of the left lung, stationary.
      • S/P left mastectomy without local recurrence or axillary lymphadenopathy is noted.
      • Newly developed hypodensity lesions at left lobe liver, suggest MRI for further evaluation
  • 2022-12-02 24hr portable ECG
    • Sinus rhythm
    • Occasional isolated apcs
    • Rare apc couplets
    • A few isolated vpcs
    • A few episodes of 2:1 sinoatrial exit block, longest R-R interval 2.26 secs at 04:44
    • No significant tachyarrhythmia
  • 2022-12-02 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-12-02 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (110 - 33) / 110 = 70%
      • M-mode (Teichholz) = 70
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis with trivial AR; mild posterior mitral annulus calcification.
    • Prominent aortic root calcification with protruding atheroma (8.8 mm of thickness); dilated proximal ascending aorta (38 mm).
  • 2020-09-03 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2019-11-19 CT - chest
    • no mediastinal mass or enlarged LN. (Lateral bulge in right superior mediastinum due to tortousity of innominate artery on chest radiograph).
    • dilated ascending aorta (4.5cm in diameter).
    • 4mm LLL nodule and old granulomas in hilum and mediastinum.
  • 2019-10-17 Upper GI panendoscopy
    • Reflux esophagitis, LA classification grade A  - Chronic superficial gastritis, whole stomach  - Gastric erosions  - s/p CLO
  • 2019-03-29 C-spine AP + Lat
    • Radiograph of the cervicaloorphic degeneration of C-spine. Decreased disc space at C5-6-7.
  • 2019-03-11 SONO - abdomen
    • suspect liver parenchyma disease/ incomplete exam of liver
  • 2019-03-11 Carotid PhonoAngiograph, CPA
    • mild atheroma on right ICA, moderate atheroma on right carotid bifurcation with diameter reduction of 42%, mild atheroma on left ICA, moderate atheroma on left carotid bifurcation with diameter reduction of 49%
    • normal flow and flow velocities on bil. extracranial carotid and vertebral arteries
  • 2018-11-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (143 - 51) / 143 = 64.34%
      • M-mode (Teichholz) = 64
    • Septal and RV hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation.
    • Dilated LV with normal LV and RV systolic function.
    • Mild AV sclerosis and posterior mitral annulus calcification with mild AR; trivial MR; mild TR.
    • Dilated proximal ascending aorta (38mm) with mild calcification; protruding non-mobile atheroma (18 mm x 7mm) at sinotubular junction.

[chemotherapy]

  • 2023-05-17 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-04-27 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-04-07 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2
  • 2023-03-16 - Enhertu (trastuzumab deruxtecan) 5.4mg/kg 200mg D5W 100mL 90min
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-2

==========

2023-07-17

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No medication reconciliation issues were identified during her current admission.

2023-07-14

Recently, a noticeable increase in ALT, AST and bilirubin levels can be seen based on the weekly lab data.

2023-07-12 S-GPT/ALT 119 U/L
2023-07-05 S-GPT/ALT 129 U/L
2023-06-28 S-GPT/ALT 132 U/L
2023-06-21 S-GPT/ALT 145 U/L
2023-06-14 S-GPT/ALT 112 U/L
2023-06-07 S-GPT/ALT 53 U/L
2023-07-12 S-GOT/AST 431 U/L
2023-07-05 S-GOT/AST 279 U/L
2023-06-28 S-GOT/AST 180 U/L
2023-06-21 S-GOT/AST 169 U/L
2023-06-14 S-GOT/AST 115 U/L
2023-06-07 S-GOT/AST 66 U/L
2023-07-12 Bilirubin total 2.73 mg/dL
2023-07-05 Bilirubin total 1.90 mg/dL
2023-06-28 Bilirubin total 1.00 mg/dL
2023-06-21 Bilirubin total 0.56 mg/dL
2023-06-14 Bilirubin total 0.40 mg/dL
2023-06-07 Bilirubin total 0.34 mg/dL

Per UpToDate, Enhertu (trastuzumab deruxtecan) is linked to a raised serum alanine aminotransferase (34% to 53%), elevated serum alkaline phosphatase (22% to 54%), increased serum aspartate aminotransferase (35% to 67%), and elevated serum bilirubin (16% to 24%).

According to the Enhertu label, there are limited data available for patients with moderate hepatic impairment, and none for patients with severe hepatic impairment. Given that metabolism and biliary excretion are the primary elimination routes for the topoisomerase I inhibitor component (DXd) in Enhertu, caution should be exercised when administering Enhertu to patients with moderate or severe hepatic impairment. The package insert does not provide dose adjustment guidelines based on LFT readings. It might be suggested to temporarily withhold the drug until the drug is ruled out as the cause of deterioration of liver function.

2023-04-07

  • Based on the patient’s medical history and current condition, it is recommended that Xarelto (rivaroxaban) be resumed after Port-A catheter placement.

2023-03-16

  • According to the recommended dosage guidelines, for patients with unresectable or metastatic breast cancer, regardless of HER2-low or HER2-positive status, Enhertu (trastuzumab deruxtecan) should be administered at a dose of 5.4 mg/kg once every three weeks until disease progression or unacceptable toxicity. Based on the patient’s body weight of 57.5kg recorded on 2023-03-15, the appropriate dosage of Enhertu would be 310mg. However, considering the patient’s advanced age and the fact that this is her first time receiving this drug, a reduced dosage of 200mg has been used.
  • Interstitial lung disease (ILD) and pneumonitis, including fatal cases, have been reported with fam-trastuzumab deruxtecan. Please monitor for and promptly investigate signs and symptoms including cough, dyspnea, fever, and other new or worsening respiratory symptoms.

700887181

230717

[diagnosis] - 20230103 admission note

  • Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck
  • Non-follicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites
  • Cardiac arrhythmia, unspecified

[present illness] - 20230103 admission note

  • This 75 y/o man is a case of HTN, CKD stage3, urothelial carcinoma, high-grade s/p TURBT on 2009-01-21, 2010-10-01 and 2011-01-20. (TURBT, transurethral resection of bladder tumor)
  • He was diagnosed with diffuse large B-cell lymphoma in 201706, stage IV with bone, bone marow involvement. He received chemotherapy with R-DA-EPOCH on 201706 ~ 201710. R-CHOP on 2018/10/17 and 2018/11/29. R-ICE (Mabthera + Etoposide + Ifosfamide) on 2018/12/26 ~ 2019/06/13. He received stem cell collection on 2019/03/05 ~ 07 but inadequate cell number was collected for auto PBSCT.

[past history]

  • Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement, diagnosed on 201706 s/p chemotherapy
  • HTN
  • CKD stage3
  • urothelial carcinoma, high-grade s/p TURBT
  • Appendicitis s/p appendectomy

[Allergy]

  • NKDA

[family history]

  • Father - prostate cancer

[lab data]

  • 2022-12-05 Anti-HCV Nonreactive
  • 2022-12-05 Anti-HCV Value 0.06 S/CO
  • 2022-12-05 Anti-HBc Reactive
  • 2022-12-05 Anti-HBc-Value 2.18 S/CO
  • 2022-12-05 HBsAg Nonreactive
  • 2022-12-05 HBsAg (Value) 0.41 S/CO
  • 2022-12-05 Anti-HBs 8.79 mIU/mL

[exam findings]

  • 2023-05-12, -05-10, -05-03 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • S/P autosuture projecting at left middle lung.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
    • Compression fracture of T12 vertebral body?
    • Spondylosis with scoliosis of the T-spine with convex to right side.
  • 2023-03-28 PET scan
    • In comparison with the previous study on 2022-11-07, the previous lesion in the lymph node in the left posterior lower neck region and the glucose hypermetabolism in the bone marrow of the skeleton are a little more evident. Lymphoma in a little more progression should be watched out. However, other glucose hypermetabolism in the left SCF and right axillary lymph nodes, bilateral pulmonary hilar lymph nodes, mediastinal lymph nodes, bilateral lungs, left lower lung pleua and left rib cage is a little less evident.
    • Increased FDG uptake in the right tonsil. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-03-09 CT - neck
    • Indication: relapsed DLBCL, Lugano stage IV
    • Head and Neck CT without IV contrast administration shows (comparison: 2022/11/23 Chest CT with and without contrast)
      • Residual enlarged LNs in left low posterior neck, the supraclavicular fossa.
      • Multiple Small bil. neck LNs also were noted.
      • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass.
    • Chest, abdomen and pelvis (noncontrast):
      • An ill-defined nodule in left anterior part of LUL, another smaller one in low posterior part, nature?
      • No evident abnormal enlarged lymph node in the mediastinum, paraaortic spaces or iliac region.
      • Gallstones were noted incidentally.
      • BPH with bladder tumor?
      • Multi-focal osteoblastic change of TL-spine also were found.
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 30) / 80 = 62.50%
      • M-mode (Teichholz) = 62
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2022-12-05, 2022-11-21, 2021-12-21, 2020-08-17, 2019-03-01 ECG
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-11-25 Patho - lymphnode biopsy
    • Lymph node, neck, left, biopsy — Diffuse large B-cell lymphoma and see comment
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Lymph node, neck, left
      • Procedure: Biopsy
      • Tumor site: Left neck
      • Histologic type: Diffuse large B-cell lymphoma
      • Immunophenotyping: CD3(-), CD20(+), PAX5(+), BCL6(+), CD10(+), and MUM1(-)
      • Comment: The findings favor germinal center B-cell subtype
  • 2022-11-25 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Hypocellular marrow without evidence of lymphoma involvement
    • The sections show hypocellular marrow (5%). Small amount of hematopoietic cells and focal hemosiderin deposition can be found. There is no evidence of lymphoma involvement in CD3, CD20, CD10, PAX5 and BCL6 immunostains.
  • 2022-11-23 CT - chest
    • Comparison was made with prior CT dated on 2021/10/30
      • Lungs:
        • a 17mm spiculated nodule at S3 with pleural tail at LUL. a nodular opacit at S6 and a long coarse reticular opacity in LLL. as compared with previous CT study.
      • Mediastinum and hila: large soft-tissue mass along the left anterior prevascular space and A-P window. small LNs in other locations of visceral space.
      • Vessels:
        • Thoracic aorta: normal in caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal in caliber.
        • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt pleural effusion.
      • Chest wall and lower neck: multiple small LNs and a 17mm LAP in left lower posterior triangle of neck. small LNs in bilateral submandibular spaces.
      • Visible abdominal-pelvic contents: splenomegaly mutliple small areas of low attenuations. enlarged prostate.
        • a small Lt renal cyst (30mm) and small-sized of Rt kidney. many gall bladder stones. no enlarged lymph node.
        • unremarkable of the liver, adrenal glands, and pancreas.
      • Visualized bones: blastic change in many vertebrae and sternum, and marked compression fracture of L1 vertebral body.
    • Impression:
      • Diffuse large B-cell lymphoma s/p treatment with residual nodular lesions and fibrotic scar or linear atelectasis in lungs, and bony involvment, stationary, and visible newly splenic involvement and mediastinal and left LAP, compared with CT 2021/10/30.
  • 2022-11-07 Whole body PET scan
    • In comparison with the previous study on 2022-01-03, most of above-mentioned lymph node regions and bilateral lungs of glucose hypermetabolism come to more evident.
    • In addition, there are several new lesions of increased FDG uptake in a lymph node in the left post. lower neck region, left ICF, right axillary region, bilateral mediastinal space, left lower lung pleua, and several upper T-spine.
    • Diffuse large B-cell lymphoma s/p treatment with tumor recurrence in multiple lymph node regions on the same side of the diaphragm and involvement of bilateral lungs, left lower lung pleura, left rib cage, and several upper T-spine, rc-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-10-26 MRI - L-spine
    • Indication:
      • DLBL, double hit (CT-guided biopsy from rt kidney), involving rt kidney, paraortic LNs, multiple bone. follow up
      • bladder CA
    • IMP:
      • herniated discs in the L1/2, L2/3, L3/4 and L4/5 discs
      • subacute compression fractures at L2 and L4 vertebral bodies
  • 2022-10-26 Cystoscopy
    • Clinical History: bladder cancer s/p TUR-BT on 20110119
    • PH:
      • bladder cancer s/p TUR-BT on 20090121 and on 20100930, s/p intravesical C/T with Cistplatin, Adriamycin
      • Hypertension
      • s/p appendectomy.
    • Comment / Suggestion:
      • BPH, No tumor recurrent
  • 2022-09-21 Tc-99m MDP whole body bone scan
    • Two new lesions of increased tracer uptake at the L4 spine and post. aspect of the left 6th rib, respectively compared with the previous study on 2021-11-22, the nature is to be determined (post-traumatic change or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
    • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, L1-2 spines, bilateral shoulders, right S-I joint, hips, and left knee.
  • 2022-01-03 Whole body PET scan
    • In comparison with the previous study on 2020-05-18, glucose hypermetabolism lesions in bilateral pulmonary hilar lymph nodes and bilateral mediastinal lymph nodes come to more evident, reactive change in response to locoregional inflammation, however, may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
    • Glucose hypermetabolism lesions in bilateral lungs show no significant chnage, probably inflammation process.
    • Glucose hypermetabolism lesions in the left 4th and 5th ribs become more evident also, post-traumatic change or lymphoma with involvement of bone marrow may show such a picture, suggesting biopsy for investigation.
    • Glucose hypermetabolism lesions in the right inguinal lymph nodes, probably reactive nodes.
    • No abnormally increased FDG uptake is evidently delineated elsewhere.
  • 2021-12-07 MRI - L-spine
    • Diffuse spinal metastases with mild ventral dural sac compression. Mild to moderate spinal canal stenoses.
  • 2021-11-22 Tc-99m MDP whole body bone scan
    • A new lesion of increased tracer uptake at the L2 spine compared with the previous study on 2020-05-27, the nature is to be determined (post-traumatic change, new bone mets or others ?), suggesting follow-up with bone scan in 3 months for further investigation.
    • Suspected benign lesions in the left high frontal region of skull, maxilla, mandible, bilateral shoulders, right S-I joint, hips, and left knee.
  • 2021-10-30 CT - chest
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Nodular lesions at both lungs up to 1.4cm at left upper lobe is found. In comparison with CT dated on 2021-07-02, the lesions are stationary.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • The liver, spleen, pancreas, and adrenals are intact.
        • Atrophy of both kidneys are found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Stationary nodular lesions at both lungs.
      • Bilateral renal atrophy.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
  • 2021-07-02 CT - abdomen
    • Comparison: prior CT dated 2021/01/30.
      • Bilateral lung nodules (more at left side), staionary.
        • Fibrotic infiltrates in bilateral upper lung.
      • The spleen shows prominence in size (the greatest anterior-posterior dimention measuring about 12.2 cm in length).
      • A renal cyst measuring 2.6 cm in left upper pole is noted.
        • Atrophy of right kidney is noted that is c/w chronic renal disease.
      • There are two gallstones (< 1 cm).
      • Prior CT identified multiple osteoblastic bony metastases in the spine and pelvic bone are not noted. please correlate with clinical condition.
        • Compression fracture of L1 vertebral body. Spondylosis with scoliosis of the L-spine with convex to left side. Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
    • Impression:
      • Bilateral lung nodules (more at left side), staionary.
  • 2021-01-30 CT - abdomen
    • Gallbladder stones.
    • Suspected left renal cyst, 2.7cm.
    • Relative atrophy of right kidney.
    • Enlarged prostate gland.
    • Persistent bilateral lung nodules.
    • Tree-in-bud infiltrates in right lower lung, could be due to inflammation.
  • 2020-09-11 Uroflowmetry
    • Q max: low
  • 2020-08-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 33.3) / 99.8 = 66.63%
      • M-mode (Teichholz) = 66.6
    • Adequate LV systolic function with no regional wall motion abnormality at resting state
    • Trivial tricuspid regurgitation
    • LV hypertrophy
    • Impaired LV relaxation
  • 2020-06-17 bladder sonography
    • PVR 9.84 mL
  • 2020-05-27 Tc-99m MDP whole body bone scan
    • All lesions are old and show stationary or less evident radioactivity compared with the previous study on 2019-08-14, indicating response to current therapy.
    • Suspected DJD at shoulders, and left knee.
  • 2020-05-20 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2020-05-18 PET
    • A mildly glucose-hypermetabolic nodule in upper lobe of left lung that had been stationary comparing with the previous study on 2019/03/20 and several previous CT scans of chest, an inflammatory lesion is likely. Please correlate with other imaging modalities and clinical findings and keep follow up for further evaluation.
    • Mild to moderate glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and some mediastinal lymph nodes, reactive change in response to locoregional inflammation may show such a picture. Please correlate with clinical findings and keep follow up to exclude the possibility of malignancy involvement.
    • In comparison with the previous study, there were newly developed, mildly to moderately glucose-hypermetabolic lesions in posterior aspect of the left 4th and 5th ribs. Post-traumatic inflammatory changes are likely but possibility of malignancy involvement cannot be totally excluded. Please correlate with clinical findings and keep follow up for further evaluation.
    • Probably reactive change resulting from locoregional inflammation in right inguinal lymph nodes.
    • Probably post-traumatic inflammatory change in right femoral head.
    • Probably an inflammatory lesion in skin overlying right sacral region.
  • 2018-09-26 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 23) / 83 = 72.29%
      • M-mode (Teichholz) = 72
    • Normal chamber size
    • Concentric LV hypertrophy
    • Adequate LV and RV performance
    • Possibly impaired LV relaxation
    • Mild MR, TR and PR
    • AV sclerosis with trivial AR
    • No regional wall motion abnormalities
  • 2018-09-22 CT - abdomen
    • History and indication: AKI suspected obstrucitve uropathy
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • Non-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of urinary bladder.
      • A nodule (2.9cm) in left kidney r/o cyst. Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
      • Tiny gall stones (2-4mm).
      • Normal appearance of liver, spleen, pancreas, adrenals.
      • Compression fracture of L1. Multiple bony metastases.
    • Impression:
      • Wall thickening of urinary bladder.
      • Right hydronephrosis. Left hydronephrosis and hydroureter. Some LNs at retroperitoneum and bil. pelvic cavity.
      • Multiple bony metastases.
      • Tiny gall stones (2-4mm).
  • 2018-09-05 MRI - T-spine
    • benign subacute compression fracture in the L1 vertebral body
    • focal heterogeneous enhancement in the T12 and T9 vertebral bodies. Nature?
  • 2018-08-16 CT - abdomen
    • Multiple bony metastases. Much regression of LAP. Suspected right renal metastases (2.0cm).
  • 2018-05-07 Tc-99m MDP whole body bone scan
    • The old lesions in the skull, multiple C-, T- and L-spine, sternum, left scapula, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilateral S-I joints and left femur show less prominent compared with the previous study on 2018/01/05, indicating response to current therapy.
    • However, a new focal lesion in the mandible is noted, and the nature is to be determined (anti-tumor drug-related, dental problem or ther nature ?), suggesting further investigation.
  • 2018-05-07 Surgical pathology Level IV
    • pathologic diagnosis
      • Kidney, right, CT guided needle biopsy —– Diffuse large B cell lymphoma
    • macroscopic description
      • Operation procedure: CT guided needle biopsy
      • Topology: Kidney, right
      • Specimen size and number: 2 cores, the longer one, 0.7 x 0.1 x 0.1 cm.
    • microscopic examination
      • 1.Histology type: B-cell neoplasms: Diffuse large B-cell lymphoma
      • Immunohistochemical stain profiles: IHC stain: CD3 (focal+), CD20 (diffuse +), B cell predominance. bcl-2 (+), bcl-6 (+), CD10 (equivocal), CK (-).
      • REFERENCE: C-myc(+, >90%) (S2017-8170) supporting double hit type.
  • 2018-04-30 CT - abdomen
    • Multiple bony metastases. Multiple enlarged LNs (0.5-3.5cm) at paraarotic region. Suspected right renal metastases (6.6cm).
  • 2018-01-05 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest that multiple bone metastases. In comparison with the previous study on 20170323, some of the previous bone lesions in the sacrum and bilateral S-I joints are less evident. However, more bone lesions in the skull, some C- and T-spines, sternum, some ribs, left pubic bone and left femur are more prominent. Please correlate with other clinical findings for further evaluation.
  • 2017-12-25 CT - abdomen
    • Multiple bony metastases. A tiny nodule (5mm) at LLL. Gall stones (5-6mm).
    • Enlargement of prostate.
  • 2017-11-14 PET
    • In comparison with the previous study on 2017/04/26, the glucose hypermetabolism in right axillary lymph node is much less evident and no prominent FDG uptake is noted in other previous lymph node lesions.
    • The previous multiple FDG avid bone lesions are either less evident or disappeared.
  • 2017-08-18 CT - abdomen
    • Malignancy lymphoma s/p treatment with regression of paraaortic lymph nodes.
    • Multiple bone metastsis.
    • GB stones.
    • Enlarged prostate gland.
  • 2017-05-26 Surgical pathology Level IV
    • Indication: Malignant bladder neoplasm, part unspecified
    • Soft tissue, left neck, excision — Malignant B cell lymphoma, consistent with diffuse large B cell lymphoma
    • Microscopically, the sections show a picture of histiocytes-rich malignant B cell lymphoma consists of some large atypical lymphoid cells.
    • The Immunohistocehmcial study reveals CD3(-), CD20(+), CD10(+), Bcl-2 (+), C-myc(+, >90%), Bcl-6(+, focal), CD30(-), CD68(-) and CK(-).
    • According to the histopathologic findings, it is consistent with diffuse large B cell lymphoma, centroblastic type, and histiocyte-rich variant maybe considered.
  • 2017-04-26 PET
    • Glucose hypermetabolic lesions in multiple sites throughout the axial skeleton, bilateral humeri, and bilateral femurs, suggesting multiple lesions of osseous metastasis. In comparison with the skeletal scintigraphy performed on 2017/03/23, the distribution of metastatic lesions in bones had extended to include the skull, both humeri, and both femurs. The finding suggested progression, and hence a very limited response to the previous treatment, of the malignancy. However, flair-up phenomenon sometimes occurs when PET/CT scan is performed too close to the last session of radiation therapy. It is suggested that PET/CT scan be arranged at least 6 weeks after the completion of radiation therapy.
    • Glucose hypermetabolic lymph nodes in bilateral inguinal regions, the right axillary region, bilateral infraclavicular and supraclavicular regions, and the left lower cervical region, suggesting metastases to both regional and distant lymph nodes.
    • Uroepithelial carcinoma of uncertain primary site, with multiple lesions of regional lymph node metastasis, distant lymph node metastasis, and bone metastasis, by this F-18-FDG PET/CT scan.
  • 2017-03-31 CT - abdomen
    • Diffuse lymph nodes metastasis (paraaortic and pelvic cavity) and bone metastasis, bladder malignancy? Suggest PSA data correlation for possibility prostate malignancy.
    • Enlarged prostate gland.
    • Suspected liver cysts.
  • 2017-03-23 Tc-99m MDP whole body bone scan
    • The scintigraphic findings suggest that multiple bone metastases should be considered. Please correlate with other clinical findings for further evaluation.
  • 2017-03-15 MRI - L-spine
    • herniated discs in the L3/4 and L4/5 discs
    • tumors in the visible L-spine and T-spine, and pelvic bones
    • mild spondylolisthesis at L3-4

[MedRec]

[consultation]

  • 2023-05-11 Infectious Disease
    • Q
      • The 76 y/o woman has relapse double hit diffuse large B-cell lymphoma with bone marow, right kidney, paraortic LNs and multiple bone involvement, Lugano stage IV will do the stem cell collaction.
      • Due to fever, we gave Tapimycin treatment, but watery diarrhea noted this morning, so we escalated to Doripenam treatment. Thanks!
    • A
      • WBC: 520, Fever: +
      • Agree with your use of Finibax.
      • Please collect B/C.
      • Protective isolation.
  • 2021-12-21 Radiation Oncology
    • Q
      • The 74-year-old man patient had history of 1) Hypertension, Chronic renal injury 2) Urothelial carcinoma, high-grade on 2011-01-24. 3) Diffuse large B-cell lymphoma, stage IV with bone, bone marow involvement since 2017. Bone scan on 2021-11-22 showed a new lesion of increased tracer uptake at the L2.
      • This time, he has flank soreness progress and numbness of both leg for 1 month. L-spine MRI on 2021-12-07 revealed diffuse spinal metastases with mild ventral dural sac compression, mild to moderate spinal canal stenoses. We need your help for tissue proof. Thanks!
    • A
      • MRI show multiple thoracic and lumbar spinal metastases.
      • Biopsy can be done at L2, for further confirmation.

[chemoimmunotherapy]

  • 2023-06-30 - busulfan 3.2mg/kg 190mg NS 400mL 3hr D1-3 + etoposide 400mg/m2 500mg NS 30mL 6hr D3-4 + cyclophosphamide 50mg/kg 2900mg NS 500mL 4hr D5-6 (BuCyE)
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + palonosetron 250ug D1 + granisetron 2mg D3-6 + aprepitant 125mg D5-7 + NS 250mL D1-6
  • 2023-05-03 - etoposide 500mg/m2 600mg NS 30mL 2hr (20% off due to impaired renal function)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-03-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-02-10 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-01-17 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2023-01-03 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2022-12-21 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D2 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 (R-GemOx)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + granisetron 2mg D2 + NS 250mL D1-2
  • 2022-12-07 - rituximab 375mg/m2 600mg NS 500mL 8hr + oxaliplatin 100mg/m2 160mg D5W 250mL 2hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D1 (R-GemOx)
    • dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + granisetron 2mg

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients - 20230104 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients

  • R-GemOx (Rituximab, gemcitabine, oxaliplatin)
    • Administration - R-GemOx includes rituximab (375 mg/m2 on day -1), gemcitabine (1000 mg/m2 on day 2), and oxaliplatin (100 mg/m2 on day 2).
    • Adverse effects - Severe hematologic toxicity occurs in half of patients and neuropathy can occur.
    • Outcomes - R-GemOx is associated with ORR in up to half of patients and CR in up to one-third of patients with r/r DLBCL.
      • Oxaliplatin has not been approved by the US Food and Drug Administration (FDA) for treatment of r/r DLBCL.

==========

2023-07-17

2023-07-16 (D9) WBC level has risen to 1.64K/uL, the recovery is obvious and the CMV viral load test showed that no virus was detected on 2017-07-17 (today). So far so good.

  • 2023-07-16 WBC 1.64 x10^3/uL D9
  • 2023-07-14 WBC 0.06 x10^3/uL D7
  • 2023-07-13 WBC 0.03 x10^3/uL D6
  • 2023-07-11 WBC 0.03 x10^3/uL D4
  • 2023-07-09 WBC 0.07 x10^3/uL D2
  • 2023-07-07 WBC 0.71 x10^3/uL D0
  • 2023-07-05 WBC 3.07 x10^3/uL
  • 2023-07-03 WBC 3.46 x10^3/uL
  • 2023-06-25 WBC 5.39 x10^3/uL

After the transplant, the patient’s kidney function levels fluctuate up and down around the upper limits of the normal range. A slight elevation in serum Cre is observed on 2023-07-13 and is to be followed.

  • 2023-07-13 Creatinine 1.39 mg/dL D6
  • 2023-07-11 Creatinine 1.21 mg/dL D4
  • 2023-07-09 Creatinine 1.22 mg/dL D2

The LFT results showed a monotonic increase in bilirubin levels after the transplant, as the enzyme levels started to fall, it might be sufficient to observe for a short time, if bilirubin still remains high, then action might need to be taken. Mycamine (micafungin) is associated with hyperbilirubinemia (UpToDate: <15%).

  • 2023-07-13 Bilirubin total 2.51 mg/dL
  • 2023-07-11 Bilirubin total 1.74 mg/dL
  • 2023-07-09 Bilirubin total 1.34 mg/dL
  • 2023-07-03 Bilirubin total 0.63 mg/dL
  • 2023-07-13 Bilirubin direct 1.63 mg/dL
  • 2023-07-11 Bilirubin direct 0.81 mg/dL
  • 2023-07-09 Bilirubin direct 0.43 mg/dL
  • 2023-07-03 Bilirubin direct 0.16 mg/dL
  • 2023-07-13 S-GPT/ALT 43 U/L
  • 2023-07-11 S-GPT/ALT 114 U/L
  • 2023-07-09 S-GPT/ALT 174 U/L
  • 2023-07-03 S-GPT/ALT 71 U/L
  • 2023-07-13 S-GOT/AST 14 U/L
  • 2023-07-11 S-GOT/AST 38 U/L
  • 2023-07-09 S-GOT/AST 101 U/L
  • 2023-07-03 S-GOT/AST 43 U/L

2023-07-10

[liver function]

It seems that the patient’s liver function has declined, as indicated by increased levels of ALT, AST, and bilirubin.

  • 2023-07-09 S-GPT/ALT 174 U/L

  • 2023-07-03 S-GPT/ALT 71 U/L

  • 2023-06-25 S-GPT/ALT 50 U/L

  • 2023-06-09 S-GPT/ALT 38 U/L

  • 2023-06-02 S-GPT/ALT 29 U/L

  • 2023-05-25 S-GPT/ALT 27 U/L

  • 2023-07-09 S-GOT/AST 101 U/L

  • 2023-07-03 S-GOT/AST 43 U/L

  • 2023-06-25 S-GOT/AST 40 U/L

  • 2023-06-09 S-GOT/AST 29 U/L

  • 2023-06-02 S-GOT/AST 22 U/L

  • 2023-07-09 Bilirubin direct 0.43 mg/dL

  • 2023-07-03 Bilirubin direct 0.16 mg/dL

  • 2023-06-25 Bilirubin direct 0.13 mg/dL

  • 2023-07-09 Bilirubin total 1.34 mg/dL

  • 2023-07-03 Bilirubin total 0.63 mg/dL

There are several drugs on the patient’s active list that could potentially contribute to the decline in liver function. These include:

  • Tenofovir Alafenamide: This drug may cause an increase in serum alanine aminotransferase (grades 3/4: 8%) and serum aspartate aminotransferase (grades 3/4: 3%), impacting liver function.
  • Fluconazole: Possible liver-related side effects include cholestatic hepatitis, hepatic failure, mixed hepatitis, hepatocellular hepatitis, hepatotoxicity, and increased serum transaminases.
  • Benazepril: This medication may cause cholestatic hepatitis, increase liver enzymes, and increase serum bilirubin levels, which can affect liver function.
  • Bisoprolol: Possible (< 1%) liver-related side effects of this medication include increased serum alanine aminotransferase and increased serum aspartate aminotransferase.

Given that another anti-HBV drug Baraclude (entecavir) can also lead to increased serum alanine aminotransferase levels (>5 x ULN: 11% to 12%; >10 x ULN and >2 x baseline: 2%), substituting tenofovir alafenamide with entecavir is not advised at present time. Similarly, another antifungal medication micafungin can lead to an increased serum alkaline phosphatase level (3% to 6%).

Considering the recent dosage increase of BaoGan (silymarin) on 2023-07-09 from 1# TID to 2# TID, rechecking the liver function tests in 2 days could be a practical strategy.

[renal function]

Aside from a slightly elevated BUN, decreasing serum creatinine and increasing eGFR suggest an improvement in the patient’s renal function. The CrCl has increased to 44 mL/min.

  • 2023-07-09 Creatinine 1.22 mg/dL

  • 2023-07-03 Creatinine 1.40 mg/dL

  • 2023-06-25 Creatinine 1.76 mg/dL

  • 2023-07-09 eGFR 61.38

  • 2023-07-03 eGFR 52.37

  • 2023-06-25 eGFR 40.21

  • 2023-07-09 BUN 26 mg/dL

  • 2023-07-03 BUN 28 mg/dL

  • 2023-06-25 BUN 25 mg/dL

If the CrCl remains above 50 mL/min stably for several days and no further decline is expected, the dose of levofloxacin could optionally be increased to 750mg daily. In addition, the fluconazole dose could optionally be increased to 2# QD once it has been determined that it is not the cause of the deterioration in liver function.

2023-07-07

[myeloablative conditioning regimen effect follow-up]

The BuCyE regimen was initiated on 2023-06-30, and there is a notable reduction in WBC, HGB, and PLT levels, which indicates that the regimen is taking effect.

  • 2023-07-07 WBC 0.71 x10^3/uL

  • 2023-07-05 WBC 3.07 x10^3/uL

  • 2023-07-03 WBC 3.46 x10^3/uL

  • 2023-06-25 WBC 5.39 x10^3/uL

  • 2023-07-07 HGB 9.3 g/dL

  • 2023-07-05 HGB 11.6 g/dL

  • 2023-07-03 HGB 12.1 g/dL

  • 2023-07-07 PLT 33 x10^3/uL

  • 2023-07-05 PLT 67 x10^3/uL

  • 2023-07-03 PLT 80 x10^3/uL

2023-07-06

[renal function follow-up]

  • Recent lab results show a decrease in serum Cre and an increase in eGFR, which suggests that kidney function seems to be improving. However, the simultaneous slight increase in BUN has resulted in a BUN-to-creatinine ratio of exactly 20. If the BUN-to-creatinine ratio continues to increase, it might indicate increased BUN reabsorption. This could potentially suggest dehydration or hypoperfusion.
    • 2023-07-03 Creatinine 1.40 mg/dL
    • 2023-06-25 Creatinine 1.76 mg/dL
    • 2023-07-03 eGFR 52.37
    • 2023-06-25 eGFR 40.21
    • 2023-07-03 BUN 28 mg/dL
    • 2023-06-25 BUN 25 mg/dL

[dosage reviewed for current renal function level]

  • Flu-D (fluconazole 150mg) 1# QD has been prescribed. The recommended dose for prophylaxis against candidiasis in patients with hematologic malignancy or hematopoietic cell transplant (HCT) recipients who do not require mold-active prophylaxis is 400 mg orally once daily, with the duration being at least until resolution of neutropenia. However, given that this patient has kidney impairment with a CrCl of 38mL/min (as of 2023-07-03), a reduction of dose by 50% has been recommended. For the time being, no adjustment is necessary, nor is it needed for the current prescription of Cravit (levofloxacin 500mg) 1.5# QOD.
  • No other drugs in the active medication list require dose adjustments either.

2023-06-28

[pharmacist shift handover to chemotherapy preparation room]

Stem Cell Infustion Date D0: 2023-07-07 (tentative)

Drug - Dose - Infusion - Frequency - Duration - Date busulfan - 3.2mg/kg - 3hr - QD - D-7 ~ D-5 - 2023-06-30 ~ 2023-07-02 etoposide - 400mg/m2 - 6hr - QD - D-5 ~ D-4 - 2023-07-02 ~ 2023-07-03 cyclophosphamide - 50mg/m2 - 4hr - QD - D-3 ~ D-2 - 2023-07-04 ~ 2023-07-05

2023-06-27

[Recommended Dose Adjustments for the BuCyE Conditioning Regimen and Associated Premedication]

  • 2023-06-25 serum Cre 1.76mg/dL, age 76 => CrCl 30mL/min; height 162cm, weight 60kg => BMI 22.9kg/m2, BSA 1.64m2; 2023-06-25 S-GPT/ALT 50U/L, S-GOT/AST 40U/L, DBI/TBI 18.31%.

  • For BuCyE conditioning regimen, dose adjustment recommendation for the scheduled ASCT in this impaired renal function patient

    • busulfan
      • no dosage adjustments provided in the manufacturer’s labeling
    • cyclophosphamide
      • CrCl ≥30 mL/minute: No dosage adjustment necessary.
      • CrCl 10 to 29 mL/minute: administer 75% of normal dose.
      • As the patient’s current CrCl is at the borderline of 30, it is recommended to start with 100% dose, while providing adequate hydration, and closely monitor kidney function to determine the direction of dose adjustment in the future.
      • mesna: there are no dosage adjustments provided in the manufacturer’s labeling (has not been studied).
    • etoposide
      • CrCl 15 to 50 mL/minute: administer 75% of normal dose.
  • For premedication

    • phenytoin
      • primarily metabolized by the liver to inactive metabolites with <5% of active drug excreted unchanged in the urine
      • no dosage adjustment necessary for any degree of kidney dysfunction
    • fluconazole
      • CrCl <= 50 mL/minute: reduce dose by 50%.
    • levofloxacin
      • CrCl 20 to <50: if usual recommended dose is 500 mg every 24 hours, 500 mg initial dose, then 250 mg every 24 hours
    • palonosetron
      • no dosage adjustment is necessary.
    • granisetron
      • no dosage adjustment necessary
    • betamethasone
      • no dosage adjustments provided in the manufacturer’s labeling
    • mannitol
      • contraindicated in severe renal impairment. Use caution in patients with underlying renal disease.

[Preparation and Administration of Mesna]

  • Mesna can be prepared in either 0.9% normal saline (NS) or 5% dextrose in water (D5W).
  • Given that the patient’s weight is 60kg, the planned dose of mesna is 12mg/kg. This translates to a total of 720mg of mesna to be dissolved in at least 50mL of the above-mentioned solvents, ensuring that the final concentration does not exceed 20mg/mL.
  • For best administration results, it is advised that the injection be given over a duration of at least 30 minutes.

2023-06-26

  • According to the PharmaCloud database, our hospital has been the sole provider for all the patient’s medical and pharmaceutical needs in recent months. Alongside treatment from the Hematology-Oncology department, the patient has received refills for Avodart (dutasteride) and Harnalidge (tamsulosin) from our urologist on 2023-06-12 and Concor (bisoprolol) and Amtrel (amlodipine, benazepril) from our cardiologist on 2023-06-06. These medications are included in the patient’s current active medication list. Consequently, there are no medication reconciliation issues identified.
  • Based on serum creatinine levels, the patient’s renal function, as indicated by eGFR, has remained relatively stable over the past three years (eGFR between 40 and 50, most recent eGFR on 2023-06-25 was 40.21). This suggests that there is no significant long-term deterioration in renal function or drug-induced impairment. It’s recommended that the patient’s renal function continue to be monitored regularly, especially when new drugs with potential nephrotoxicity are added to the treatment plan. At this time, there is no need for renal function adjustments to current active medications.

2023-01-27

  • Anti-HBc tested reactive in the lab on 2022-12-05; Vemlidy (tenofovir alafenamide) is administered appropriately.
  • Additionally, Brosym (cefoperazone + sulbactam) was prescribed for the patient’s febrile neutropenia without an issue. ref: Efficacy and safety of cefoperazone-sulbactam in empiric therapy for febrile neutropenia: A systemic review and meta-analysis. Medicine (Baltimore). 2020;99(8):e19321. doi:10.1097/MD.0000000000019321
  • As far as the active prescription is concerned, there is no problem.

2023-01-18

  • The patient’s serum creatinine has shown a slow upward trend during the past month. R-GemOx, the regimen initiated since 2022-12-07, contains gemcitabine and oxaliplatin, which may cause this. Please continue to follow up as usual.
    • 2023-01-17 Creatinine 1.81 mg/dL
    • 2023-01-12 Creatinine 1.60 mg/dL
    • 2022-12-30 Creatinine 1.63 mg/dL
    • 2022-12-21 Creatinine 1.63 mg/dL
    • 2022-12-15 Creatinine 1.62 mg/dL
    • 2022-12-07 Creatinine 1.57 mg/dL
  • There is a history of hypertension in the patient. During this hospitalization, the patient’s blood pressure appears to be well controlled according to the records of the vital sign panel.

701307426

230717

[past history]

  • Nontuberculosis mycobacteria under Tx since 2021-09.
    • 2021-08-27 ~ 2022-03-10 - AKuriT-4 for TB

[lab data]

2023-06-28 HIV Ab-EIA Nonreactive
2023-06-28 Anti-HIV Value 0.09 S/CO
2023-06-26 MTBC PCR DETECTED CFU/ml
2023-06-26 MTBC PCR Value 10000 - 100000 CFU/ml

[exam findings]

  • 2023-07-15 CXR
    • Ground glass opacities in bil. lungs.
  • 2023-06-21 Patho - esophageal biopsy
    • Low esophagus, near stent proximal end, biopsy — Ulcer with atypical cells, favor reactive atypia
  • 2023-06-21 Esophagogastroduodenoscopy, EGD
    • Esophageal fully-covered metallic stent at lower esophagus, across ECJ, without obvious tumor ingrowth
    • Esophageal lesion, near stent proximal end, r/o granulation tissue, s/p biopsy
    • Superficial gastritis, antrum
  • 2023-06-17 CT - chest
    • Indication: Esophageal cancer for follow up
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Cystic Bronchiectatic change over right upper lobe and left upper lobe and tree in bud appearance at both lower lobes is found.
        • Left Pneumothorax without mediastinal shifting is noted.
        • s/p espohageal stent placement from middle to lower third esophagus. In comparison with CT dated on 2023-03-27, the condition is stationary.
        • Faint aveolar opacity over right lower lobe is found.
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
        • Small lymph nodes are found at both sides of the mediatinum. In enlargement.
      • Visible abdomen:
        • S/P jejunaltube placement from LUQ.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • Increased intestinal gas is found.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
    • Imp:
      • Esophageal cancer s/p stenting with stationary esophageal condition but the mediastinal lymph nodes enlarged. Infected lymph nodes or metastatic lymph nodes should be further determined.
      • Bronchiectatic change and bronchiolitis at both lungs. The bronchiolitis progressed, probably due to repeated aspiration.
  • 2023-05-31, -05-03, -04-24, -04-17, -04-10 CXR
    • S/P port-A implantation.
    • S/P esophageal stenting
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Linear infiltration over both lower lung zone is noted. please correlate with clinical symptom to rule out Bronchopneumonia.
    • Enlargement of cardiac silhouette.
  • 2023-04-11 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hiatal hernia
      • Reflux esophagitis,Gr A
      • C/w Esophageal malignant stricture,lower esophagus s/p SEMS
      • Superficial gastritis,antrum
      • Incomplete EGD examination
    • Suggestion
      • Medication and OPD f/u
      • EGD may be planned for Esophageal malignant stricture and Poor distension of stomach f/u later
  • 2023-04-06 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Right bundle branch block
    • Rightward axis
    • Abnormal ECG
  • 2023-03-27 CT - chest
    • Indication: Esophageal cancer for F/U.
    • Comparison was made with previous CT dated on 2022/01/20
      • Lungs: abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes and patchy consolidations and reticular opacities at RLL, stationary as compared with previous CT 2022/12/09
      • Mediastinum and hila: s/p esophageal stenting from m/3 to L/3 with increased soft-tissue density in periesophageal fat space. enlarged LNs at Rt precarinal and A-P window regions. small pericardial effusion.
      • Pleura: small Rt pleural effusion.
      • Chest wall and visible lower neck: unremarkable..
      • Visible abdominal-pelvic contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. s/p jejunostomy
      • Visualized bones: unremarkable.
    • Impression
      • esophageal cancer with regional LNs metastases, post stenting from m/3 to L/3, with periesophageal fat space inflammation.
      • RLL pneumonia or treatment related pneumonitis and both upper lobes TB, stable.
  • 2023-01-06 CXR
    • S/P esophageal stenting
    • S/P port-A implantation.
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-12-19 ECG
    • Right bundle branch block
    • indeterminated axis
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal malignant stricture s/p SEMS
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • NPO for 12 hours and start liquid food coming morning.
  • 2022-12-09 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Cavitatory lesions at bilateral upper lobes and some irregular patches at right lower lobe is found. In comparison with CT dated on 2022-08-18, the lesions incresaed in size and numbers mostly at right lower lobe. Either progressoin of the meta or some new aspiration pneumonitis should be D.D.
        • Wall thickening at lower third esophagus and EG junction is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p jejunostomy.
        • Minimal ascites is found.
    • IMp: Lower third esophageal cancer with bilateral lung meta. Increased nodularities at right lower lobe, either new meta or aspiration pneumonia should be D.D.
  • 2022-11-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • C/W esophageal cancer, s/p CCRT, with scarring (32~36cm below incisor) and luminal stricture (36cm below incisor)
      • Incomplete study due to esophageal stricture
  • 2022-11-04 Esophagography
    • Esophagraphy shows
      • Water soluble contrast medium was delivered from oral cavity.
      • Up to 90% stenosis at lower third esophagus is found. The contrast medium could only pass the narrowing lumen slowly.
      • The EG junction is intact.
    • Imp: Compatible with esophageal cancer at lower third with almost complete stenosis.
  • 2022-08-18 CT - chest
    • Findings
      • Cavitatory lesions are found at bilateral upper lobes with solid nodularity. Metastatic leion is favored but aspiration is also possible (Less likely due to lobar consideration). In comparison with CT dated on 2022-05-10 and 2021-08-27, the lesions regressed partially.
      • Diffuse wall thickening from upper third esophagus into lower third. Esophageal cancer mixed with esophatitis is favored.
      • The pleural tagging at right lower lobe is still visualized.
    • Imp
      • Long segmental esophageal cancer with bilateal lung and right pleural mets, in regression.
  • 2022-08-02 Patho - esophageal biopsy
    • Low esophagus, biopsy — Chronic inflammation with reactive atypia
    • Microscopically, the sections show a picture of chronic inflammation with some inflammatory cells infiltration, scant necrotic debris, focal crush artifact and focal mild enlarged nuclei of squamous epithelium, favor reactive atypia, Follow up.
  • 2022-08-02 Esophagogastroduodenoscopy, EGD
    • Findings
      • Esophagus: A stricture was noted at 35 cm. The scope cannot advance over the lesion. Biopsy was done.
      • Stomach: Not check
      • Duodenum: Not check
    • Diagnosis
      • Esophageal stricture, low esophagus s/p biopsy
      • Incomplete study
  • 2022-05-10 CT - lung/mediastinum/pleura
    • Finding
      • Lungs:
        • abnormal consolidative opacities with reticular and nodular opacities, cavitary lesions of varying sizes, and bronchiectasis, at both upper lobes. in regression as compared with previous CT exam.
      • Mediastinum and hila:
        • significant regression of a Long segmental circumferential wall thickening of the middle to lower third of the thoracic esophagus, with decreased luminal narrowing as compared with previous CT exam.
        • no enlarged LN.
      • Aorta: normal appearance of thoracic aorta and central pulmonary arteries: normal in caliber. Heart: normal in size of cardiac chambers.
      • Pleura: regression of Rt lower pleural metastasis with effusion as compared with previous CT exam.
      • Chest wall and visible lower neck: unremarkable..
      • Visible abdominal-pelvic contents:
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. s/p jejunostomy
      • Visualized bones: unremarkable.
    • Impression:
      • esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT exam.
  • 2022-02-10 Patho - esophageal biopsy
    • Esophagus, 30cm below incisors, biopsy — squamous cell carcinoma, moderately differentiated, at least.
    • The grade of tumor differentiation might be the same or might be upgraded when the entire tumor is resected for further pathological evaluation.
  • 2022-01-20 Patho - esophageal biopsy
    • Labeled as ‘Esophagus, 30cm below incisors’, biopsy — squamous cell carcinoma.
    • IHC stain: p16(-).
  • 2022-01-20 CT - lung/mediastinum/pleura
    • Esophageal cancer with lung mets.
    • Previous tubercuosis at bilateral apical lungs.
  • 2022-01-20 Miniprobe endoscopic ultrasound
    • Advanced esophageal squamous cell carcinoma, at least T3N2Mx
  • 2022-01-19 Whole body PET scan
    • A glucose hypermetabolic lesion in the middle to lower third esophagus, compatible with the primary esophageal cancer.
    • A glucose hypermetabolism in the gastrohepatic lymph node, reactive node or cancer with regional lymph node metastasis may show this picture, suggesting biopsy for further investigation.
    • Increased FDG uptake in the left pulmonary hilar region, left upper lung, left lower lung, and right upper lung, TB or cancer with both lungs metastases may show this picture.
    • Glucose hypermetabolic lesions in the right lower lung pleura, cancer with pleura metastases should be considered, suggesting biopsy for further investigation also.
    • Esophageal cancer, cT4aN0-1M0-1, c-stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-01-18 Tc-99m MDP whole body bone scan
    • Increased activity in the lower C-spine. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2022-01-07 Esophagogastroduodenoscopy, EGD
    • One lumen occupied mass lesion with friability was noted at 30cm below incisors. The scope cannot advance over the lesion.
    • Highly suspected esophageal cancer.
  • 2021-08-27 CT - lung/mediastinum/pleura
    • Cavitatory lesion at left apical lung about 5.58cm and traction fibrotic mass at right upper lobe are found. Smaller nodules mixed with fibrotic change is found at bilateral upper lobes. Tuberculosis is more favored.

[MedRec]

  • 2023-04-06 ~ 2023-04-29 POMR Hemato-Oncology
    • Discharge diagnosis
      • Esophageal cancer, MD squamous cell carcinoma with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, stage IV, jejunostomy and left Port-A implantation on 2022/01/21 and concurrent chemoradiotherapy and Chemotherapy with PF4 (CDDP 75mg/m2, 5FU 1000mg/m2 x 4 days) from 2022/02/01, regression, s/p Immunity therapy with Q2W OPDIVO (Nivolumab, 3mg/kg) from 2023/01/10.
      • Pneumonia, bilateral lung with 2023/04/17 sputum/C showed Pseudomonas aeruginosa
      • Acute kidney failure, unspecified
      • Chronic obstructive pulmonary disease, unspecified
      • Hypomagnesemia
      • Anemia due to antineoplastic chemotherapy
      • Gastro-esophageal reflux disease with esophagitis
    • CC: Severe cough for 3 days.

[consultation]

  • 2022-01-21 hematology & oncology
    • A
      • O
        • CT show Esophageal cancer with lung meta.
        • Previous tubercuosis at bilateral apical lungs.
      • Impression:
        • Advanced esophageal middle third squamous cell carcinoma with lung meta, cT3N2M1
        • History of nontuberculosis mycobacteria under RINA
        • COPD
      • Suggestion
        • advanced or metastasis disease, systemic therapy is indicated. Ex: FLuorouracil (or capecitabine) with cisplatin (or oxaliplatin), or clinical trial
        • please check anti Hbc for HBV evaluation
  • 2022-01-20 radiation oncology
    • A
      • Diagnosis: Esophageal cancer, L/3, MD SqCC with paraesophageal LAPs, lung, pleural metastasis, cT3N2M1, jejunostomy and left Port-A implantation (scheduled on 2022/01/21); nontuberculosis mycobacteria (NTM) under treatment; ECOG: 1.
      • Plan: Clinical trial may be considered if he fits the inclusion criteria. RT to esophageal tumor & LAPs for 5040cGy/28 fx is suggested for tumor control.

[surgical operation]

  • 2022-01-25
    • Surgery
      • Bowel decompression and revision of jejunostomy
    • Finding
      • Detached peritonization of jejunum over superior direction with exposure of jejunostomy tube.
      • Mild edematous and dilated proximal jejunum without ischemia.
      • Total 4000ml of gastric juice drained by upper gastrointestinal endoscope.
      • Failure of nasogastric tube insertion.
      • Estimated blood loss: 20ml.
  • 2022-01-21
    • Surgery
      • mini-laparoscopic feeding jejunostomy + port-A insertion
    • Finding
      • 8 Fr. port-A via left cephalic vein
      • 18 Fr. foley with balloon removal as jejunostomy tube
      • patent tube function during intra-operative feeding test

[radiotherapy]

  • Plan: RT to lung metastasis for 4900cGy/14 fractions is suggested for tumor control. Diet education. RTC 9/15. (RTC = return to clinic)
  • 2022-07-28 ~ 2022-08-15 - 4550cGy/13 fractions (6 MV photon) to RLL pleural tumors.
  • 2022-04-13 ~ 2022-04-25 - 3150cGy/9 fractions (6 MV photon) to RML/RLL tumors (n=3)
  • 2022-02-04 ~ 2022-03-16 - 5040cGy/28 fractions (15 MV photon) to esophageal tumor & LAPs

[chemotherapy]

  • 2023-05-17 - fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4
    • dexamethasone 4mg + NS 250mL
  • 2023-03-30 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-29 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-23 - carboplatin AUC 5 300mg NS 500mL 2hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W. in fact, there is no cisplatin this time)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-22 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2023-01-11 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-10 - nivolumab 3mg/kg 200mg NS 100mL 1hr (Opdivo Q2W)
    • diphenhydramine 30mg + NS 250mL
  • 2022-12-12 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-06 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-08 - cisplatin 75mg/m2 110mg NS 500mL 24hr + fluorouracil 1000mg/m2 1400mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-18 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1450mg 24hr D1-4 (PF4)
  • 2022-07-01 - cisplatin 75mg/m2 105mg 24hr D1 + fluorouracil 1000mg/m2 1420mg 24hr D1-4 (PF4)
  • 2022-06-08 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
  • 2022-05-10 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1460mg 24hr D1-4 (PF4)
  • 2022-04-11 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
  • 2022-03-14 - cisplatin 75mg/m2 110mg 24hr D1 + fluorouracil 1000mg/m2 1490mg 24hr D1-4 (PF4)
  • 2022-02-11 - cisplatin 75mg/m2 120mg 24hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-4 (PF4)

==========

2023-07-17

[tube feeding]

For patients on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking the capsule open and pouring the small granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be administered through the feeding tube. Note that these granules should not be crushed or chewed, and the prepared solution should be used immediately after it’s prepared.

[reconciliation]

According to the PharmaCloud database, it appears that the patient has only been receiving medical care at our hospital for the past three months. No discrepancies or issues were identified during the medication reconciliation process for this patient during his current admission.

[assessment]

It appears that the patient’s renal function deteriorated last weekend. 2023-07-15 CXR showed ground-glass opacities in both lungs. CRP 13.8 mg/dL. There is a high incidence of AKI in patients hospitalized for CAP. It is advisable to be alert for the prevention and early detection of AKI in CAP patients. ref: Incidence and Risk Factors of Acute Kidney Injury in Patients Hospitalized with Pneumonia: A Prospective Observational Study. Med J Islam Repub Iran. 2021;35:150. Published 2021 Nov 10. doi:10.47176/mjiri.35.150

  • 2023-07-15 Creatinine 1.76 mg/dL

  • 2023-07-06 Creatinine 1.08 mg/dL

  • 2023-07-03 Creatinine 1.05 mg/dL

  • 2023-07-15 eGFR 43.10

  • 2023-07-06 eGFR 75.73

  • 2023-07-03 eGFR 78.23

The current dosage of Tapimycin (peperacillin 4g, tazobactam 0.5g) at 4.5g Q8H is still within a reasonable range, considering the patient’s current renal function.

2023-06-16

  • In patients who are on tube feeding, Dexilant (dexlansoprazole 60mg/cap) can be administered by breaking open the capsule and pouring the tiny granules into an appropriate amount of drinking water. After mixing well, this prepared solution can be delivered via the feeding tube. Do bear in mind that these granules shouldn’t be crushed or chewed, and the prepared solution must be used right after its preparation.

  • From 2023-03-28 to 2023-06-16, the patient has experienced significant weight loss, dropping from 53.1kg to 41.6kg. This indicates a loss of over 10kg within a span of approximately 2.5 months. A consultation with a dietitian took place on 2023-05-19. However, cachexia remains a current health issue for this patient. The patient is currently on tube feeding and is also taking the progesterone analogue megestrol without an issue. Glucocorticoids could potentially improve the patient’s appetite to a similar extent as the progesterone analogues. However, considering the potential for toxicities and decreased effectiveness with prolonged use, the application of glucocorticoids as an appetite stimulant is typically reserved for individuals with an estimated life expectancy ranging from a few weeks to a couple of months. Consequently, the use of glucocorticoids is not advised at this time.

  • The patient’s renal function markers continue to be elevated, so hydration has been administered (NS 500mL Q8H currently). The TPR panel reveals that the patient was experiencing tachycardia (122/min), tachypnea (21/min), and potentially inadequate SpO2 (92%), alongside a relatively low blood pressure reading (81/52 mmHg). Close monitoring is necessary in this case.

    • 2023-06-16 Creatinine 1.44 mg/dL
    • 2023-05-31 Creatinine 1.45 mg/dL
    • 2023-05-16 Creatinine 1.58 mg/dL
    • 2023-05-03 Creatinine 1.82 mg/dL
    • 2023-06-16 BUN 42 mg/dL
    • 2023-05-31 BUN 35 mg/dL
    • 2023-05-16 BUN 33 mg/dL
    • 2023-05-03 BUN 17 mg/dL

2023-05-17

  • For tube feeding, Dexilant (dexlansoprazole 60 mg/cap) may be administered by opening the capsule and emptying the small granules into adequate drinking water to complete the preparation.

2022-09-12

  • The current regimen is still effective, as evidenced by recent CT scans on (2022-08-27, 2022-08-18, 2022-05-10) showing partially regression, however this does not square with the elevated SCC and CEA levels on 2022-09-09.
  • There is a low body mass index (BMI) of 16 in the patient (based on a height of 167 cm and weight of 45 kg on 2022-09-08), suggesting an increase in food intake is necessary.
  • Patients with malnutrition (~low body mass index), cirrhosis, diarrhea, or long-term diuretic use are more likely to suffer from hypomagnesemia (1.6mg/dL 2022-09-08). Magnesium supplements might be beneficial.
  • There is a gradual decrease in HGB levels (12.7 g/dL 2021-08-27 to 8.3 g/dL 2022-09-08), which should be noted and monitored regularly to determine if an intervention is necessary.

2022-06-09

  • Current regimen is effective. CT (2022-05-10) showed esophageal cancer with pleural and regional LNs metastases, post treatment, with significant regression of as compared with previous CT on 2022-01-20.
  • Lab data on 2022-06-07 indicated low K (3.1 mmol/L) and low Mg (1.7 mg/dL) have been treated with Radi-K (potassium gluconate) tablets and magnesium sulfate injections.
  • As the patient has a low BMI of 15 (based on BH 165 cm and BW 43.3 kg, 2022-06-08), an increase in food intake may be beneficial.
  • Trend of HGB is decreasing gradually (12.7 g/dL 2021-08-27 -> 9.5 g/dL 2022-06-07) which should be noted and regularly observed.
  • All the oral drugs in active prescription can be administered with nasogastric tube.
  • No issue with current medication.

2022-04-12

  • An economically not advantaged divorced man living with his school-age daughters has recently learned that he has an advanced esophageal squamous cell carcinoma and is undergoing 5-Fu + cisplatin since early February 2022.
  • According to the most recent lab results reported on 2022-04-07, liver and kidney function were normal and there were no obvious abnormalities with CBC and WBC readings.
  • Trastuzumab might be added to first-line chemotherapy for HER2 overexpression positive adenocarcinoma (HER2 testing result not found yet).
  • Oxaliplatin is generally preferred over cisplatin due to lower toxicity.

2022-04-11

[tube feeding]

  • Broen-C (bromelain, L-cysteine) enteric coated tablets should not be ground for tube feeding, acetylcysteine is available to act as an alternative.

701463845

230717

[exam findings]

  • 2023-04-29 CT - brain
    • Indication: Traumatic SAH.
    • Without-contrast CT of brain shows:
      • SAH in bilateral frontal and temporal regions, in regression.
      • Prominent sulci, fissures, and cisterns. Dilatation of the ventricles.
      • No midline shift.
      • Left occipital skull linear fracture.
      • Left occipital scalp swelling.
    • Impression
      • Traumatic SAH, in regression
  • 2023-04-26 CTA - brain (head, neck)
    • With and without-contrast axial brain CT revealed:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
      • No midline shift.
      • Intact bony structures.
      • Widening of cortical sulci and dilatation of ventricles.
      • No abnormal intracranial enhancement.
    • IMP:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
  • 2023-04-26 CT - brain
    • Non-contrast brain CT revealed:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
      • No midline shift.
      • Degeneration and spondylosis of C-spine.
      • Widening of cortical sulci and dilatation of ventricles.
    • IMP:
      • Bil. SAH. Swelling of left parietal and occipital scalp.
  • 2023-04-26 Sacrum & Coccyx
    • Minimal fracture of coccyx.
    • S/P left side double J catheter insertion.
  • 2023-04-21 PET scan
    • A glucose hypermetabolic lesion in the upper lobe of right lung. A metastatic lesion should be watched out.
    • Mild glucose hypermetabolism in a focal area in the lower lobe of right lung. Post-operative inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out the possibility of recurrent tumor of low FDG uptake.
    • Glucose hypermetabolism in a focal area in the midline anterior lower abdominal wall. The nature is to be determined (post-operative inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral shoulders, compatible with arthritis.
    • Increased FDG accumulation in the colon, both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2023-04-08 CT - abdomen
    • Clinical history: 70 y/o female patient with alignant neoplasm of sigmoid colon sigmoid cancer s/p OP and C/T
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P double J catheter drainage, left side. Relative atrophy of left kidney.
      • Bilateral renal cysts, up to 3cm in right kidney.
      • Cystic lesion, 0.8cm in pancreatic body.
      • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
    • Impression:
      • Post-op at the colon.
      • S/P double J catheter in left kidney, relative atrophy of left kidney.
      • Bilateral renal cysts.
      • Pancreatic body cystic nodule, 0.8cm, suggest follow up.
      • Soft tissue, 1.3cm in RLL around prior surgical clips. Recurrent tumor?
  • 2023-01-16 Tc-99m MDP bone scan
    • A hot spot in the lateral aspect of the right 10th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the maxilla, some C-, T- and L-spine, bilateral sternoclavicular junction, shoulders, S-I joints, and hips.
  • 2023-01-13, -01-12 CXR
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Borderline cardiomegaly
  • 2022-12-21 All-RAS + BRAF
    • Cell block No: S2022-22267 A4
    • RESULTS:
      • All-RAS: There was no variant detect in the KRAS/NRAS gene.
      • BRAF: There was no variant detect in the BRAF gene.
  • 2022-12-13 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, sigmoid colon, sigmoid colectomy —- Adenocarcinoma, moderately differentiated
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Negative for malignacny (0/40)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIA, pT3N0(if cM0)
    • Gross Description:
      • Operation procedure: sigmoid colectomy
      • Specimen site: sigmoid colon
      • Specimen size: 10.7 cm in length
      • Tumor size: 5.2 x 4.1 x 1.5 cm
      • Tumor location: 4.5 cm and 2.1 cm away from the two resection margins, respectively
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1: colon, non-tumor; A2-5: tumor; A6-12: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma with marked acute suppurative inflammation
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved; Distance of tumor from margin: 5 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 0/40
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply):
        • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-12-13 Patho - lung wedge biopsy
    • PATHOLOGIC DIAGNOSIS:
      • Lung, right, lower lobe, wedge resection —- Atypical carcinoid tumor
      • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/3)
      • AJCC 8th edition pTNM Pathology stage: pStage IA1, pT1aN0(if cM0)
    • MACROSCOPIC EXAMINATION:
      • Specimen:
        • Lung, size: 5.5 x 3.0 x 1.2 cm; 8g
        • Lymph nodes, a bottle, group 9; maximal size: 0.2 x 0.1 x 0.1 cm
      • Tumor Site: Periphery
      • Tumor Size: Solitary: 1.0 x 0.9 x 0.8 cm
      • Gross tumor patterns: poorly defined, Pleural retraction
      • Tissue for sections: A1: resection margin; A2 and A4: lung, non-tumor; A3: tumor; B: lymph node, group 9.
    • Microscopic Description
      • Tumor Focality: Single tumor
      • Histologic Type (select all that apply): Atypical carcinoid tumor; The immunohistochemical stains reveal CK(+), TTF-1(+), CD56(+), and Synaptophysin(+). The Ki-67 is about 4%. The Congo red special stain is negative.
      • Histologic Grade: G1: Well differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): Not identified
      • Direct Invasion of Adjacent Structures (select all that apply): No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin (centimeters): 1.2 cm
        • Specify closest margin: resection margin
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/3
      • Extranodal Extension: Not identified
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT1a: Tumor ≤1 cm or less in greatest dimension;
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-12-09 CT - abdomen
    • History: 20221208 colonoscopy: Colon cancer at 30 cm from AV with nearly total obstruction, biopsy was done. Tattooing was performed.
    • Indication: sigmoid colon cancer, CT staging
    • Findings:
      • There is segmental asymmetrical wall thickening of the sigmoid colon with medial exophytic growing, measuring 7 cm in length that is c/w adenocarcinoma.
        • The left side obliterated umbilical artery shows increasing thickness that may be tumor invasion? (T4b).
        • In addition, The fat plane between sigmoid tumor and left fallopian tube shows obliteration that also may be tumor invasion.
      • There are at least 10 enlarged nodes in the adjacent mesocolon that are c/w metastatic nodes (N2b).
      • There is a soft tissue nodule in RLL of the lung, measuring 0.8 cm in size at lung window setting.
        • Lung metastasis (M1a) is highly suspected.
      • There is a cystic lesion 1 cm in the pancreatic body.
        • Simple cyst or macrocystic adenoma is highly suspected.
      • There are several renal cysts on both kidney and the largest one measuring 3.3 cm in size at right middle pole.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1a (M_value) STAGE:IVA(Stage_value)
  • 2022-12-09 Flow Volume Loop Chart
    • Mild restrictive ventilatory impairment
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 33) / 118 = 72.03%
      • M-mode (Teichholz) = 72
    • Conclusion:.
      • Normal chamber size
      • Thickening of IVS and LVPW
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • No regional wall motion abnormalities

[MedRec]

  • 2023-04-26 ~ 2023-04-29 POMR Neurosurgery

    • Discharge diagnosis
      • Traumatic subarachnoid hemorrhage with loss of consciousness of 30 minutes or less, initial encounter
      • Unspecified fracture of skull, initial encounter for closed fracture
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Malignant neoplasm of sigmoid colon
      • Malignant neoplasm of lower lobe, right bronchus or lung
    • CC
      • collapse, fall down then head injury on 2023/04/25 23:30
    • Present illness
      • This is 70 years old female who sufferred from collapse, fall down then head injury on 2023/04/25 23:30. She was brought to our emergency room for help. At emergency room, dizziness and right lower limbs weakness were noted. Swelling of left parietal and occipital scalp. Follow brain CT showed bilateral traumatic subarachnoid hemorrhage. Swelling of left parietal and occipital scalp. Follow brain computed tomography angiography showed non-specific.
      • Anticonvulsants with keppra use for seizure prevent, hemostatic agent with transamin 1000mg q8h and famotidine 20mg q12h IVD for stress ulcer prevention were given. After neurosurgeon consulted who suggested arrange admission and monitor neurological condition.
    • Course of inpatient treatment
      • After admission, anticonvulsants with keppra use for seizure prevent. Analgesic agents with acetaminophen 1tab qid for pain control. Hemostatic agent with transamin 1000mg q8h. Local ice packing of occipital lobe. Repeat brain CT showed traumatic subarachnoid hemorrhage was in regression. Under her stable condition, she was discharged and outpatient follow-up was mandatory.
    • Discharge prescription
      • Acetal (acetaminophen 500mg) 1# PRNQ12H
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Keppra (levetiracetam 500mg) 1# BID
      • Neurontin (gabapentin 100mg) 1# HS
      • Norvasc (amlodipine 5mg) 1# BID
      • Trynol (amitriptyline 25mg) 1# QN
      • Tulip (atorvastatin 20mg) 1# QN
      • Canaglu (canagliflozin 100mg) 1# QDAC
      • Relinide (repaglinide 1mg) 1# TIDAC15
      • Trajenta (linagliptin 5mg) 1# QD
      • Uformin (metformin 500mg) 1# TIDCC
  • 2023-04-18 SOAP Hemato-Oncology

    • P: Arrange Lung/Abd/Pelvis CT Q3M, next on 2023-07-03.
  • 2023-04-11 ~ 2023-04-14 POMR Metabolism and Endocrinology (not completed)

  • 2023-02-15 SOAP Hemato-Oncology

    • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2022-12-27
      • High risk stage II, post-op Adjuvant Chemotherapy。
  • 2022-12-20 SOAP Hemato-Oncology

    • A/P
      • Lab: HBV, HCV, Tumor markers (CEA, CA199)
      • Admission for Lab tests (CBC/DC, biocemistry), Port-A insertion by Chief Hsieh, and C/T with FOLFOX on 2023-01-10
      • Treatment: FOLFOX x 12 courses

[surgical operation]

  • 2022-12-12
    • Surgery
      • 3D VATS RLL wedge + LN dissection.
    • Finding
      • One nodular lesion was noted over RLL, size about 0.6cm in diameter.
      • One 20 Fr. straight chest tube was inserted via right 7th ICS.
  • 2022-12-12
    • Surgery
      • Sigmoid colectomy        
    • Finding
      • Sigmoid cancer about 7x6x5 cm , nearly total obstruction with left side abdominal wall, peritoneum involved, Mesentaric lymph nodes enlargement also noted
    • Procedure
      • Patient was placed in the modified lithotomy position.
      • The abdomen was prepared and draped in the standard fashion to provide wide exposure.
      • The patient was placed in a steep Trendelenburg position, the surgeon stands on the left side of the patient.
      • Midline incision was made. Dissection and division begin from the left lateral attachment of the sigmoid and identification of left ureter.
      • After the inferior mesenteric vessels have been divided and ligated, the mesenteric vessels & marginal artery were ligated . Left colon is transected using linear stapler.
      • The dissection moves first to the right and then to the left of the rectum, the rectosigmoid is pulled up and rectal washing was done using the B-I solution . Rectosigmoid was transected by TA-linear stapler. Then the specimen was removed.
      • End-to-end anastomosis using double stapled method , air tight was tested and anastomosis was rechecked using rigid proctoscope; Tissel 4ml apply on the anastomosis.
      • Check bleeders and clean the abdominal cavity using warm saline
      • Close the wound in layers
  • 2022-12-12
    • Surgery
      • Left DBJ insertion     
    • Finding
      • smooth bladder mucosa
      • bilateral U/O (+)

[chemotherapy]

  • 2023-07-03 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 450mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-05-23 - FOLFOX @ Thailand

  • 2023-05-09 - FOLFOX @ Thailand

  • 2023-04-25 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-28 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-14 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 300mg/m2 500mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 300mg/m2 500mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-03-01 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2023-02-15 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 48hr (in infusor) (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-16 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr (Y-sited Oxa) + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-07-17

[reconciliation]

  • The patient is not from the local area, so no records are available in the PharmaCloud database.

  • On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). On the same day, our neurosurgeon prescribed Keppra (levetiracetam), Neurontin (gabapentin), Norvasc (amlodipine), and Tulip (atorvastatin). These prescriptions, which are valid for 70 days, were added to the patient’s current medication list with no discrepancies identified during medication reconciliation.

[assessment]

A recent lab reading taken on 2023-07-11 revealed a significantly elevated serum glucose level of 253mg/dL, despite the administration of four antiglucemic agents - Canaglu (canagliflozin), Trajenta (linagliptin), Uformin (metformin), and Kludone (gliclazide). It would be advisable to ensure regular monitoring of the patient’s blood sugar levels, and these readings should be displayed in the TPR panel.

2023-07-03

[reconciliation]

  • The patient is a non-native individual, therefore no records are accessible from the PharmaCloud database.
  • On 2023-05-03, our endocrinologist prescribed Canaglu (canagliflozin 100mg) 1# QDAC, Trajenta (linagliptin 5mg) 1# QD, Uformin (metformin 500mg) 1# TIDCC, Kludone (gliclazide 60mg) 1# BID. On the same day, our neurosurgeon prescribed Keppra (levetiracetam 500mg) 1# BID, Neurontin (gabapentin 100mg) 1# HS, Norvasc (amlodipine 5mg) 1# BID, Tulip (atorvastatin 20mg) 1# QN. These prescriptions, valid for 70 days, were added to the patient’s active medication list with no reconciliation discrepancies noted.

[bedside visit, patient education]

  • I visited the patient at about 15:00 on 2023-07-03. Two of the patient’s relatives (?) were also present in the room - a man lying on the bench by the window and a woman sitting on a chair. I asked the patient how she was feeling today, and she replied that she was generally well and didn’t have any particular complaints. During my visit, I observed that the patient was in a fairly good state of mind and did not appear to be too tired to respond.
  • As the patient has already received several doses of the FOLFOX regimen, including the continuation of the same treatment when she returned to Thailand in May 2023, she was not entirely unfamiliar with this regimen. I provided her with information sheets on the use of oxaliplatin and fluorouracil, highlighting the key points for her to be aware of, and also left the contact details of the pharmacology department’s drug counseling service for her to use if needed.

701469090

230717

[exam findings]

  • 2023-06-29 Patho - bone marrow biopsy
    • Bone marrow, clinical history of leukemia s/p chemotherapy, iliac, biopsy — acute myelogenous leukemia.
    • Section shows piece(s) of bone marrow with 80% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with many immature leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 10-15%; CD34: 5-10 %; MPO: 80%, CD61: 5 %; CD71: 10% (of the nucleated cells).
  • 2023-05-04 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-02-20 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Acute myeloid leukemia (AML)
    • The sections show hypocellular marrow (10%). Focal reduced fat cells with accumulation of extracellular gelatinous substances, decrease in trilinage hematopoietic cells including megakaryocyts, CD71+ erythroid precursors and MPO+ myeloid cells, scattered CD138+ mature plasma cells, fibroblastic proliferation, vascular dilatation, and stromal edematous change are present. Residual CD34-/CD117+ blasts, account for 20% of nuclear cells can be found. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-02-20 KUB
    • Spondylosis with scoliosis of the L-spine with convex to right side
    • Non-specific bowel gas pattern in the middle abdomen is noted. please correlate with clinical condition. Follow up is indicated.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-08 Abdomen - standing (diaphragm)
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at left lateral aspect of L3-4.
    • Disk space narrowing and Marginal osteophyte formation of L5-S1.
  • 2023-01-30 Patho - bone marrow biopsy
    • Bone marrow, biopsy — acute myeloid leukemia (AML)
    • NOTE: Correlation of peripheral blood, bone marrow smear, flow cytometry, molecular genetic study and clinical feature is recommended.
    • Microscopically, it shows hypercellularity (90%) with proliferation of myeloblasts hightlighted by CD117 (> 90%).
    • Immunohisotchemical stain reveals CD34(-), CD20 (focal+), CD138 (-), MPO(+), CD71(focal+), TdT(-).

[consultation]

  • 2023-02-25 Infectious Disease
    • Q
      • The 59 y/o woman has APL post chemotherapy least 2023/02/12. Due to intermittent fever without bacteremia from culture, so we need your help for management. Thanks
    • A
      • intermittent fever still noted despite Mepem, vancomycin, and Mycamine use.
      • No significant culture report available.
      • CxR clear lungs that urinalysis showed mild bacteriuria without pyuria.
      • There are diffuse skin lesions over trunk and lower limbs, etiology uncertain, which should be related to fever.
      • Suggestion:
        • check HSV and VZV viral load
        • check CMV viral load
        • continue the present antibiotic regimen
        • empirical iv steroid can be tried.
  • 2023-02-23 Dermatology
    • Q
      • for suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum
      • The 59 y/o woman dosen’t have any history.
      • This time, she sufferes from hand, back ecchymosis and both leg petechia, so she sent to Cardinal Tien Hospital. LRP transfusion for thrombocytopenia 16000/uL on 2023/01/20. Due to elevated blast and suspect leukemia, so she transfered to our ED for help. Her BW loss 5 kg around 1 year. Got fatigue noted after postive of COVID (2022-09). At ED, the lab data showed WBC 8170/uL, Hb 10.0 g/dL, PL 44 *10^3/uL, Blast 58%. Under the impression of APL, so she was admitted.
      • chemotherapy with (3+7) Idarubicin/Cytarabine on 2023/02/06 ~ 2023/02/12
      • This time, suspect Herpes Zoster at bilateral waist, and skin rash at bilateral groin, the painful, skin rash at perineum , so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from diffuse non-blanchable erythema lesions over trunk and lower legs.
      • Under the impression of thrombopenia purpura with fine vesicle/bullae formation r/o allergic purpura.
      • The following sugeetion:
        • exclude herpes zoster infection episode currently.
        • correct patient underlying state as your experist.
          • for fine vesicle or bullae, Betason-N onit 2 tube topical bid use.
          • for itchy skin lesions, Mycomb cream 1 tube topical bid use.
        • enhance skin mositurization, Sinphraderm cream 1 tube QN use over fine scales/xerotic area after body clean.

[chemotherapy]

  • 2023-06-05 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-04-28 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-03-23 - cytarabine 1500mg/m2 2400mg NS 500mL 3hr Q12H D1-3 (HD Ara-C, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + granisetron 2mg D1-3 + NS 250mL D1-3
  • 2023-02-06 - idarubicin 10mg/m2 16mg NS 100mL D1-3 + cytarabine 100mg/m2 165mg NS 500mL D1-7 (3+7 idarubicin/cytarabine, Q4W)
    • dexamethasone 4mg D1-3 + diphenhydramine 30mg D1-3 + palonosetron 250ug D1 + granisetron 2mg D2-3 + NS 250mL D1-3

G-CSF (filgrastim) 150ug

  • 2023-03-27 ~ 2023-04-05 (prior C/T on 2023-03-23)
  • 2023-02-15 ~ 2023-03-02 (prior C/T on 2023-02-06)

WBC

  • 2023-05-02 WBC 2.79 x10^3/uL
  • 2023-04-28 WBC 3.57 x10^3/uL 2023-04-28 C/T
  • 2023-04-19 WBC 4.14 x10^3/uL
  • 2023-04-10 WBC 2.54 x10^3/uL
  • 2023-04-08 WBC 4.58 x10^3/uL
  • 2023-04-06 WBC 13.57 x10^3/uL
  • 2023-04-04 WBC 0.85 x10^3/uL
  • 2023-04-02 WBC 0.21 x10^3/uL
  • 2023-03-31 WBC 0.56 x10^3/uL
  • 2023-03-29 WBC 7.65 x10^3/uL
  • 2023-03-27 WBC 2.22 x10^3/uL
  • 2023-03-25 WBC 3.79 x10^3/uL 2023-03-23 C/T
  • 2023-03-22 WBC 3.84 x10^3/uL
  • 2023-03-15 WBC 4.14 x10^3/uL
  • 2023-03-08 WBC 1.35 x10^3/uL
  • 2023-03-06 WBC 1.76 x10^3/uL
  • 2023-03-04 WBC 2.72 x10^3/uL
  • 2023-03-02 WBC 3.18 x10^3/uL
  • 2023-02-28 WBC 0.91 x10^3/uL
  • 2023-02-26 WBC 0.29 x10^3/uL
  • 2023-02-24 WBC 0.23 x10^3/uL
  • 2023-02-22 WBC 0.21 x10^3/uL
  • 2023-02-20 WBC 0.26 x10^3/uL
  • 2023-02-18 WBC 0.26 x10^3/uL
  • 2023-02-16 WBC 0.25 x10^3/uL
  • 2023-02-14 WBC 0.19 x10^3/uL
  • 2023-02-12 WBC 0.24 x10^3/uL
  • 2023-02-10 WBC 0.53 x10^3/uL
  • 2023-02-08 WBC 1.44 x10^3/uL
  • 2023-02-06 WBC 8.30 x10^3/uL 2023-02-06 C/T
  • 2023-02-04 WBC 7.75 x10^3/uL
  • 2023-02-03 WBC 7.53 x10^3/uL
  • 2023-02-01 WBC 8.69 x10^3/uL
  • 2023-01-30 WBC 11.71 x10^3/uL
  • 2023-01-30 WBC 10.55 x10^3/uL
  • 2023-01-28 WBC 7.74 x10^3/uL
  • 2023-01-26 WBC 6.40 x10^3/uL
  • 2023-01-25 WBC 8.17 x10^3/uL

==========

2023-07-17

After reviewing the PharmaCloud database, no reconciliation issues were found.

[exploring CNS involvement]

An increased level of LDH is more common seen in patients with AML involving the CNS. Given that this patient was admitted with symptoms of dizziness and tinnitus, it could be worthwhile to conduct further investigations.

  • 2023-07-17 LDH 20297 U/L
  • 2023-07-03 LDH 7732 U/L
  • 2023-06-04 LDH 936 U/L
  • 2023-05-31 LDH 467 U/L
  • 2023-04-19 LDH 112 U/L
  • 2023-04-06 LDH 131 U/L
  • 2023-04-02 LDH 77 U/L

2023-05-02

  • The patient experienced 2 episodes of grade 4 neutropenia each time after chemotherapy treatments and showed improvement with more than 1 week of G-CSF use.
  • As the patient received her 3rd treatment during this hospitalization, it is suggested that the use of prophylactic G-CSF be considered to prevent recurrence of severe neutropenia.

2023-03-29

  • The patient’s WBC count, which had been low, has returned to a normal range after receiving filgrastim (G-CSF) (planned for 10 days) since 2023-03-28. The patient’s oral thrush has also improved.
    • 2023-03-29 WBC 7.65 x10^3/uL
    • 2023-03-27 WBC 2.22 x10^3/uL
    • 2023-03-25 WBC 3.79 x10^3/uL
  • It appears that the patient may be more susceptible to leukopenia when receiving the “HD Ara-C” regimen compared to the “3+7 Idarubicin/Cytarabine” regimen based on the WBC levels observed during these limited treatments.

700979859

230714

[exam findings]

  • 2023-06-09 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx and hypopharynx; fair vocal cord movement.
  • 2023-04-27 Aspiration - thyroid
    • Indication: PET - Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected,
    • PATHOLOGIC DIAGNOSIS: Atypia, favor lymphocytic thyroiditis
    • MICROSCOPIC EXAMINATION: Two wet smears show colloid, dispersed lymphocytes, neutrophils and some atypical oncocytic follicular cells with mild to moderate anisonucleosis, lymphocytic thyroiditis maybe first considered. Clinical and laboratory correlation is needed. Follow up
  • 2023-04-18 Patho - esophagus subtotal/total resection
    • Diagnosis
      • Esophagus, lower third, VATS esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
      • Stomach, cardia, partial gastrectomy —- Squamous cell carcinoma, moderately differentiated, by direct invasion —- Gastrointestinal stromal tumor (GIST)
      • Azygos vein, right, excision —- Negative for malignancy
      • Resection margin: Negative for malignancy; proximal cutend of esophagus: Negative for malignancy
      • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      • Lymph node, middle paraesophageal, specimen 1, dissection —- Negative for malignancy (0/4)
      • Lymph node, lower paraesophageal, specimen 1, dissection —- Negative for malignancy (0/0)
      • Lymph node, peri-gastric, specimen 1, dissection — Squamous cell carcinoma, metastatic (1/9)
      • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/14)
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/5)
      • Lymph node, right, group 11, dissection —- Negative for malignancy (0/1)
      • AJCC 8 th edition pT N M Pathology stage:
        • Esophagus: ypStage IIIB, ypT3N1(if cM0)
        • Stomach GIST: pStage IA, pT1N0(if cM0)
    • Gross Description:
      • Procedure: VATS esophagectomy and gastric tube reconstruction; Size: Esophagus: 12.5 cm in length with a portion of gastric tissue measuring 4.7 cm in length. Azygos vein: 1.1 x 0.5 x 0.5 cm
      • Tumor Site: Distal esophagus (low thoracic esophagus) with involving esophagogastric junction (EGJ)
      • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
      • Tumor Size: 3.5 x 1.5 cm
      • A calcified nodule, measuring 1.0 x 0.5 x 0.5 cm, is seen in the gastric wall and 0.6 cm away from the distal gastric resection margin.
      • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: esophagus; A4: stomach tumor; A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal; A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, right group 7; D: lymph node, right group 11; E: azygos vein; F: proximal cutend of esophagus.
    • Microscopic Description:
      • Histologic Type: Squamous cell carcinoma, s/p CCRT; The immunohistochemical stains reveal CK(+) and p40(+).
      • Histologic Grade: G1: Well differentiated
      • Tumor Extension: Tumor invades adventitia
      • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
        • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm ; Specify closest margin: adventitia resection margin
        • Proximal resection margin: 6.0 cm
        • Distal resection margin: 5.0 cm
      • Treatment Effect : Present, Single cells or rare small groups of cancer cells (near complete response, score 1)
      • Lymphovascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors: y (posttreatment)
          • Primary Tumor (pT): pT3: Tumor invades adventitia
          • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings: A gastrointestinal stromal tumor is seen and very close (< 0.1 cm) to serosal surface. The immunohistochemical stains reveal CD34(+), CD117(+), and DOG-1(+). The mitotic rate < 5/5 mm (square).
  • 2023-04-14 Treadmill Exercise Test
    • Diagnosis
      • Squamous cell carcinoma of lower third of esophagus, cT3N1M0 stage III
      • Hypertension
      • Carrier of viral hepatitis B
    • Exam Object: Pre-op evaluation
    • Exam Record:
      • Ergometer protocol: incrementa
      • Ergometer type: cycle ergometer, work rate: 15 watt/min
      • Load time: 6.9 min
        • ΔVO2/ΔWR (Normal > 8.6 ~ 10.3): 5.9
        • AT: 628/1830 = 34
      • Predict
        • MIP :143 -( 0.55 * 59 ) = 110.55
        • MEP :268 -( 1.03 * 59 ) = 207.23
      • Meas
        • MIP :125 / 110.55 ) = 113
        • MEP :148 / 207.23 ) = 71
      • Cause of stop:
        • Rest BP: 120/79 mmHg
        • Max BP: 222/99 mmHg
      • Max Exercise: 104 watts
      • Dyspnea: 3-4 points
      • leg fatigue: 7-8 points
      • CAT: 11000121 = 6
    • Conclusion
      • low exercise capacity (VO2 55% <85%, WR 80%)
      • small airway disease with significant reveresibility (FVC 101%, FEV1 83%, MMEF 46 -> 63)
      • normal inspiratory muscle strength (MIP 113%, MEP 71%)
      • No SpO2 desaturation < 90% during exercise
      • normal stroke volume response during exercise
      • maximal HR 74% (<85%) but normal response slope
      • work efficiency low
      • anaerobic threshold low
      • oxygen pulse low
      • high BP response, BP 120/79 -> 222/99
      • EKG: no specific findings
      • Health-related quality of life, CAT = 6, OK
    • Impression:
      • deconditioning with low exercise capacity
      • small airway disease with significant reveresibility (MMEF 46->63)
      • HTN during exercise
    • suggestions:
      • treat underlying condition
      • give bronchodilator for small airway diseases
      • control BP
      • suggest home or hospital based exercise training after operation
  • 2023-04-13 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-04-12 PET
    • Compared with the previous study on 2022-12-27, the glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction is old and comes to less evident, and the glucose hypermetabolic lesion in adjacent paracardial area disappears, indicating cancer with respopsne to current therapy.
    • Glucose hypermetabolism in a nodular lesion in the left upper lung, the nature is to be determined (inflammation process, metastasis or other nature ?), suggesting further investigation.
    • Mild glucose hypermetabolism in the right mediastinal space and bilateral pulmonary hilar regions, probably reactive nodes.
    • Increased FDG uptake in a focal area in the right lobe of the thyroid gland, another primay thyroid cancer is highly suspected, suggesting biopsy for investigation.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2023-04-11 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/12/29, no prominent change is noted in the lesions in some T- and L-spines. Degenerative change may show this picture.
    • No prominent change is noted in the faint hot spots in the sternum and bilateral rib cages, possibly more benign in nature.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2023-04-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 20.0) / 82.6 = 75.79%
      • M-mode (Teichholz) = 73.7
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • No PR, mild TR, normal IVC size
  • 2023-03-07 CT - chest
    • Indication: esophagus cancer, cT3N1M0, stage III
    • Comparison was made with previous CT dated on 2022/12/26
      • Lungs: no abnormal nodule in the lungs,
        • moderate centrilobular emphysema at both upper lobes. and subpleural paraseptal emphysema
        • minimal subpleural fibrosis at LLL and RLL,
      • Mediastinum and hila: no enlarged LN or abnormal enhancing LN.
        • lymphadenopathy in stations
        • interval significant decrease in size of L/3 esophageal tumor with visible luminal wide as compared with CT on 2022/12/26
        • (residual circumferential wall thickness is 11.4mm).
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • s/p percutaneous gastrostomy.
      • Mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • L/3 esophageal cancer s/p C/T with partial response.
  • 2023-03-06 Abdomen - standing (diaphragm)
    • S/P ileostomy
    • S/P posterior instrumentation fixation from L5 to S1.
  • 2023-02-06 KUB
    • S/P posterior instrumentation fixation from L5 to S1.
    • Fecal material store in the colon.
    • S/P Foley’s catheter projecting at left abdomen?
  • 2023-01-10 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 23) / 100 = 77.00%
      • M-mode (Teichholz) = 77
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
  • 2022-12-30 MRI - brain
    • No evidence of intracranial lesion.
  • 2022-12-29 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in the sternum and bilateral rib cages and increased activity in some T- and L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in some T- and L-spines. Degenerative change is more likely.
      • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-12-28 Miniprobe Endoscopic Ultrasound
    • EUS findings
      • Using EUS-DP- 25R, EUS showed a mucosal lesion invading into the adventitia of esophageal wall at the lesion site.
      • At least 2 lymph nodes were noted. The biggest lymph node was noted with size about 4.6 mm.
    • Diagnosis
      • Esophageal cancer, at least cT3N1, 40cm below incisor. s/p chromoendoscopy
  • 2022-12-28 SONO - abdomen
    • Finding
      • Mass-like lesion in lower esophagus just above EG junction, suspected to be circumferential wall thickening up to 2.33 cm, compatible with lower esophageal tumor
    • Diagnosis
      • Probable lower esophageal tumor
    • Suggestion
      • Correlate with CT scan and endoscopy
  • 2022-12-27 Whole body PET scan
    • There was increased FDG uptake in the lower portion of the esophagus and adjacent EG junction (SUVmax early: 11.59, delay: 18.82), in a focal area in adjacent paracardial area (SUVmax early: 6.52, delay: 10.97) and bilateral pulmonary hilar regions (SUVmax early: 3.23, delay: 5.50). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters.
    • IMPRESSION:
      • A glucose hypermetabolic lesion involving the lower portion of the esophagus and adjacent EG junction, compatible with primary esophageal malignancy.
      • Glucose hypermetabolism in a focal area in adjacent paracardial area. A metastatic lymph node should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-12-27 Flow volume chart
    • Suspected small airway obstruction
  • 2022-12-26 CT - chest
    • Findings: segmental wall thickening in the lower esophagus.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:3(T_value) N:0(N_value) M:0(M_value) STAGE:IIA(Stage_value)
  • 2022-12-19 Patho - esophageal biopsy
    • DIAGNOSIS:
      • Esophagus, lower, from EG junction to 35 cm below incisor, biopsy — Squamous cell carcinoma, moderately differentiated
    • MICROSCOPIC DESCRIPTION:
      • Section shows pieces of squamous mucosa with infiltration of nests of neoplastic squamous cells. The immunohistochemical stain of p40 is positive.
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Advanced Esophageal cancer, lower esophagus, with luminal narrowing, s/p biopsy
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia
      • Superficial gastritis, antrum and body.
    • Suggestion
      • keep PPI
      • arrange magnified endoscopy/miniprobe EUS, chest/neck CT for cancer stage.
  • 2018-10-15 SONO - abdomen
    • Probable parenchymal liver disease
    • Status post cholecystectomy
  • 2018-06-09 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Hiatal hernia with Reflux esophagitis, Gr D   - Propable Distal esophageal diverticulum   - Superficial gastritis, antrum   - Duodenitis, bulb
    • Suggestion
      • Medication and OPD f/u   - Repeated EGD was suggested for GERD F/u 3 months later
  • 2018-06-08 CT - abdomen
    • Long segmental wall edema of colon.
    • Focal dilatation of lower esophagus.
  • 2018-01-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (122 - 38) / 122 = 68.85%
      • M-mode (Teichholz) = 69
    • Conclusion
      • Mild septal and RV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • AV sclerosis and mild aortic root calcification.
      • Trivial MR.

[consultation]

  • 2022-12-28 Hemato-Oncology
    • A
      • This 58 year old man is a case of lower esophagus squamouse cell carcinoma (inital presentation was postmeal vomiting since 2 weeks ago with acid regurgitation and heartburn sensation). We are consulted for further evaluation.
      • Arrange PET CT scan for staging. If no evidence of M1 unresectable disease, arrange Endoscopic ultrasound (EUS) and consult chest surgeon for possible of resection.
      • If unresectable advance esophagus cancer, CCRT is suggest. -> Arrange port A insertion, For nearing total obstruction esophagus cancer, before CCRT, please arrange jejunostomy for nutrition support.
      • PPN is suggested
  • 2022-12-27 Radiation Oncology
    • Diagnosis:
      • Esophageal cancer, MD squamous cell carcinoma, cT3N1M0 at least, with LAP metastasis over EG junction & lumen obstruction (liquid diet only); ECOG =1. PortA implantation and feeding ileostomy is scheduled on 2023/01/02.
    • Plan: EUS for staging if feasible. Preoperative CCRT to esophageal tumor, EG junction LAP & regional lymphatics for 5040cGy/28 fx is suggested for locoregional tumor control. Possible treatment toxicity (radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2023/01/03 14:30 after PortA implantation and feeding ileostomy is done. Psychological support & diet education is given to him.

[chemotherapy]

  • 2023-07-14 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-06-12 - NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1300mg NS 500mL 24hr D1-4 (PF4, CDDP 80%, 5-FU 80%)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-06 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1670mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-03 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1640mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-09 - NS 500mL 2hr (before cisplatin) + cisplatin 75mg/m2 125mg NS 500mL 4hr + NS 500mL 2hr (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF4)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-03-06

  • The patient’s renal function is showing a gradual decline and requires close monitoring.
    • 2023-03-06 BUN 29 mg/dL
    • 2023-02-15 BUN 28 mg/dL
    • 2023-02-06 BUN 17 mg/dL
    • 2023-02-02 BUN 22 mg/dL
    • 2023-01-09 BUN 15 mg/dL
    • 2023-03-06 Creatinine 0.98 mg/dL
    • 2023-02-15 Creatinine 0.97 mg/dL
    • 2023-02-06 Creatinine 0.85 mg/dL
    • 2023-02-02 Creatinine 0.81 mg/dL
    • 2023-01-09 Creatinine 0.68 mg/dL
  • Cisplatin can cause severe renal toxicity, including acute renal failure. Severe renal toxicities are dose-related and cumulative. Adequate hydration has been considered, specifically, NS 500mL is given both before and after the cisplatin infusion, which is administered in NS 500mL as well. However, if there is continued acceleration of the decline in kidney function, dose reduction or alternative treatment options should also be considered for this patient.

700385067

230713

  • diagnosis - 2022-10-19 discharge note
    • Malignant neoplasm of mediastinum, part unspecified
    • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) since 2022/09/20
    • Unspecified viral hepatitis B without hepatic coma
  • lab data
    • 2022-09-17 Urine-Creatinine 142.38 mg/dL
    • 2022-09-17 U-Cr (24hr) 2135.7 mg/kg/24 hr
    • 2022-09-17 HBsAg Reactive
    • 2022-09-17 HBsAg (Value) 3335.07 S/CO
    • 2022-09-17 Anti-HBc Reactive
    • 2022-09-17 Anti-HBc-Value 7.18 S/CO
    • 2022-09-17 Anti-HCV Nonreactive
    • 2022-09-17 Anti-HCV Value 0.11 S/CO
    • 2022-09-16 beta-HCG 20.2 mIU/mL
    • 2022-09-16 AFP 1.6 ng/mL
    • 2022-09-15 LDH 397 U/L
    • 2022-09-15 AFP (nuclear medicine) 3.617 ng/ml
    • 2022-09-15 CEA (nuclear medicine) 12.729 ng/ml
    • 2022-09-15 SCC (nuclear medicine) 1.61 ng/mL
    • 2022-09-15 CA-199 (nuclear medicine) 23.149 U/ml
    • 2022-09-15 CA-125 (nuclear medicine) 24.131 U/ml
    • 2022-09-15 CyFra 21-1 (nuclear medicine) 14.0 ng/mL

[exam findings]

  • 2023-06-07, -05-19, -05-03, -04-30 CXR
    • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, stable in size that is c/w Germ cell tumor S/P C/T with stable disease.
  • 2023-04-18 CXR
    • Prior plain chest film identified left superior mediastinal widening and enlarged Lt hilum is noted again, marked decreasing in size that is c/w Germ cell tumor S/P C/T with partial response.
  • 2023-03-27, -03-20, -03-10 CXR
    • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2023-02-18 CT - chest
    • Indication: germ cell tumor of left mediastinal progress and severe cough noted
    • Chest CT with and without IV contrast ehnancement shows:
      • Minimal interstitial change at bilateral peripheral lung fields is found.
      • Huge soft tissue mass with central necrotic part at superior mediastinum encasing great vasculature is found measuring 8.4cm in largest dimension. In comparison with CT dated on 2022-12-13, the lesion is stationary.
      • Calcified coronary arteries is found.
    • Imp:
      • Mediastinal mass, compatible with germ cell tumor. Stationary.
      • Interstitial change at both lungs. Either treatment effect or idiopathic pullmonary fibrosis should be considered. Suggest follow up.
  • 2022-12-13 CT - abdomen
    • History and indication: Germ cell tumor of left mediastinal invasion
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
      • Liver cysts (up to 1.0cm).
    • IMP:
      • Mild regression of germ cell tumors with mediastinnal invasion. S/P Port-A infusion catheter insertion. A thrombus at SVC. Some LNs at bil. neck and mediastinum.
  • 2022-11-30 CXR
    • There is left superior mediastinal widening and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2022-11-15, -11-01, -10-19, -10-05, -09-27 CXR
    • There is marked superior mediastinal widening (Lt greater than Rt), and enlarged Lt hilum that is c/w Germ cell tumor after correlate with CT and pathology.
  • 2022-10-26 MRI - brain
    • Findings
      • mild dialted intraventricular and extraventricular CSF spaces
      • some white matter gliosis int he bilateral frontal brain parenchyma
      • unremarkable change in the skull base
      • no abnormal brain parenchymal enhancement
    • IMP:
      • no evidence of brain metastasis.
  • 2022-09-19 CXR
    • marked superior mediastinal widening (Lt greater than Rt), displacing the trachea to Rt, and prominent soft-tissue over Lt supraclavicular fossa and enlarged Lt hilum, due to extensive lymphadenopathy or tumor and lymphadenopathy
    • Normal heart size
    • no pneumothorax or pleural effusion
  • 2022-09-19 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 43 dB HL; LE 39 dB HL.
    • R’t mild to moderately severe MHL.
    • L’t mild to moderate MHL.
  • 2022-09-16 CT - abdomen
    • History: Mediastinal mass, pathology: germ cell tumor
    • Indication: for cancer survey
    • Findings:
      • Prior CT identified a heterogeneous soft tissue mass at left upper anterior mediastinum, measuring 10 cm in the largest dimension, with encasement of left subclavian artery and aortic arch, causing mild right lateral deviation of the trachea and esophagus, and multiple enlarged nodes in left lower neck, paratracheal space, and left hilum are noted again, stationary.
        • Germ cell tumor is highly suspected.
      • There are several hepatic cysts in both lobes and the largest one 0.9 cm in size at S5.
    • Impression:
      • Germ cell tumor of left upper anterior mediastinum is highly suspected.
  • 2022-09-16 Pulmonary function test
    • normal standard spirometry
    • negative BDT (bronchial dilation test)
    • normal DLCO (diffusion capacity of carbon monoxide)
  • 2022-09-14 Bronchoscopy
    • no endotracheal or endobronchial lesion
  • 2022-09-12 Patho - lung transbronchial biopsy
    • Mediastinum, CT-guide biopsy — in favor of germ cell tumor
    • Sections show nests of large pleomorphic tumor cells infiltrating in fibrous stroma with tumor necrosis.
    • The immunohistochemical stains reveal CK(+), SALL4(focal +), beta-hCG(focal +), CK7(-), CK20(-), CK5/6(-), TTF-1(-), Napsin A(-), p40(-), GATA3(focal +), PSA(-), CDX2(+), CD117(-), and CD56(-). According to the results, germ cell tumor (embryonal carcinoma or choriocarcinoma) is favored. Thymic tumor, lung cancer, mesothelioma, or lymphoma is less likely. Please correlate with the clinical presentation and image study.
  • 2022-08-31 CT at ShuangHo Hospital
    • Findings: A 7.6 cm mass at LUL with mediastinal invasion causing confluence of lymph nodes in the paratracheal, prevascular, subcarinal and left hilar regions. Encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted.
    • DDX: bronchogenic carcinoma, thymic carcinoma or other malignancy. Advise further work-up.
  • 2022-08-31 Aspiration Cytology - lymph node
    • Clinical diagnosis: Paralysis of vocal cords and larynx, unspecified
      • Hoarseness for a month.
      • Previous URI(+)
      • Choking(+)
    • Cytological diagnosis
      • Left level IV mass: Positive for malignancy
    • Four wet smears show lymphocytes, neutrophils and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2022-08-31 SONO - neck
    • Findings
      • Multiple LNs in bilateral neck, with size up to 1.42 cm in length at right and 2.37cm at left.
      • No abnormal fluid collection.
    • Imp: Multiple bilateral neck LNs.
  • 2022-08-30 SONO - head and neck soft tissue
    • cervical lymph node: 1.34*3.0cm LAP at left supraclavicular fossa
  • 2022-08-03 SONO - abdomen
    • Diagnosis
      • GB polyp, large R/O focal wall thickening
      • Parenchymal liver disease
    • Suggestion
      • Keep regular follow up

[MedRec]

  • 2023-04-18 ~ 2023-05-05 POMR Hemato-Oncology
    • Discharge diagnosis
      • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
      • Neutropenia due to infection post chemotherapy blood culture: no growth for 5 days aerobically & anaerobically
      • Hypokalemia
      • Hypomagnesemia
      • Anemia due to antineoplastic chemotherapy
    • Chief Complaints
      • for C2 chemotherapy with TIP & autologout stem cell collection
    • Present illness
      • Port-A implantation on 2023/03/10.
      • C1 chemotherapy with TIP was given on 3/21-3/25 23 and autologous hematopoietic cell transplantation was performed on 4/3 23.
      • Today, he was admitted for C2 chemotherapy with TIP & autologous hematopoietic cell transplantation on 4/18 23.
    • Course of inpatient treatment
      • After admission, chemotherapy with TIP (Taxol 250mg/m2, self-paid D1 4/19 ) & Mesna (300mg/m2, IVD 15mins, after Ifosfamide at 0, 4, 8 hour on 4/20-4/23), Ifosfamide 1500mg/m2 (D2-D5 4/20-4/23), Cisplatin (25mg/m2, D2-D5 4/20-4/23) were given, smoothly without obvious side effect. Lenograstim started since 4/25 23 was added. He complained of watery diarrhea and Imodium was given for symptom relief. Will arrange autologout stem cell collection on 5/4-5/5 23. Lenograstim 250mcg & G-CSF 150mcg sc qd was given for post C/T. He complained of watery diarrhea post C/T and Imodium 1# po prnq6h was added.
      • Fever with chills was developed on 4/27 23 afternoon and septic work-up was performed and antibiotic with Cefim 2000mg ivd q8h was given for neutropenia fever. The blood culture report showed No growth for 5 days aerobically & anaerobically. Blood transfusion with LPRBC 2U was given on 5/2 23. Double lumen was inserted on 5/3 23 and autologous stem cell collection on 5/3-5/4 23 and CD34+: 0.01% & CD34 + count (5/3 23): 25/uL, CD34+: 0.02% & CD34 + count (5/4 23): 60/uL were noted. Intravenous KCL 10cc & MgSO4 1amp was given for hypokalemia & hypomagnesemia. Double lumen was removed on 5/5 23 and he was discharged on 5/5 23 with stable condition and will follow-up at OPD.
  • 2023-03-09 ~ 2023-04-03 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of mediastinum, part unspecified
      • Germ cell tumor with left medistainal invastion, stage IV, S/P BEP chemotherapy with refractory, S/P TIP chemotherapy and autologous stem cell collection
      • Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20 to 2023/01/04
    • Present illness
      • This 53 year-old man suffered from hoarsness in 2022/08. He went to local clinic first and they suggested hospital follow up. He then went Shuang Ho Hospital for help. According to CT report from Shaung Ho, there is a 7.6 cm mass at LUL with mediastinal invasion and encasement of left subclavian artery and displacing trachea, esophagus and left CCA noted. Differential diagnosis included bronchogenic carcinoma, thymic carcinoma or other malignancy.
      • He then came to our otorhinolaryngology clinic for further evaluation. Nasopharyngoscopy on 2022/08/30 showed smooth nasopharynx, oropharynx, hypopharynx and left vocal cord palsy. Neck sonography revealed left supraclavicular lymphadenopathy. Moreover, sono-guide fine needle aspiration revealed metastatic malignancy. He was reffered to our chest surgery clinic for further management.
      • After admission, CT-guide biopsy of left mediastinal mass on 2022/09/12 showed left mediastital mass revealed germ cell tumor, embryonal carcnimoa or choriocarcinoma is favored. Upper GI endoscopy on 2022/09/13 revealed reflux esophagitis. Bronchoscopy on 2022/09/14 showed no endotracheal or endobronchial lesion. Abdominal/Pelvic CT on 2022/09/16 showed germ cell tumor of left upper anterior mediastinum is highly suspected.
      • For pre-chemotherapy evaluation, pulmonary function test (FRC + DLCO) on 2022/09/16 normal standard spirometry, 24 urine CCR on 2022/09/17 showed 178.7 ml/min / urine 1500 ml/day, pure-tone audiometry test on 2022/09/19 showed R’t mild to moderately severe MHL, L’t mild to moderate MHL. Port-A insertion on 2022/09/19.
      • Chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2 and Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/202022/09/25(C1D1D5), 2022/09/28(C1D9), 2022/10/202022/10/25(C2D1D5), 2022/10/28(C2D9), 2022/11/01(C2D16), 2022/11/152022/11/20(C3D1D5), 2022/11/22(C3D9), 2022/12/062022/12/11(C4D1D5), 2022/12/14(C4D9), 2022/12/17-2023/01/01(C5D1~D5), 2023/01/04(C5D9).
      • CXR on 2022/09/27 showed mediastinal widening (left greater than right) improving, and enlarged left hilum. Brain MRI on 2022/10/26 showed no evidence of brain metastasis. CXR on 2022/11/15 showed mediastinal widening (left greater than right) mild improving. Abdominal CT on 2022/12/13 showed mild regression of germ cell tumors with mediastinnal invasion, a thrombus at SVC and some lymph nodes at bil. neck and mediastinum.  
      • He had COVID-19 infection on 2023/02, but he denied cough, sputum or fatigue. But, before C6D1 chemotherapy, he has fever with chills suddenly, so we hold chemo and check blood studies. R’t Port-A was removed by CS for yield Pseudomonas spp on 2023/02/10. Fever also noted durine Cefepime, consider tumor fever related. He received Chest CT showed mediastinal mass, compatible with germ cell tumor stationary and interstitial change at both lungs on 2023/02/18, but image showed mediastinal mass got bigger and due to a 1cm x 1cm LN over left suparclavicle, so we thick the disease in progress. After well infection control, discharged on 2023/02/22.
      • This time, he had mild fever at home (highest to 37.6’C), and he had mild cough without sputum, no fever, mild dysphagia was noted. He was admitted for port-A implantation and receive new regimen chemotherapy.
    • Course of inpatient treatment
      • After admission, consult CS for Port-A implantation on 2023/03/10, funtion well. Pain control with Tramacet 37.5 & 325mg/tab 1# PO Q12H. He was transfered to Dr. Wan service for autologous hematopoietic cell transplantation (autoHCT). Palitaxel on (2023/03/21) -> Ifosfamide, cisplatin (2023/03/22-2023/03/25). G-CSF 150mcg, granocyte 500mcg (2023/03/27-). We would keep on monitoring his clinical manifestation and provide necessary treatments.
      • On 2023/04/03, we placed a double lumen catheter for stem cell collection. After one day with 18 liters of peripheral blood circulation through the cell separater and CD34+ cell collection. Total 1.99 x 10 ^6/kg of CD 34+ cells were collected. Removal of the double lumen catheter and disharged at today. The next chemotherapy and then stem cell collection will be scheduled at April 11.

[consultation]

  • 2022-12-08 Dermatology
    • Q
      • This 53-year-old man patient is a case of Germ cell tumor of left mediastinal invasion, stage IV s/p chemotherapy with BEP (Bleomycin 30unit on D2.9.16/ Etoposide 80mg/m2、Cisplatin 15mg/m2 on D1-5 Q3W) from 2022/09/20~. He was admitted for chemotherapy with BCP(C4). this time, for left upper arm redness rash without itch, R/O hemangioma. Now, for evaluate left upper arm redness rash therapy. Thank you.
    • A
      • The patient had sufferred from germ cell tumor under chemotherapy. region telangetasia with vascular dialation was noted over left upper limb.
      • Besides, no regional swelling or tenderness was noted.
      • Under the impression of peripheral vsaculopathy, be aware of progressive vasculitis, favor IV form medication-related.
      • The following suggestion:
        • notify IV form electrolyte infusion rate, decrease osmotic imbalance as possible.
        • Due to no obvious clinical symptom, further regional skin care and moisturization with Sinphraderm cream 1 tube topical bid use.
  • 2022-09-26 Hemato-Oncology
    • Q
      • This 53-year-old man was admitted under impression of LUL mediastinal mass.
      • CT-guide biopsy was done and pathology revealed germ-cell tumor (embryonal carcinoma or choriocarcinoma is favored)
        • LDH 397
        • AFP 3.617
        • CEA 12.7
        • CA 199 23.1
        • CA 125 24.1
        • CyFra 14
      • We need your expertise for this patient’s further management
    • A
      • Impression:
        • LUL mediastinal mass s/p CT guide biopsy, pathology show germ cell tumor (embryonal carcinoma or choriocarcinoma is favored) LDH 397, AFP 3.617-B HCG: pending.
      • Suggestion:
        • For germ cell tumor cancer work up, please arrange abdominal/pelvic CT and Pending B-HCG level
        • Prepare cancer treatment, please arrange pulmonary function test (FRC + DLCO), 24 urine CCR, Pure-tone audiometry test, HbsAg, Anti Hbc, Anti HCV
        • On port-A if patient agree further systemic chemotherapy. We wound like to take over this case, if you agree.
        • Thanks for your consultation. If there is any problem, please feel free to let us known

[chemoimmunotherapy]

  • 2023-06-07 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL + mesna 300mg/m2 510mg NS 250mL 15min (x3 at 0, 4, 8 hr after ifosfamide) + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL] D1-5 + palonosetron 250ug D1 + aprepitant 125mg PO D1-3
  • 2023-04-19 - paclitaxel 250mg/m2 430mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2600mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
  • 2023-03-20 - paclitaxel 250mg/m2 420mg NS 500mL 24hr D1 + [ifosfamide 1500mg/m2 2580mg NS 500mL ………………………………………………………………. + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 250mL 1hr + NS 500mL 2hr (after cisplatin)] D2-5 (for PBHSC harvest)
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL + palonosetron 250ug] D1-5
  • 2023-02-07 - etoposide 80mg/m2 140mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 27mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
    • [dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5 + famotidine 20mg D1
  • 2023-01-04 - bleomycin 30mg NS 100mL 10min D2,9,16
    • dexamethasone 8mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-27 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
    • dexamethasone 8mg ST D1 & 8mg QD D2-5 + diphenhydramine 30mg ST & 30mg QD D2-5 + palonosetron 250ug D1 + aprepitant 125mg ST D1 & 125mg QD D2-3
  • 2022-12-13 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1222, 1223)
    • dexamethasone 8mg + diphenhydramine 30mg
  • 2022-12-06 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-11-22 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1130, 1201, 1202)
  • 2022-11-15 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-11-01 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1101, 1108, 1110)
  • 2022-10-28 - bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-10-19 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16
  • 2022-09-28 - bleomycin 30mg NS 100mL 10min D2,9,16 (G-CSF 1105, 1106, 1107)
  • 2022-09-20 - etoposide 80mg/m2 135mg NS 400mL 1hr D1-5 + cisplatin 15mg/m2 25mg NS 500mL 24hr D1-5 + bleomycin 30mg NS 100mL 10min D2,9,16

Granocyte (lenograstim) 250mg SC

  • 2022-12-22, -23 (20221221 OpdRx)
  • 2022-12-01, -02 (20221130 OpdRx)
  • 2022-11-30 (20221115 IpdRx)
  • 2022-11-08, -10 (20221101 OpdRx)
  • 2022-11-01 (20221019 IpdRx)
  • 2022-10-05, -06, -07 (20221005 OpdRx)

lab WBC

  • 2022-12-27 WBC 9.45 *10^3/uL BEP 1227
  • 2022-12-21 WBC 2.00 *10^3/uL G-CSF 1222, 1213
  • 2022-12-13 WBC 2.66 *10^3/uL bleomycin 1213
  • 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
  • 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
  • 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
  • 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
  • 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
  • 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
  • 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
  • 2022-10-12 WBC 6.84 *10^3/uL
  • 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
  • 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
  • 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
  • 2022-09-12 WBC 4.52 *10^3/uL

[note]

==========

2023-07-13

  • Over the last three months, this patient has solely been utilizing our hospital’s outpatient and inpatient hemato-oncology services. There have been no issues identified regarding medication reconciliation.

2023-06-08

  • Based on the PharmaCloud database, this patient has exclusively been visiting our hospital for outpatient and inpatient hemato-oncology services over the past three months. No medication reconciliation issues have been identified.

2022-12-28

  • CT on 2022-12-13 showed mild regression of germ cell tumors with mediastinal invasion, suggesting that the current BEP regimen is effective in inhibiting tumor progression. CS opinioned on 2022-12-22 that the tumor was not suitable for surgical removal due to the fact that it encased large vessels over the mediastinum.
  • In accordance with the appropriate G-CSF administration timing, there have been no WBC events less than 2K/uL since December 2022.
  • Although magnesium supplements were administered, lab results showed a slow decline in serum magnesium levels (now slight below LLN).
    • 2022-12-27 Mg (Magnesium) 1.8 mg/dL
    • 2022-12-21 Mg (Magnesium) 1.8 mg/dL
    • 2022-12-13 Mg (Magnesium) 1.6 mg/dL
    • 2022-12-06 Mg (Magnesium) 1.7 mg/dL
    • 2022-11-30 Mg (Magnesium) 1.6 mg/dL
    • 2022-11-23 Mg (Magnesium) 1.7 mg/dL
    • 2022-11-15 Mg (Magnesium) 1.9 mg/dL
    • 2022-10-28 Mg (Magnesium) 1.8 mg/dL
    • 2022-09-26 Mg (Magnesium) 1.9 mg/dL
    • 2022-09-20 Mg (Magnesium) 2.0 mg/dL
  • Magnesium losses from both the upper and lower gastrointestinal tract can induce hypomagnesemia. In general, magnesium depletion is more commonly due to diarrhea than to vomiting. As there have been no recent diarrhea or vomiting-related events recorded, these may be less likely to be to blame.
  • Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity and can be severe. It is dose related and can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, regular monitoring is essential.
  • There is no problem with the active prescription.

2022-12-07

  • It appears that the approximate cycled trough WBC count occured around one week after the administration of single bleomycin agent, the G-CSF administration might follow this pattern.

    • 2022-12-06 WBC 6.11 *10^3/uL BEP 1206
    • 2022-11-30 WBC 1.73 *10^3/uL G-CSF 1130, 1201, 1202
    • 2022-11-23 WBC 3.52 *10^3/uL bleomycin 1122
    • 2022-11-15 WBC 5.84 *10^3/uL BEP 1115
    • 2022-11-01 WBC 2.38 *10^3/uL G-CSF 1108, 1110
    • 2022-10-28 WBC 3.01 *10^3/uL G-CSF 1101; bleomycin 1028
    • 2022-10-19 WBC 6.04 *10^3/uL BEP 1019
    • 2022-10-12 WBC 6.84 *10^3/uL
    • 2022-10-05 WBC 1.17 *10^3/uL G-CSF 1105, 1106, 1107
    • 2022-09-26 WBC 11.36 *10^3/uL bleomycin 0928
    • 2022-09-20 WBC 5.46 *10^3/uL BEP 0920
    • 2022-09-12 WBC 4.52 *10^3/uL
  • The AFP/beta-HCG/LDH tests might be conducted again in December 2022 to make the monitor frequency not fall below two months. (There were still superior mediastinal widening and an enlarged Lt hilum on the CXR of 2022-11-30)

  • Pulmonary fibrosis is the most severe toxicity associated with bleomycin. The most frequent presentation is pneumonitis occasionally progressing to pulmonary fibrosis. Its occurrence is higher in elderly patients and in those receiving more than 400mg total dose, but pulmonary toxicity has been observed in young patients and those treated with low doses.

    • 2022-09-16 pulmonary function test showed the patient with normal standard spirometry, negative BDT, normal DLCO.
    • As of 2022-12-07, there has been 240mg (30mg x 8) of cumulative exposure to bleomycin.
    • Please monitor for signs of lung deterioration on a regular basis.

2022-11-16

  • Lab data from selected tumor markers revealed that each marker had a different trend without an overall trend.
    • 2022-11-01 AFP 16.6 ng/mL
    • 2022-09-16 AFP 1.6 ng/mL
    • 2022-07-05 AFP 1.4 ng/mL
    • 2022-11-01 beta-HCG 5.8 mIU/mL
    • 2022-09-16 beta-HCG 20.2 mIU/mL
    • 2022-10-19 LDH 377 U/L
    • 2022-10-12 LDH 349 U/L
    • 2022-09-26 LDH 253 U/L
    • 2022-09-15 LDH 397 U/L
  • The WBC is boosted with lenograstim when neutropenia is observed following the BEP regimen.
  • Chronic hepatitis B is treated appropriately with Baraclude (entecavir) 0.5mg QDAC.
  • The active prescription is not subject to any issues.

2022-10-20

  • The primary chemotherapy regimen for germ cell tumors could be BEP, which consists of the following components (NCCN).

    • Etoposide 100 mg/m2 IV on Days 1-5
    • Cisplatin 20 mg/m2 IV on Days 1-5
    • Bleomycin 30 units IV weekly on Days 1, 8, and 15 or Days 2, 9, and 16
    • Repeat every 21 days
  • AST, ALT, Cre, and eGFR (2022-10-19) did not exhibit abnormalities, therefore no dose adjustment would be required for the BEP regimen based on pharmacokinetics.

  • The dose used is slightly lower than that recommended by the NCCN (currently: 80mg/m2 of etoposide, 15mg/m2 of cisplatin. NCCN: 100mg/m2, 20mg/m2). Given that the patient’s performance status scale is ECOG 0, it might be an option to upgrade the dose to meet the guideline to obtain more expected effects if no other considerations exist.

700014611

230712

(not completed)

[exam findings]

[chemotherapy]

==========

2023-07-12

[reconciliation]

This patient intermittently visits a local ophthalmology clinic due to symptoms in his left eye. His most recent visit was on 2023-06-30, and the prescription given, which was valid for 3 days, has now expired. Please decide whether to refer him to our hospital’s ophthalmology department based on his current clinical condition.

700536529

230712

[MedRec]

  • 2023-07-10 MultiTeam - Palliative Care
    • Multidisciplinary Team Suggestions
    • Consultation date: 2023-07-10
    • Response: Together with Dr. Chen from the Department of Family Medicine, the co-care nurse visited the patient, who is in fair spirits and reports no discomfort. The foreign caregiver was taking care of the patient at the bedside. The patient is expected to be discharged tomorrow. The co-care nurse called the patient’s eldest son (0933221580) and introduced the concept of palliative care. The eldest son expressed the wish to discuss palliative care face-to-face with his siblings. He would contact the co-care nurse when he arrives at the hospital tomorrow morning, and left the co-care nurse’s contact number for future follow-ups. In the afternoon, the eldest son called to arrange a face-to-face meeting at 16:30 today. The co-care nurse explained the concept of palliative care (palliative care ward, co-care palliative, home palliative care) to the eldest son, the patient’s daughter, and the patient’s son-in-law. The eldest son agreed to direct the patient’s care towards palliative care, hoping that the patient can be comfortable and not suffer. The patient is aware of his cancer diagnosis and has previously stated that he does not want resuscitation. The co-care nurse introduced the concept of Advance Care Planning (ACP) for palliative care and suggested that they complete the ACP.
    • Conclusion and Suggestions: Palliative co-care, Follow-up on the Advance Care Planning for Palliative Care.
    • Responder: Chen Hui
    • Reply date: 2023-07-10 17:42

==========

2022-01-18

  • Recent lab data

    • 2022-01-18 serum glucose 191mg/dL
    • 2022-01-17 serum glucose 164mg/dL
    • 2022-01-11 serum glucose 154mg/dL
    • 2021-11-10 ascites glucose 150mg/dL
  • Elevated serum glucose. This patient has type 2 DM and CVD, SGLT2i might be a choice to protect heart while lowering blood sugar.

  • SGLT2i such as empagliflozin, dapagliflozin, canagliflozin are available in stock could be prescirbed if UTI is unlikely.

701462990

230712

[chemotherapy]

  • 2023-07-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-20 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-26 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-04-28 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL
  • 2023-04-03 - atezolizumab 1200mg NS 250mL 1hr + bevacizumab 15mg/kg 900mg NS 100mL 90min
    • diphenhydramine 30mg + NS 250mL

701486110

230712

[exam findings]

  • 2023-06-14 CT - chest
    • Indication: One mass was noted in the rectum (12 cm from anal verge) with partial obstruction, for cancer staging
    • Chest CT without IV contrast ehnancement shows:
      • Perifissural nodule at right middle lobe measuring 0.36cm is found. Old insult is more favored.
      • Calcified coronary arteries is found.
    • Imp: Right middle lobe perissural nodule. 0.36cm
  • 2023-06-13 Patho - colon biopsy
    • Colorectum, rectum, 12 cm above anal verge, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-06-08 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection. Some LNs at pelvic cavity.
      • Tiny liver and renal cysts.
      • Atherosclerosis of aorta, iliac arteries.
      • A nodule (3mm) at RML, nature ?
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)

[consultation]

  • 2023-06-15 Radiation Oncology
    • A
      • Preoperative CCRT first followed by surgical treatment was suggested. CT-simulation will be arranged on 2023/06/20. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 2023/06/26. Thank you very much.
  • 2023-06-15 Hemato-Oncology
    • Q
      • For neoadjuvant CCRT
      • This 51-year-old male got intermittent right lower abdominal pain, bloody stool for two months and got worse in recent days. Thus, he vistit our CRS OPD then referred to our ER on 2023/06/08. Lab data revealed leukocutosis and CRP level 10.9. Abdominal CT showed wall thickening of R-S junction of colon with adjacent fat stranding and fluid collection, along with some lymph nodes at pelvic cavity. Uner the diagnosis of diverticulitis of R-S colon, the patient was admitted for further evaluation. After admission, NPO with adequate fluid supplement and empirical antibiotic treatment with Brosym were prescribed. After medical treatment, his abdominal pain improved much. Sigmoidoscopy was arranged and revealed one mass was noted in the rectum (12 cm from anal verge) with partial obstruction. Biopsy was done and pathology proved adenocarcinoma. Chest CT showed right middle lobe perissural nodule. 0.36cm.
      • After fully explained of the condition, preoperative CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of CCRT. Thanks a lot !!
    • A
      • Dear doctor: This 51 year old man is a case of newly diagnosis rectal cancer, cT4aN2b , stage IIIc. We are consulted for total neoajuvant chemotherapy.
      • We will discuss with patient about total neoajuvant chemotherapy (CCRT followed by systemic chemotherapy 12-16 week) and then restaging for operation.
      • Please arrange port A insertion. Please check HBsAg, Anti HBc, AntiHBs, Anti HCV. Transfer to 11A or 10B on Dr

[radiotherapy]

[chemotherapy]

  • 2023-06-26 - [leucovorin 20mg/m2 30mg NS 250mL 10min + fluorouracil 400mg/m2 630mg NS 100mL 10min] D1-5 (CCRT)

==========

2023-07-12

The patient previously visited WanFang Hospital on 2023-06-02 for treatment of hemorrhoids and was given a 14-day supply of medication, which has now expired. As the patient did not report any problems related to his hemorrhoids at the time of his current admission, no concerns were identified during the medication reconciliation process.

2023-06-20

Continuing from the previous pharmacist note, confirm that Baraclude (entecavir 0.5 mg) 1# QDAC has been prescribed. There are no other medication-related problems at this time.

2023-06-16

Lab 2023-06-16 Anti-HBc positive. If immunosuppressive chemotherapy is to be used, it is advisable to use either Baraclude (entecavir 0.5 mg) 1# QDAC or Vemlidy (tenofovir alafenamide 25 mg) 1# QD as a precaution, at least during the course of chemotherapy. This would help protect against the potential reactivation of HBV infection by chemotherapy.

700067411

230711

[exam findings]

  • 2023-06-15 KUB
    • Radiopaque spots are noted at both renal region. Bilateral renal stones are considered.
    • There is no evidence of destructive bone lesion.
  • 2023-05-15 Uroflowmetry
    • Q max : fair
    • flow pattern : obstructive
  • 2023-05-15 Bladder sonography
    • PVR: 24 mL
  • 2023-05-06 CT - abdomen
    • Clinical history: 63 y/o male patient with peri-unbilical pain since 2 hours ago, nausea, no vomtiing. loose stool.
    • WITHOUT contrast enhancement CT of abdomen–whole:
      • Gallbladder stone with wall edema of gallbladder, r/o cholecystitis.
      • Bilateral renal stones.
      • Dilatation of right pelvicaliceal system with right upper ureteral wall thickening, may consider URS study.
    • Impression:
      • GB stones with gallbladder wall edema, r/o cholecystitis.
      • Bilateral renal stones.
      • Right hydronephrosis with upper ureteral wall thickening, suggest URS study.
  • 2023-05-06 CXR
    • Presence of ileus.
    • Presence of bil. renal stones.
  • 2023-05-06 KUB
    • Presence of bil. renal stones.
    • Intact bony structure(s).
  • 2023-02-10 Patho - salivary gland biopsy
    • Labeled as “right parotid”, needle biopsy — poorly differentiated carcinoma.
    • Section shows nests of round blue cells with abundant infiltration of lymphoid cells.
    • IHC stain of CK highlight irregular nests of CK (+) sheets which is also focal P40 (+), morphologically is similar to nasopharyngeal carcinoma.
  • 2023-02-09 PET
    • Glucose hypermetabolism involving the nasopharynx, compatible with primary nasopharyngeal malignancy.
    • Glucose hypermetabolism in bilateral retropharyngeal lymph nodes and in multiple neck lymph nodes in bilateral parotid areas, bilateral neck level II to III regions and left neck level IV region, suggesting metastatic lymph nodes.
    • Increased FDG accumulation in both kidneys and urethra. Physiological FDG accumulation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-02-08 ENT Hearing Test
    • Tymp:
      • RE type B; LE type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 73 dB HL; LE 36 dB HL.
      • RE normal to moderate SNHL.
      • LE moderate to profound mixed type HL.
  • 2023-02-07 MRI - nasopharynx
    • Indication: nasopharyngeal ccancer, for cancer work up
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A right nasopharynx tumor, up to 3.7 cm, no obvious parapharyngeal or skull base invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple bilateral retropharyngeal and neck LAPs, with central necrosis, below the low border of cricoid cartilage at left.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
    • IMP: Right NPC with bil. neck LAPs. T1N3Mx stage IVA.
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N3(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2023-02-06 ECG
    • Sinus rhythm with Premature supraventricular complexes
  • 2023-02-06 CXR
    • Borderline heart size. No mediastinal widening. Enlargement of right hilar region?
    • No active lung lesion. Intact bony thorax.
  • 2023-02-02 SONO - abdomen
    • Fatty liver, mild
    • Suspected GB stone
    • Suspected chronic renal parenchymal disorders, bil
    • Suspected renal cysts, bil
    • Suspected renal stones, bil
    • Pancreas not shown
    • Suboptimal examination of liver due to poor echo window
  • 2023-01-18 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, biopsy — Nasopharyngeal carcinoma, non-keratinizing and undifferentiated
    • Microscopically, section shows nasopharyngeal carcinoma characterized by diffuse sheets of non-keratinizing invasive carcinoma closely infiltrated by prominent lymphoplasmacytic cells. The tumor shows nclear hyperchromasia, high N/C ratio and mitotic figures.
    • Immunohistochemical stain reveals CK(+) for tumor cells.
  • 2023-01-18 Nasopharyngoscopy
    • Findings
      • smooth oropharynx, hypopharynx
      • yellowish mucopus over nasopharyngeal granular tumor
      • s/p submucosla turbinectomy,bil
    • Diagnosis, conclusion
      • Nasopharyngeal tumor, occupying bil choanae s/p biopsy

[consultation]

  • 2023-02-10 Radiation Oncology
    • A
      • Diagnosis: Nasopharyngeal cancer, nasopharyngeal carcinoma, non-keratinizing and undifferentiated, cT1N3M0, with bilateral neck and retropharyngeal LAP metastasis; 2.2-cm Rt parotid tumor s/p biopsy on 2023/2/10; ECOG =1.
      • Plan: After teeth treatment, CCRT to NPX tumor & LAPs (and parotid tumor) for 7140cGy/34 fx is suggested for tumor control. CT simulation will be arranged after teeth extraction. Possible treatment toxicity of radiotherapy (radiation dermatitis, mucositis, pharyngitis & esophagitis) is told.
  • 2023-02-08 Oral and Maxillofacial Surgery
    • Q
      • This is a 63 y/o male with history of HBV carrier
      • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, T1N3Mx, stage IVA, CCRT is indicated. We need your expertise on dental evaluation before radiotherapy.
    • A
      • This is a 63 y/o male with history of HBV carrier. This time, he was admitted due to nasopharynx carcinoma, cT1N3Mx, stage IVA and was scheduled for further CCRT. We were consulted for pre-RT dental evaluation.
      • O:
        • Panoramic findings:
          • Missing: 18,17,16,11,21,22,28,38-34,32-48
          • Impaction: Nil
          • Caries: 14,13,23,26,27
          • Crown and bridges: nil
          • Periodontal condition: Severe periodontitis
        • Full mouth severe periodontitis with advanced periodontal bone destruction was noted.
        • Multiple deep caries and residual roots was noted.
        • Poor oral hygiene.
      • P:
        • Explained the findings and treatment plan to the patient
        • Suggest extraction of all teeth including 15,14,13,12,23,24,25,26,27,33
        • Patient needed to consider.
        • If the patient needs a tooth extraction, please contact Dr. Xia’s clinic assistant to arrange the extraction time and prescribe prophylactic antibiotics. Thank you.

[chemotherapy]

  • 2023-07-10 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-06-07 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF Q4W, 5-FU 800mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-11 - cisplatin 40mg/m2 70mg NS 500mL (Y-sited with NS 500mL) (CDDP QW)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-27
  • 2023-04-13
  • 2023-04-06
  • 2023-03-30
  • 2023-03-23
  • 2023-03-16
  • 2023-03-09
  • 2023-03-02

==========

2023-07-11

This patient just refilled a prescription for Harnalidge (tamsulosin) on 2023-07-06 for his benign prostatic hyperplasia with lower urinary tract symptoms. This drug has been included in the active medication list with no reconciliation issues identified.

700370136

230711

[exam findings]

  • 2023-05-24 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion
      • Nasopharynx: smooth
      • Oropharynx: no tumor lesion, mucosa erythema
      • Larynx: left vocal fixation
      • Hypopharynx: left hypopharygeal tumor with left vocal fixation, some ulcer
      • airway patent
    • Diagnosis/Conclusion:
      • Left hypopharynx SqCC, T4aN2bM0. Stage IVA under induction C/T
      • Gr II mucositis
  • 2023-05-16 ENT hearing test
    • PTA
    • Reliability FAIR
    • Average RE 23 dB HL; LE 33 dB HL.
      • RE normal to moderate SNHL
      • LE normal to moderately severe SNHL
  • 2023-05-03 Nasopharyngoscopy
    • Findings
      • Nose: no tumor lesion,
      • Nasopharynx: smooth
      • Oropharynx: no tumor lesion
      • Larynx: no tumor lesion, bilateral vocal movement: left vocal cord fixation
      • Airway patent currently
      • Hypopharynx: left hypopharyngeal tumor
    • Diagnosis/Conclusion
      • hypopharyngeal SqCC cT4aN2bM0
      • Airway patent currently
  • 2023-04-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, upper C-spine, some L-spines, bilateral shoulders, hips, knees and feet in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the upper C-spine and some L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
      • No definite evidence of bone metastasis.
  • 2023-04-28 SONO - abdomen
    • Liver calcification, S5/8
    • Gallbladder polyp
  • 2023-04-28 Patho - larynx biopsy
    • Labeled as “left hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
    • Section shows squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-04-17 ECG
    • Right bundle branch block
    • Inferior infarct, age undetermined
  • 2023-04-10 CT - neck
    • Head and Neck CT with and without IV contrast administration shows:
      • A left hypopharynx tumor mass, up to 38 mm in length, with thyroid cartilage invasion.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple enlarged necrotic left neck LNs.
    • IMP: Left hypopharynx CA, T4AN2BMX, Stage IVA.
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T: 4A(T_value) N: N2B(N_value) M: M0(M_value) STAGE: IVA (Stage_value)
  • 2023-04-06 Nasopharyngoscopy
    • left hypopharyngeal tumor with left vocal fixation, suspect malignancy
  • 2018-02-05 Bladder sonography
    • bladder volume: 27.1 CC
  • 2018-01-15 Post Void Residual, PVR
    • acceptable PVR: 15.99 CC
  • 2017-09-28 Pure Tone Audiometry, PTA
    • R’t mild SNHL
    • L’t mild to moderately severe MHL

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology
    • A/P
      • Already discussion with patient regarding the options:
        • OP -> first option
        • Induction C/T -> OP
        • CCRT -> OP
      • After discussion with patient favor neoadjuvant chemtoehrapy
      • Admission for 24 hours CCr, audiometry, TPF
  • 2023-05-03 SOAP Ear Nose and Throat
    • S
      • patient asked for organ preservation
      • refer to oncologist for induction CCRT
    • O
      • finish staging.
      • left hypopharynx SqCC, T4aN2bM0.
  • 2023-01-12 SOAP Metabolism and Endocrinology
    • O
      • 2023/01/03 Cholesterol total = 245 mg/dL;
      • 2023/01/03 LDL-C = 147 mg/dL;
      • 2023/01/03 Triglyceride (TG) = 217 mg/dL;
    • A/P
      • reinforce compliance to medication
      • reinforce diet control
      • SMBP (self-measured blood pressure monitoring)
      • 3m
    • Diagnosis
      • Nontoxic goiter, unspecified E04.9
      • Hyperlipidemia, unspecified E78.5
      • Essential (primary) hypertension I10
      • Impaired fasting glucose R73.01
    • Prescription
      • Crestor (rosuvastatin 10mg) 1# QD
      • Diovan (valsartan 160mg) 0.5# QD
      • Suwell (aluminum hydroxide 200mg, magnesium hydroxide 200mg, simethicone 25mg) 1# QD
      • Norvasc (amlodipine 5mg) 2# QD
      • Lipanthyl (fenofibrate 160mg) 1# QD

[chemotherapy]

  • 2023-07-10 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
  • 2023-06-12 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4
  • 2023-05-17 - docetaxel 75mg/m2 140mg NS 250mL 1hr D1 + cisplatin 75mg/m2 150mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 500mL 1hr (after CDDP) D3 + furosemide 20mg NS 30mL 10min (after CDDP) D3 + 1000mg/m2 2000mg NS 500mL D2-5
    • dexamethasone 4mg D1-2 + NS 250mL D1-2 + palonosetron 250ug D2 + aprepitant 125mg D2-4

==========

2023-07-11

Our otorhinolaryngologist prescribed a regimen on 2023-07-05 that included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Shitan (bromhexine), Acetal (acetaminophen), Ulstop (famotidine), and Nincort Oral Gel (triamcinolone). Additionally, our endocrinologist provided prescriptions for Crestor (rosuvastatin), Diovan (valsartan), Suwell (aluminum hydroxide, magnesium hydroxide, simethicone), Bokey (aspirin), Norvasc (amlodipine), and Lipanthyl (fenofibrate) on 2023-06-29. All these medications are currently present on the patient’s active medication list, with no detected issues relating to medication reconciliation.

2023-06-13

  • Our otorhinolaryngologist issued a prescription on 2023-06-07, which included Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), Broen-C (bromelain, L-cysteine), Tramacet (tramadol, acetaminophen), and Nincort Oral Gel (triamcinolone) to address the patient’s ENT symptoms. The prescription was given a 14-day duration and is currently still valid. However, none of these drugs appear on the active medication list. Please verify if the related symptoms have resolved, which would explain the absence of these medications from the active list. Thank you!

  • Laboratory data show that the patient experienced an episode of leukopenia with a WBC count of 2.39K/uL on 2023-05-24, one week after starting his 1st dose of the current treatment regimen on 2023-05-17. Granocyte (lenograstim 250ug) was administered for 3 consecutive days (from 2023-05-24 to 2023-05-26) to increase the WBC count. The 2nd administration of the regimen began on 2023-06-12, maintaining the same dose level as the first cycle. Therefore, a similar incidence of leukopenia might be expected and prophylactic use of G-CSF may be considered to mitigate this potential risk.

    • 2023-06-12 WBC 7.44 x10^3/uL
    • 2023-06-01 WBC 7.14 x10^3/uL
    • 2023-05-24 WBC 2.39 x10^3/uL
    • 2023-05-16 WBC 6.75 x10^3/uL
    • 2023-05-04 WBC 7.63 x10^3/uL
    • 2023-04-17 WBC 7.96 x10^3/uL

701475086

230711

[lab data]

2023-04-07 Anti-HBc Reactive
2023-04-07 Anti-HBc-Value 6.97 S/CO
2023-04-07 Anti-HBs 49.82 mIU/mL
2023-04-07 SCC 1.9 ng/mL
2023-04-07 CEA 0.82 ng/mL

2023-03-29 RPR/VDRL Nonreactive
2023-03-29 HBsAg Nonreactive
2023-03-29 HBsAg (Value) 0.44 S/CO
2023-03-29 Anti-HCV Nonreactive
2023-03-29 Anti-HCV Value 0.09 S/CO
2023-03-29 HIV Ab-EIA Nonreactive
2023-03-29 Anti-HIV Value 0.06 S/CO

[exam findings]

  • 2023-05-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 27) / 81 = 66.67%
      • M-mode (Teichholz) = 66
    • Conclusion:
      • Concentric LV hypertrophy and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild PR; mild aortic root calcification.
      • Sinus tachycardia.
  • 2023-05-08 CXR
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-04-17 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
    • R’t : 14 dB HL
    • L’t : 16 dB HL
    • Bil WNL
  • 2023-04-01 CT - abdomen
    • No definite abnormality in this study
  • 2023-03-31 MRI - larynx
    • Impression (Imaging stage) : T:4a N:2b M:0 STAGE:IVA
  • 2023-03-29 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, elbows, sternoclavicular juncions, S-I joints, hips, knees, and right ankle.
  • 2023-03-29 Patho - stomach biopsy
    • Stomach, midbody, GC side. Biopsy (A) — Hyperplastic polyp
    • EC junction, biopsy (B)— low grade dysplasia. Please follow up.
  • 2023-03-20 Patho - tongue biopsy
    • Tongue, right, biopsy— moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis.The tumor cells have abundant eosinophilic cytoplasm,round to oval nuclei,prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals CK(+) and p16(-).

[consultation]

  • 2023-04-17 Dermatology
    • Q
      • The 49 y/o man has right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA. He was admitted for chemotherapy. Due to skin itchy over legs, scrotum, axillary. We need your help for r/i scabies. Thanks!
    • A
      • This patietn suffered from multiple erytheamtous papules on trunk for days.
      • Imp: Scabies
      • Suggestion:
        • BB lotion (benzyl benzoate) x 1 BT /QD
        • Ulex cream (hydrocortisone, crotamiton) x 15 tubes /BID
  • 2023-04-01 Hemato-Oncology
    • Q
      • For chemotherapy.
      • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. Larynx MRI arranged and showed right lateral tongue cancer T4aN2bM0, STAGE:IVA. We request your consultation for chemotherapy.
    • A
      • Patient examined and Chart reviewed, my suggestions would be:
        • Well explain and educate to the patient (Already done).
        • Surgical intervention would be first considered if no distant mets.
        • If the surgical intervention is not feasible, may consider CCRT.
        • Please arrange my OPD visit after being discharged.
  • 2023-03-30 Oral and Maxillofacial Surgery
    • Q
      • This 49-year-old male denied of having chronic disease before. The patient is a case of right lateral tongue cancer. He was admitted for cancer work up. We request your consultation for dental evaluation.
    • A
      • Panoramic findings:
        • impacted tooth: 38,48
        • deep caries: tooth 18
        • Missing tooth: nil
        • cystic change of impacted tooth 48 was present
      • Plan:
        • Explain the findings
        • suggest extraction of tooth 18 and 48 prior to radiotherapy or remove the tooth 18 and 48 perioperatively

[MedRec]

  • 2023-04-13 SOAP Hemato-Oncology
    • Anti-HBc (+), Anti-HBs (+), HBs Ag (-), Anti-HCV (-)
  • 2023-04-13 SOAP Oral and Maxillofacial Surgery
    • O: full mouth heavy plaque and calculusdeposition
    • P: full mouth scaling
  • 2023-04-07 SOAP Radiation Oncology
    • This 49 year old man is a case of right tongue cancer, moderately differentiated squamous cell carcinoma, cT4aN2b stage IVA
    • Suggest (OP + adjuvant CCRT) or (induction C/T + OP + adjuvant CCRT)
  • 2023-04-06 SOAP Oral and Maxillofacial Surgery
    • S: pre-CCRT dental evalution
    • O: deep caries of tooth 18 and cystic change of impacted tooth 48
    • A: Tongue cancer, prepared for CCRT.
    • P:
      • Explain the risk/benefit of the treatment to the patient, about the risk of communication between the maxillary sinus and oral cavity
      • Sign informed consent.
      • Block anesthesia of right maxilla
      • Complicated extraction of tooth 18
      • Suture the gingiva with Vicryl 4-0.
      • Prescribe Acetal and Amoxicillin.
      • Teach the patient how to do home care and OPD follow-up.
  • 2023-04-06 SOAP Hemato-Oncology
    • A:
      • cT4aN2bM0, Stage IVA.
        • Suggest OP is the first consideration.
        • If OP is not feasible, then consider CCRT.
    • P:
      • Surgical intervention would be first considered if no distant mets.
      • If the surgical intervention is not feasible, may consider CCRT.
  • 2023-03-24 SOAP ENT
    • 2023/03/20 PATHO - tongue biopsy: Tongue, right, biopsy — moderately differentiated squamous cell carcinoma
    • suggest admission for staging
  • 2023-03-14 SOAP ENT
    • right tongue swelling tender ulcer for 6 months
    • right tongue border indurated ulcer, suggest biopsy first

[chemotherapy]

  • 2023-07-10 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D3 + furosemide 20mg NS 30mL 10min (after cisplatin) D3 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
  • 2023-06-09 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D2 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D2 + NS 250mL D2 + aprepitant 125mg PO D2-4
  • 2023-04-24 - docetaxel 60mg/m2 120mg NS 250mL 1hr D1 + cisplatin 75mg/m2 145mg NS 500mL 24hr (Y-sited 5-FU) D1 + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) D2 + furosemide 20mg NS 30mL 10min (after cisplatin) D2 + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (TPF Q3W)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg PO D1-3

TPF regimen in in-hospital “Prescription Collection of Chemotherapy for Head and Neck Cancer” protocol (dated 2023-03-31)

  • Neo-adjuvant Chemotherapy regimen - TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU 750~1000 mg/m2 IVD (24 hs) D1-2, D8-9
    • Q3W for 1~3 cycles
    • Modified from Posner MRI et al. N.Engl.J.Med.357 (2007):1705-1715.
  • Induction Chemotherapy modified with TPF
    • Docetaxel 40 mg/m2 IVD (1 hs) D1, 8
    • Cisplatin 40 mg/m2 IVD (2 hs) D1, 8
    • 5-FU+Leucovorin 1000mg/m2+100mg/m2 IVD (24 hs) D2, 9
    • Q3 week x 3cycles (Q1W, Q2W, Q3W: rest)
    • Modified from Jérôme Fayette et al. Oncotarget 2016;7(24):37297-37304

Docetaxel, cisplatin, and fluorouracil induction chemotherapy followed by radiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX323) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F72461&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for 4 cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 75 mg/m2 IV
      • Dilute in 250 mL NS and administer over 60 minutes. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 750 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 5

Docetaxel, cisplatin and fluorouracil induction chemotherapy followed by chemoradiotherapy for locally advanced, squamous cell carcinoma of the head and neck (TAX324) 2023-06-12 https://www.uptodate.com/contents/image?imageKey=ONC%2F65438&topicKey=ONC%2F85694

  • Cycle length: Every 21 days for 3 cycles.

  • Regimen

    • Docetaxel
      • 75 mg/m2 IV
      • Dilute in 250 mL NS to a final concentration of 0.3 to 0.74 mg/mL and administer over 60 minutes.
      • Day 1
    • Cisplatin
      • 100 mg/m2 IV
      • Dilute in 250 mL NS and administer over 30 minutes to three hours. Do not administer with aluminum needles or IV sets.
      • Day 1
    • Fluorouracil (FU)
      • 1000 mg/m2/day IV
      • Dilute in 500 to 1000 mL D5W or NS and administer as a continuous infusion over 24 hours.
      • Days 1 through 4

==========

2023-07-11

[reconciliation]

According to the PharmaCloud database, the patient only receives medical services from our hospital. Therefore, there are no identified medication reconciliation issues.

2023-06-12

  • After examining the PharmaCloud medical records, it’s evident that this patient has been solely receiving care from our hospital over the past three months. All prescriptions have been issued by our outpatient and inpatient hemato-oncology services. Consequently, no medication reconciliation issues have been identified.

  • The docetaxel/cisplatin/fluorouracil regimen was administered to the patient on 2023-04-24 and 2023-06-09. Historical lab data showed a drop in WBC count below 1000/uL from 2023-05-01 to 2023-05-05, indicating leukopenia roughly 1 to 2 weeks after the initial round of the regimen. A total of 6 doses of Granocyte (lenograstim 250ug) were administered daily between 2023-05-01 and 2023-05-07. Given that the seconnd round of the regimen started on 2023-06-09 with the same dosage as the first, it is plausible that another leukopenia episode could occur about one week after treatment. Therefore, a prophylactic administration of G-CSF post-chemotherapy might be considered.

    • 2023-06-09 WBC 7.39 x10^3/uL
    • 2023-05-23 WBC 6.43 x10^3/uL
    • 2023-05-16 WBC 7.54 x10^3/uL
    • 2023-05-12 WBC 6.38 x10^3/uL
    • 2023-05-10 WBC 9.71 x10^3/uL
    • 2023-05-08 WBC 15.33 x10^3/uL
    • 2023-05-06 WBC 1.89 x10^3/uL
    • 2023-05-05 WBC 0.57 x10^3/uL
    • 2023-05-04 WBC 0.30 x10^3/uL
    • 2023-05-03 WBC 0.16 x10^3/uL
    • 2023-05-02 WBC 0.12 x10^3/uL
    • 2023-05-01 WBC 0.52 x10^3/uL
    • 2023-04-17 WBC 6.25 x10^3/uL
    • 2023-03-28 WBC 5.14 x10^3/uL

2023-04-18

  • Our dermatologist suggested BB lotion (benzyl benzoate) and Ulex cream (hydrocortisone, crotamiton) for the patient’s scabies treatment. If the symptoms do not improve, topical permethrin or oral ivermectin may also be considered as subsequent treatment options.

700072194

230707

{autologous Peripheral Blood Stem Cell Transplantation}

  • past history
    • DM with triopathy for 10+ years with regular OHA control. (triopathy of diabetes - retinopathy, nephropathy, and neuropathy.)
  • lab data
    • 2022-08-18 EB VCA IgG Positive Ratio
    • 2022-08-18 EB VCA IgG Value 6 Ratio
    • 2022-08-17 EB VCA IgM Negative Ratio
    • 2022-08-17 EB VCA IgM Value 0.2
    • 2022-08-15 RPR/VDRL Nonreactive
    • 2022-08-15 Anti-HCV Nonreactive
    • 2022-08-15 Anti-HCV Value 0.04 S/CO
    • 2022-08-15 Anti-HBc Reactive
    • 2022-08-15 Anti-HBc-Value 5.04 S/CO
    • 2022-08-15 HBsAg Nonreactive
    • 2022-08-15 HBsAg (Value) 0.39 S/CO
    • 2022-08-15 Anti HTLV I/II Nonreactive
    • 2022-08-15 Anti HTLV I/II Value 0.06 S/CO
    • 2022-08-15 CMV IgM Nonreactive
    • 2022-08-15 CMV IgM Value 0.04 Index
    • 2022-08-15 CMV_IgG Reactive
    • 2022-08-15 CMV_IgG Value 157.5 AU/mL
    • 2022-08-15 HIV Ab-EIA Nonreactive
    • 2022-08-15 Anti-HIV Value 0.06 S/CO
    • 2022-05-25 %CD34+ 0.09 %
    • 2022-05-25 CD34+ Count 322 /uL
    • 2022-05-25 %CD34+ 0.01 %
    • 2022-05-25 CD34+ Count 4 /uL
    • 2022-05-24 %CD34+ 0.13 %
    • 2022-05-24 CD34+ Count 535 /uL
    • 2022-05-24 %CD34+ 0.02 %
    • 2022-05-24 CD34+ Count 10 /uL
    • 2022-05-23 %CD34+ 0.14 %
    • 2022-05-23 CD34+ Count 610 /uL
    • 2022-05-23 %CD34+ 0.04 %
    • 2022-05-23 CD34+ Count 17 /uL
    • 2022-02-17 %CD34+ 0.21 %
    • 2022-02-17 CD34+ Count 880.0 /uL
    • 2022-02-16 %CD34+ 0.27 %
    • 2022-02-16 CD34+ Count 1030 /uL
    • 2022-02-15 %CD34+ 0.31 %
    • 2022-02-15 CD34+ Count 1638 /uL
    • 2022-01-14 %CD34+ 0.02 %
    • 2022-01-14 CD34+ Count 50 /uL
    • 2022-01-13 %CD34+ 0.05 %
    • 2022-01-13 CD34+ Count 100 /uL
    • 2022-01-12 %CD34+ 0.04 %
    • 2022-01-12 CD34+ Count 60 /uL
    • 2022-01-11 %CD34+ 0.04 %
    • 2022-01-11 CD34+ Count 20 /uL
    • 2019-08-09 %CD34+ 0.11 %
    • 2019-08-09 CD34+ Count 610 /uL
    • 2019-08-08 %CD34+ 0.08 %
    • 2019-08-08 CD34+ Count 410 /uL
    • 2019-08-07 %CD34+ 0.07 %
    • 2019-08-07 CD34+ Count 255 /uL
    • 2019-07-05 %CD34+ 0.14 %
    • 2019-07-05 CD34+ Count 230 /uL
    • 2019-07-04 %CD34+ 0.06 %
    • 2019-07-04 CD34+ Count 55 /uL
  • exam finding
    • 2022-07-18 Whole body PET scan
        1. The increased FDG uptake in the right posterior pleura and adjacent soft tissue, in bilateral axillary lymph nodes, and in an upper abdominal preaortic lymph node disappears or comes to very faint compared with the previous study on 2021-09-16, indicating partial to good response to current therapy.
        1. Increased FDG accumulation in bilateral kidneys, probably physiological uptake of FDG.
        1. Lymphoma s/p treatment with partial to good response, by this F-18 FDG PET scan.
    • 2022-07-09 CT - chest
      • S/p port-A placement with its tip at Superior vena cava
      • No evidence of lymphadenopathy in the study.
    • 2022-06-30 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Atherosclerotic change of aortic arch
    • 2022-03-08 CT - chest
      • stationary of Rt posterior inferior pleural thickening as compared with CT on 2021/12/17, could be posterior treatment change.
    • 2022-01-17 Bronchoscopy
      • Diagnosis
          1. LUL and Left lingular lobe acute bronchitis
          1. Sleep apnea
          1. Chronic sinusitis
      • Findings
        • The nasal mucosa was hypertrophic.
        • The nasal lumen was severely narrowed.
        • The was copious mucoid nasal discharge retained in the nasal cavity.
        • Mucosa of nasopharynx was hypertrophic .
        • Nasopharynx was severely narrowed.
        • Mucosa of pharynx cobble-stone in shape .
        • Movement of the both. vocal cord(s) was / werenormal .
        • Bilateral arytenoid proceww was normal .
        • Trachea whole segment . : patent and the mucosa was hypertrophic .
        • Main carina: sharp and movable on deep breathing.
        • Bilateral endobronchial trees:
          • LUL, left lingular lobe mucosal swelling with some purulent sputum.
          • No endobronchial lesions
    • 2021-12-17 CT - chest
      • No evidence of recurrent/residual lymphadenopathy in the study.
      • Calcified coronary arteries is found.
    • 2021-10-06 Patho - bone marrow biopsy
      • Bone marrow, iliac, (clinical history of Hodgkin’s lymphoma stage IV, biopsy — Negative for malignancy.
      • IHC stains: CD30: (-).
      • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
    • 2021-09-27 Patho - pleural/pericardial biopsy
      • Tissue, labeled “right chest”, CT-guide biopsy — Nodular sclerosis classical Hodgkin lymphoma, recurrent
      • Immunohistochemical stain profiles: CD3: positive, CD20: positive, CD15: focal positive, CD30: focal positive
    • 2021-09-25 CT guide biopsy
      • Right pleural mass, s/p CT-guided biopsy
    • 2021-09-16 Whole body PET scan
      • The FDG PET finding are compatible with recurrent lymphoma (stage IV) involving the right posterior pleura and adjacent soft tissue (Deauville 5), some bilateral axillary lymph nodes (Deauville 4) and an upper abdominal preaortic lymph node (Deauville 5) 2. Mild glucose hypermetabolism in some bilateral inguinal lymph nodes (Deauville 2). The nature is to be determined (inflammation? lymphoma of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • 2021-09-08 CT - chest
      • progression of Rt posterior inferior pleura tumor compared with CT on 20210209.
    • 2021-02-09 CT - abdomen
        1. Stationary right lower pleural thickening.
        1. Bilateral inguinal lymph nodes.
        1. Ascending colon diverticula.
    • 2020-11-16 Tc-99m MDP whole body bone scan
        1. In comparison with the previous study on 2017/12/29, the lesion in L3 spine had disappeared, indicating a malignant lesion with response to treatment and in metabolic regression.
        1. Mildly increased radiotracer uptake in diffusely increased radiotracer uptake in posterior aspect of right lower rib cages was newly noted in this study. Increased vascularity and vascular permeability associated with malignant pleural effusion in right lower posterior pleural space may show such a picture. Please correlate with other imaging modalities and keep follow up, however, to exclude the possibility of lymphomatous marrow involvement in multiple right lower ribs.
        1. Mildly and non-focally increased radiotracer uptake in middle T-spine, lower L-spine and sacrum, degenerative spine diseases may show such a picture.
        1. Some areas of mildly increased radiotracer uptake in maxilla and mandible, dental lesions may show such a picture.
        1. Probably degenerative joint lesions in shoulders, sternoclavicular junctions, and knees.
    • 2020-11-05 CT - abdomen
      • Thickening of right lower pleura.
      • Some LNs (5-11mm) in bil. inguinal regions.
    • 2020-07-02 CT - chest
      • Mild bronchiectatic change over right middle lobe with increased peribronchial infiltration at right middle lobe
      • Right pleural effusion. Mild.
      • Small left axillary lymph nodes
    • 2020-03-06 CT - abdomen
      • Finding
          1. Prior CT identified some enlarged lymph nodes in bilateral inguinal area are noted again, stable in size. However, a newly-developed soft tissue mass measuring 2.8 cm in right inguinal area, near the penis base is noted that may be recurrent lymphoma.
          1. Mild thickening in right posterior basal CP angle pleura area is noted that also may be recurrent lymphoma. please correlate with clinical condition.
      • IMP:
        • Recurrent lymphoma in right posterior basal CP angle pleura and right inguinal area are suspected. please correlate with clinical condition.
    • 2019-10-24 Whole body PET scan
        1. In comparison with the previous study on 2019/04/01, the previous FDG avid lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node all disappeared (Deauville score 1).
        1. Faint glucose hypermetabolism (Deauville score 2) in some bilateral inguinal lymph nodes. The nature is to be determied (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
        1. Mild glucose hypermetabolism in the right hip. Benign joint lesion such as arthritis may show this picture.
        1. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
    • 2019-10-21 CT - abdomen
      • Some LNs (5-10mm) in bil. inguinal regions.
    • 2019-08-05 CXR - chest
      • Hypoinflation of both lung is noted.
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura thickening or effusion ?
    • 2019-07-20 CT - abdomen
        1. Regression of right posterior intercostal tumor as compare with CT study on 20190307.
        1. Ascending colon diverticula.
    • 2019-04-01 PET
      • In comparison with the previous study on 2018/07/06, the lesions in the right posterior chest wall, multiple skeletal sites, and a right supraclavicular lymph node were all new lesions (Deauville 5), suggesting lymphoma in progression.
        1. Hodgkin’s lymphoma, rc-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2019-03-18 Surgical pathology Level IV
      • clinical diagnosis
        • Hodgkin’s disease, nodular sclerosis, intra-abdominal lymph nodes;
      • pathologic diagnosis
        • Mass, unspecified ciste?, biopsy — Compatible with Hodgkin lymphoma
      • Microscopically, the section shows a picture of some lymphoid cells with follicles embedded in collagenous stroma, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical large cells, which immunohistocehmcial study reveals CD15(+, focal), CD30(+), CK(-), CD20(-) and EMA(+, scatter). According to above histopathologic findings and previous pathologic report, it is compatible with Hodgkin lymphoma.
    • 2019-03-07 CT - abdomen
      • A mass lesion (5x6cm) in right posterior back.
    • 2018-11-02 CT - abdomen
      • Stationary lymph nodes in left pelvic cavity and inguinal regions.
    • 2018-07-06 PET
        1. In comparison with the previous study on 2017/12/19, the glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville score 2), right inguinal region (Deauville score 2), left lower pelvic region (Deauville score 2) and left inguinal region (Deauville score 3) and the glucose hypermetabolism at the L3 spine (Deauville score 2) are all less evident, suggesting partial response to the treatment. Please correlate with other clinical findings for further evaluation.
        1. Increased FDG accumulation in the colon. Physiologic FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 2018-06-19 CT - abdomen
      • Left inguinal lymph nodes, in regression
    • 2018-03-02 CT - abdomen
      • Regression of enlarged lymph nodes in left inguinal region and pelvic cavity.
    • 2017-12-29 Tc-99m MDP whole body bone scan
        1. Increased activity in the L3 spine. Bone metastasis can not be ruled out. Please correlate with other imaging modalities for further evaluation.
        1. Increased activity in the lower C-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
        1. Some faint hot spots in the lateral aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesion.
    • 2017-12-19 PET
        1. Glucose hypermetabolism at multiple lymph nodes in the abdominal left paraaortic region (Deauville 4), right inguinal region (Deauville 4), left lower pelvic region (Deauville 4) and left inguinal region (Deauville 5), compatible with lymphoma involving multiple lymph node regions on the same side of the diaphragm.
        1. Glucose hypermetabolism in the L3 spine (Deauville 5). Lymphoma involving L3 spine should be considered. Please correlate with other clinical findings for further evaluation.
    • 2017-12-18 Doppler color flow mapping
        1. Borderline dilated LA and LV; adequate LV systolic function with normal resting wall motion
        1. Trivial MR and trivial TR
        1. Preserved RV systolic function
    • 2017-12-07 Surgical pathology Level IV
      • clinical diagnosis
        • Neoplasm of uncartain behavior of connective and other soft tissue;
      • pathologic diagnosis
        • Tumor, left pelvis, excisional biopsy — Compatible with Hodgkin lymphoma, nodular sclerosis
      • Microscopically, the section shows a picture of broad bands of collagen replace patches of remaining tissues with focal marked crushed artifact, consists of mixed lymphocytes, neutrophils, eosinophils, macrophages and a few atypical individual or multinucleated large cells, which immunohistocehmcial study reveals CD15(+), CD30(+), PAX-5(scant, weakly +), CK(-), S-100(-), SMA(-) and ALK(-). According to above histopathologic findings, it is compatible with Hodgkin lymphoma, nodular sclerosis type.
    • 2017-11 Initial presentation
      • the patient noted fever and cold sweating, and palpable abdominal mass over left lower abdomen also found.

chemotherapy with Mabthera on 12/27,Etoposide 500mg/m2 total given 963mg Q12H on 12/28-30 followed by PBSC harvest,GCSF 300mcg QD on 12/31-1/14.Port-A removal on 2022/1/14.

  • radiotherapy
    • 2017 after ABVD chemotherapy

[chemoimmunotherapy]

  • 2023-07-07 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-30 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-08 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-17 - brentuximab vedotin 1.8mg/kg 132mg NS 150mL 30min (Adcetris for post-ASCT consolidation)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-17 - busulfan 3.2mg/kg 260mg 2hr D1-3 + etoposide 400mg/m2 567mg 1hr D3-4 + cyclophosphamide 50mg/kg 4000mg D5-6 (BuCyE)

  • 2021-12-27 - rituximab 375mg/m2 720mg 8hr D1 + etoposide 500mg/m2 963mg 4hr D2-4

  • 2021-11-19 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE) followed by PBSC harvest, GCSF 300mcg QD on 2021-12-31 ~ 2022-01-14.

  • 2021-10-27 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

  • 2021-10-06 - etoposide 100mg/m2 190mg 2hr D1-3 + carboplatin AUC5 350mg 24hr D2 + ifosfamide 5000mg/m2 9400mg 24hr D2 + mesna 5000mg/m2 9400mg with ifosfamide (ICE)

  • 2019-04-03 ~ 2019-09-07 - ESHAP 7 cycles

  • 2017-12-30 ~ 2018-06-01 - ABVD

==========

2023-07-07

The patient underwent an autoPBSCT procedure in August 2022, almost a year ago. Based on the Guidelines for Vaccination of Adult BMT Patients provided by Stanford Healthcare, the proposed vaccination schedule is as follows (ref: https://med.stanford.edu/content/dam/sm/bugsanddrugs/documents/clinicalpathways/SHC-Vaccination-BMT.pdf):

  • Influenza: Annually starting at 6 months post transplant
  • Pneumococcal: 12 months post transplant
  • Meningococcal Group A: 12 months post transplant
  • Haemophilus: 12 months post transplant
  • Diptheria/tetanus/pertussis: 12 months post transplant
  • Hepatitis: 12 months post transplant
  • Papillomavirus: 12 months post transplant

According to the guideline, most vaccinations are started 12 months after transplant, so it may be an appropriate time to start planning the vaccination schedule for this patient. This can help reduce the risk of infection and promote the patient’s overall health and recovery.

2022-08-19

[preparation and administration of mesna]

  • Usual diluents
    • D5W, NS
  • Usual dose
    • 100 ml, 15-30 min, concentration range: 1-20 mg/ml
  • Dosing
    • usual dose=20% of ifosfamide dose given just before and 4 and 8 hours after ifosfamide (total=60%).
    • May also be given as a continuous IV infusion concurrently with ifosfamide. Total daily dose= 60% to 160% of ifosfamide dose or 60% to 200% of cyclophosphamide dose. May give 20% W/W 15min prior, and then q3hrs x 3-6 doses.
  • Administration
    • IVPB in 50 ml or more of D5W or normal saline over 5 minutes or longer. Also by continuous IV infusion.
  • Storage/stability:
    • Vials stored at RT. Diluted solutions (1-20 mg/ml) - 24 hrs. 20 mg/ml (D5W) - 48hrs RT; 1-mg/ml (D5W) - 24 hours RT.
  • Preparation:
    • May be further diluted in D5W, NS, D5/.45NS, or LR to a final concentration of 1-20 mg/ml.
  • Prevention of cyclophosphamide-induced hemorrhagic cystitis: Limited data available: Note: Specific protocols should be consulted for combination regimens with cyclophosphamide. Mesna dosing schedule is typically repeated with each day cyclophosphamide is received; mesna dosing should be adjusted if cyclophosphamide dose is adjusted (decreased or increased) to maintain the mesna-to-cyclophosphamide ratio for the protocol.
    • Infants, Children, and Adolescents:
      • Standard (low)-dose cyclophosphamide: Note: Some pediatric oncology experts have defined as cyclophosphamide dose <1800 mg/m2/day in protocols.
        • IV: Reported regimens variable: Mesna doses equivalent usually 60% to 100% of the cyclophosphamide daily dose although some protocols have used up to 160%.
          • Short IV infusion (intermittent): Mesna dose equal to 60% of the cyclophosphamide dose given in 3 divided doses (0, 4, and 8 hours after the start of cyclophosphamide) has been used by some centers; others have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of cyclophosphamide) (Gal 2007).
          • Continuous IV infusion: Some centers have used a mesna dose equal to 60% of the cyclophosphamide dose as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose and completed at least 8 hours after the end of the cyclophosphamide infusion.
        • Oral: Some centers have used a total mesna dose equal to 100% of the cyclophosphamide dose, begin with IV dose equal to 20% for initial dose followed by oral dose at 40% of the cyclophosphamide dose at 2 and 6 hours after start of cyclophosphamide; Note: Typically, oral doses of mesna are twice the IV dose.
      • High-dose cyclophosphamide: Note: Some pediatric oncology experts have defined cyclophosphamide dose ≥1800 mg/m2/day in protocols: IV: Some centers have used a mesna dose equal to 100% of the cyclophosphamide dose as short IV infusions in 5 divided doses (0, 3, 6, 9, and 12 hours after the start of) (Gal 2007) or as a continuous IV infusion beginning 15 to 30 minutes before the first cyclophosphamide dose.
    • Other dosing strategies have been used in combination with cyclophosphamide for specific regimens/protocols: Limited data available: HDCAV/IE regimen for Ewing sarcoma: Children and Adolescents: IV: 2100 mg/m2/day continuous infusion (mesna dose is equivalent to the cyclophosphamide dose) for 2 days with cyclophosphamide infusion during cycles 1, 2, 3, and 6 (Kolb 2003).
  • reference:

2022-11-01

[Teicoplanin Dose]

  • blood creatinine readings reported:
    • 2022-01-10 1.64mg/dL
    • 2022-01-08 1.83mg/dL
    • 2022-01-06 1.72mg/dL
    • 2022-01-03 1.31mg/dL
  • teicoplanin has been administered since 2022-01-06, the elevated serum creatinine maintains stable for half week, no dose adjustment needed for now, keep monitoring renal function as regular.

700068505

230706

{Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC}

  • diagnosis
    • 2022-08-18 discharge diagnosis
      • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
      • Hypertensive heart disease without heart failure
      • Type 2 diabetes mellitus without complications
      • Hyperlipidemia, unspecified
      • Chronic viral hepatitis B without delta-agent
  • past history (as of Aug 2022)
      1. Hypertension and hyperlipidemia for 20 years with regular medication at Tzu Chi H.
      1. Hyperuricemia and gout for years with irregular medication.
      1. Pre-diabetes mellitus was noted for 13 years with diet control.
      1. Birth control s/p vasectomy at 2013-06-19 at Tzu Chi H.
  • initial presentation
    • 2021 Feb low back pain, pain aggravated when changing position

[lab data]

  • 2021-07-20
    • All-RAS mutation detected
    • BRAF mutation not detected

[exam findings]

  • 2023-06-15 CT - abdomen
    • History and indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
      • S/P Port-A infusion catheter insertion.
      • Renal cysts (up to 5.7cm).
      • Hyperplasia of bil. adrenal glands.
      • Atherosclerosis of aorta.
      • S/P posterior longitudinal transpedicular screws and rods fixation.
    • IMP:
      • Progression of peritoneal seeding, LNs, bony/ liver and lung metastases. Ascites and right pleural effusion. General subcutaneous edema.
  • 2023-06-14, -04-19, -04-03 Forearm LT
    • Pathologic fracture of left proximal radius S/P external fixation.
  • 2023-04-18 AP and lateral films of the T-L spine
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • Degeneration and spondylosis of L-S spine.
  • 2023-04-18 KUB
    • S/P foley catheter indwelling.
    • Degeneration and spondylosis of L-S spine.
  • 2023-03-14 T-spine AP + Lat.
    • S/P posterior instrumentation fixation from T7 To T9.
    • Spondylosis of the T-spine and L-spine .
  • 2023-03-13 Patho - interveterbral disc (Y1)
    • Bone and joint, vertebra, thoracic 8, excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation — adenocarcinoma.
    • Section shows pieces of bone, degenerated ligament, and cartilage with focal adenocarcinoma.
    • IHC stains: CDX2 (+), CK7 (-), CK20 (+), PSA- (-), TTF-1 (-), a pattern, in favor of colorectal origin.
  • 2023-03-11 Long Bones series
    • Osteolytic fracture of left proximal radius is noted that is c/w bony metastasis.
  • 2023-03-09 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-09, 2022-10-07 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2023-03-08 MRI - T-spine
    • Indication: Sigmoid cancer with T-spine bone metastasis, T3N2aM1c, stage IVC, with severe back pain
    • With and Without-contrast multiplanar spine MRI revealed
      • severe extenal mass effect on the T8 cord.
      • heterogeneous enhancing tumors in the T8, L2, S1, S2, S3 and S4 vertebral bodies with peri-vertebral invasion and invasion the the T7, T8 and T9 spinal canal.
      • multiple hepatic metastasis.
    • IMP
      • multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord.
      • multiple hepatic metastasis.
  • 2022-12-28 Tc-99m MDP whole body bone scan
    • As compared with the previous study on 2022-10-04, some new bone lesions in the right rib cage nd left S-I joint are noted and most of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
    • Suspected benign lesions in the maxilla, sternum and right shoulder.
  • 2022-12-28 CT - abdomen
    • Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
    • Findings:
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions.
      • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
      • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
      • Prior CT identified lung metastases are noted again, decreasing in size.
      • Prior CT identified bony metastases in right sacrum and bilateral acetabulum, and T8 vertebral body are noted again, stable in size.
      • Hyperplasia of bil. adrenal glands.
      • Renal cysts (up to 3.5cm).
    • Impression:
      • Prior CT identified several metastases on both hepatic lobes are noted again, increasing in size in most lesions. please correlate with clinical condition.
  • 2022-10-05 CT - abdomen
    • Indication: Sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04, partial response
    • Findings:
      • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size.
      • Prior CT identified multiple metastases in the omentum and mesentery are noted again, stable in size.
      • Prior CT identified regional/ non-regional LNs, are noted again, stable in size.
      • Prior CT identified two lung metastases are noted again, stable in size.
      • Renal cysts (up to 3.5cm).
      • Hyperplasia of bil. adrenal glands.
    • Impression:
      • Prior CT identified several metastases on both hepatic lobes are noted again, stable in size in few lesions. However, three of them show mild increasing in size. please correlate with clinical condition.
  • 2022-10-04 Tc-99m MDP whole body bone scan
    • As compared with the previous study on 2022-06-29, some new bone lesions are noted and most of the previous bone lesions are a little more evident, suggesting multiple bone metastases in progression.
    • Suspected benign lesions in the maxilla, sternum and right shoulder.
  • 2022-06-30 CT - abdomen
    • Findings
      • Stable condition of S-colon cancer, regional/ non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
      • S/P Port-A infusion catheter insertion.
      • Renal cysts (up to 3.5cm).
      • Hyperplasia of bil. adrenal glands.
      • Atherosclerosis of aorta.
    • IMP:
      • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
  • 2022-06-29 Tc-99m MDP whole body bone scan
    • Most of the previous metastatic bone lesions come to less evident compared with the previous study on 2021-10-06; a lesion in middle T-spine, however, becomes more prominent, and the nature is to be determined (severe DJD, new bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, sternum, L3-4 spine, and bilateral shoulders.
  • 2022-03-31 CT - abdomen, pelvis
    • Stable condition of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/ liver and lung metastases.
  • 2022-01-24 2D transthoracic echocardiography
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, concentric LVH; impaired LV relexation
    • Trivial MR, mild AR and trivial TR
    • Preserved RV systolic function
  • 2022-01-06 CT
    • Much regression of S-colon cancer, regional/non-regional LNs, peritoneal seeding, bony/liver and lung metastases.
  • 2021-10-06 Tc-99m MDP whole body bone scan
    • Multiple hot spots in bilateral rib cages and increased activity in the sacrum, bilateral S-I joints, and right acetabulum, cancer with bone metastasis is highly suspected.
    • Suspected benign lesions in the maxilla, sternum, middle T-spine, L3-4 spine, bilateral shoulders and right foot.
  • 2021-10-05 CT
    • Diffuse metastatic tumors in the liver, peritoneum, bones, metastatic lymph nodes in paraaortic and left neck.
    • Regression as compare with CT study on 2021-6-21.
    • Mild pericardial effusion.
  • 2021-06-25 Patho - Colon biopsy
    • Colon, sigmoid 20cm above anal verge, biopsy - Adenocarcinoma.
    • IHC: EGFR(+); PMS2(+), MSH6(+), MSH2(+), MLH1(+).
  • 2021-06-22 Tc-99m MDP whole body bone scan
    • Increased activity in the sacrum, right S-I joint and right iliac bone. Bone metastases should be considered first.
    • Increased activity in the middle T-spines and L4 spine. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Multiple hot spots in the sternum and bilateral rib cages and mildly increased activity in bilateral femoral trochanters. The nature is to be determined (bone metastases? post-traumatic change? other nature?).
    • Increased activity in bilateral shoulders. Benign joint lesions is more likely.
  • 2021-06-21 CT
    • Impression (Imaging stage): T3N2aM1c, stage IVC
  • 2021-06-15 Patho - Bone pathologic fragment, at right first sacral tumor/mass.
    • Labeled as “sacrum”, CT guided biopsy - adenocarcinoma.
    • IHC:
      • CK20(+), CDX2(+): please check gastrointestinal tract first.
      • PSA(-): dis-favor prostatic origin.
      • TTF-1(-), Napsin-A(-): dis-favor pulmonary origin.
  • 2021-06-02 MRI - L-spine:
    • tumors in the sacrum.

[consultation]

  • 2023-04-20 Oral and Maxillofacial Surgery
    • Q: For 1) The area behind the left tooth has collapsed, and the tooth keeps scraping the tongue. 2) Xgeva use. We need your consultation for evaluation.
    • A
      • We are consulted for dental problem.
      • As the patient appeared with weakness muslce strength, we wil examine the condition at bedside this afternoon.
  • 2023-04-20 Orthopedics
    • Q: For left proximal radius pathological fracture was noted since 2023/03/11, we need your consultation for evaluation.
    • A:
      • 59 Male
      • Dx: Left proximal radius pathological fracture, displaced
      • Plan:
        • OPD f/u
        • Keep current management
        • Pain management
        • Surgical intervention not indicated due to poor prognosis of the underlying disease
  • 2023-03-11 Orthopedics
    • Q: For radial bone fracture
    • A
      • left proximal radius pathological fracture was noted
      • considering patient’s condition
      • splint immobilization and sling protection is suggested
  • 2023-03-09 Anesthesiology
    • Q
      • This time, for prepare 2023/03/10 T8 spine OP. Now, for anesthesia assessment. Thank you.
    • A
      • I’ve vistied the patient and reviewed the past history:
        • Pt: 58 y/o M
        • Current problem: T8 spine bone metastasis
        • Operation: intraspinal tumor excision on 3/10
        • Past History : Sigmoid cancer with lung, liver and bone metastasis s/p bone radiotherapy and chemotherapy; HTN, DM, HBV
        • GCS: E4 V5 M6
        • Vitals stable
        • Labs : Within acceptable range for anesthesia
          • Hb 12.7
          • EKG pending
          • CXR pending
        • 2021 Cardiac echo LVEF 75%
      • Assessment: ASA 3
      • Plan
        • We will arrange ETGA for this patient
        • The patient and his family have been informed on the anesthesia- and surgery-associated risks, including cardiovascular risks (hypotension, stroke, acute myocardial infarction, shock), pulmonary risks (hypoxia, pulmonary embolism,delay extubation) and other possible complications
        • Postoperative ICU care might be needed
  • 2023-03-08 Neurosurgery
    • Q
      • This 58-year-old man patient is a case of sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p bone radiotherapy and chemotherapy with Avastin/FOLFIRI from 2021/08/04 to 2022/09/16 for 25 cycles, progression s/p palliative chemotherapy with FOLFOX from 2022/10/05 to 2023/02/21 for 9 cycles, progression of liver tumor and bone metastases. palliative radiotherapy evaluation of S-I joint, 1600cGy/8 fractions of the right SI joint to right hip area from 2023/02/15 to 2023/02/24. T-spine MRI on 2023/03/08 showed multiple vertebral body metastasis, more on the T8 vertebral body with significant mass effect on the T8 cord and multiple hepatic metastasis. Now, for evaluate T8 spine surgery of pain control. Thank you.
    • A
      • T8 spine surgery is indicative for the patient.
      • We will arrange operation for the patient this Friday. We will full explained risk and outcome to the patient and family.
  • 2023-02-09 Radiation Oncology
    • A
      • A: Adenocarcinoma of the sigmoid colon, stage cT3N2aM1c, with liver, lung, and bone metastasis, s/p palliative radiotherapy, with progression.
      • P: Radiotherapy is indicated for this patient with the following indicators: pain of the right SI joint to right hip area.
        • Goal: palliation
        • Treatment target and volume: right SI joint to right hip area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 1600cGy/8 fractions of the right SI joint to right hip area.
        • The treatment modality and the possible effects of re-irradiation were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-2-13.
  • 2021-07-14 Rehabilitation
    • Assessment
      • sigmoid cancer with lung, liver and bone metastasis, T3N2aM1c, stage IVC s/p Palliative radiotherapy to sacrum, right S-I joint and peripheral involved area from 2021/07/01~2021/07/14 for 2000cGy/10 fractions. Chemotherapy with FOLFOX(Oxalip 85mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2)(C1D1) from 2021/07/02~2021/07/04.
      • Polio with LLE weakness
    • Plan
      • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength
  • 2021-07-01 Dermatology
    • This patient suffered from erytheamtous plaque on back and buttock for days
    • Imp: Tinea corporis
    • Suggestion: Excelderm cream x 2 tubes/bid

[surgical operation]

  • 2023-03-10
    • Surgery: Excision of intraspinal malignant tumor and posterior spinal fusion with instrumentation, microscopy and fluoroscopy
    • Finding: Thoracic 8 level pathological fracture (metastaticl lesion)

[chemoimmunotherapy]

  • 2023-06-12 - oxaliplatin 85mg/m2 100mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus, reduced Oxa)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-17 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFIRINOX, no 5-FU bolus for 20230515 WBC 2.9K)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-31 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + irinotecan 120mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFIRINOX) (20230419 WBC 2.27K)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-07 - oxaliplatin 65mg/m2 114mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-17 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-29 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-12-12 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-11-28 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-11-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-10-24 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-10-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 100mL 10min + fluorouracil 2400mg/m2 4300mg NS 500mL 46hr (FOLFOX, Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-D3
  • 2022-09-16 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 750mg 2hr + fluorouracil 400mg/m2 750mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

    • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC
  • 2022-08-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

    • diphenhydramine 30mg + dexamethasone 4mg + palonosetron 250ug + atropine 0.5mg SC
  • 2022-08-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-08-01 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-07-15 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-06-30 - irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-06-13 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-05-25 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 270mg 90min + leucovorin 400mg/m2 730mg 2hr + fluorouracil 400mg/m2 730mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (FOLFIRI, Q2W)

  • 2022-05-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-04-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-03-30 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-03-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-02-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-02-11 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-01-24 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2022-01-03 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (FOLFIRI, Q2W)

  • 2021-12-20 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-11-23 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-11-10 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 400mg/m2 690mg 10min + fluorouracil 2400mg/m2 4100mg 46hr (FOLFIRI, Q2W)

  • 2021-10-22 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-10-07 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-09-14 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-09-01 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-08-19 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-08-04 - bevacizumab 5mg/kg 400mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFIRI, Q2W)

  • 2021-07-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 4000mg 46hr (FOLFOX, Q2W)

  • 2021-07-02 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg/m2 3900mg 46hr (FOLFOX, Q2W)

==========

2023-07-06

  • This patient has only been visiting our hospital for the past three months, primarily to the Hemato-Oncology Department and secondarily to the Cardiology Department. The former is for the treatment of sigmoid colon cancer, while the latter is for the treatment of type 2 diabetes mellitus and hypertensive heart disease.
  • The medications Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zanidip (lercanidipine) prescribed by our cardiologist on 2023-04-12 have been added to the active formulary. No medication reconciliation issues were identified.

2023-06-13

  • Based on the PharmaCloud database, it’s evident that this patient has been receiving outpatient and inpatient medical services exclusively at our hospital for the past three months. As per the records, our Cardiologist prescribed a refillable order of Concor (bisoprolol), Doxaben (doxazosin), Forxiga (dapagliflozin), Hyzaar (losartan, hydrochlorothiazide), Pravafen (pravastatin, fenofibrate), and Zandip (lercanidipine) on 2023-04-12. These medications are accurately reflected in the patient’s active medication list. Consequently, no medication reconciliation issues have been identified.

  • Lab data showed a worsening liver function. The patient is currently prescribed OxyNorm (oxycodone 5mg). The package insert for OxyNorm indicates that plasma concentrations may increase in patients with mild to moderate renal impairment and mild hepatic impairment. Therefore, a conservative approach should be taken when adjusting the dosage. For patients with hepatic impairment, the starting dose should be one third to half of the usual initial dose, followed by careful dose adjustment. It is worth noting that 10 mg oral oxycodone is equivalent to 20 mg oral morphine. There is no evidence to suggest that the current dosage of 5mg Q6H is inappropriate. However, close monitoring for potential adverse reactions is recommended.

    • 2023-06-12 Bilirubin total 2.06 mg/dL
    • 2023-05-15 Bilirubin total 0.90 mg/dL
    • 2023-06-12 Bilirubin direct 1.15 mg/dL
    • 2023-05-15 Bilirubin direct 0.26 mg/dL
    • 2023-06-12 S-GOT/AST 74 U/L
    • 2023-05-15 S-GOT/AST 45 U/L
    • 2023-06-12 S-GPT/ALT 24 U/L
    • 2023-05-15 S-GPT/ALT 13 U/L

2023-06-12

  • The most recent lab data (2023-05-16) shows a direct bilirubin level of 0.26mg/dL and an AST level of 45U/L, both slightly exceeding the upper limit of normal. This could indicate potential liver insufficiency. Since fentanyl is primarily metabolized into inactive metabolites in the liver, hepatic insufficiency could potentially slow its elimination. Therefore, patients with impaired liver function using the fentanyl transdermal patch should be monitored for signs of toxicity, and the dose might need to be reduced if necessary. Please update the patient’s liver function readings. If mild to moderate hepatic impairment is confirmed, then the dose is adviced to be reduced by 50%. It’s not recommended to use the fentanyl patch in patients with severe hepatic impairment.

  • The patient was treated with FOLFIRI from 2021-08 to 2022-09, then with FOLFOX from 2022-10 to 2023-02, and then with FOLFIRINOX since 2023-03. However, due to the obvious upward trend of tumor markers, it is possible that the disease may have developed further resistance to these changed regimens.

    • 2023-06-12 CEA 733.40 ng/mL
    • 2023-05-16 CEA 621.44 ng/mL
    • 2023-04-19 CEA 676.57 ng/mL
    • 2023-03-31 CEA 450.06 ng/mL
    • 2023-01-11 CEA 189.62 ng/mL
    • 2022-11-22 CEA 156.62 ng/mL
    • 2022-10-19 CEA 53.26 ng/mL
    • 2022-09-13 CEA 33.27 ng/mL
    • 2023-05-16 CA199 1794.87 U/mL
    • 2023-04-19 CA199 1447.66 U/mL
    • 2023-03-31 CA199 1173.49 U/mL
    • 2023-01-11 CA199 497.53 U/mL
    • 2022-11-22 CA199 285.59 U/mL
    • 2022-10-19 CA199 180.53 U/mL
    • 2022-09-13 CA199 156.34 U/mL
  • The current FOLFIRINOX regimen is being administered without a bolus of 5-FU and with a reduced dose of oxaliplatin, due to observed adverse events and/or patient’s performance status. This is considered an appropriate adjustment and there are no issues identified with this approach.

2023-05-16

  • This patient has been diagnosed with sigmoid colon cancer that has metastasized to the lungs, liver and bones. He has also undergone posterior longitudinal transpedicular screw and rod fixation and is dealing with degeneration and spondylosis of the L-S spine as well as a pathologic fracture of the left proximal radius for which he has undergone external fixation.
  • Given the high risk of fractures, it is advisable to consider adding therapeutics such as oral bisphosphonates, zoledronic acid, vitamin D3, denosumab, or teriparatide to the patient’s treatment regimen, as these may help reduce the risk of potential fractures. ref: Bone health in cancer: ESMO Clinical Practice Guidelines https://www.annalsofoncology.org/article/S0923-7534(20)39995-6/fulltext

2022-12-28

  • It has been arranged for a CT and bone scan to be performed during this hospitalization at intervals of three months.
  • The patient’s blood pressure has returned to normal range (186/121 -> 135/72 mmHg) and there are no abnormalities in his vital signs or 2022-12-27 laboratory results.
  • The underlying conditions of hypertension, diabetes mellitus, hyperlipidemia, and hepatitis B are appropriately managed with self-carried medication without complications.

2022-12-13

  • The blood pressure was still high (at around 170/95) under Concor (bisoprolol), Doxaben (doxazosin), Hyzaar (losartan, hydrochlorothiazide) and Zanidip (lercanidipine).
  • For hypertensive emergencies, hydralazine 10 to 20 mg every 4 to 6 hours might be used (a beta-blockers has been used to prevent reflex tachycardia).

2022-11-29

  • After image studies in early Oct 2022 revealed a number of lesions with a mild increase in size, and multiple bone metastases in progress, the regimen was changed from FOLFIRI to FOLFOX.

  • In the past three months, certain tumor markers have been elevated.

    • CEA
      • 2022-11-22 CEA 156.62 ng/mL
      • 2022-10-19 CEA 53.26 ng/mL
      • 2022-09-13 CEA 33.27 ng/mL
    • CA199
      • 2022-11-22 CA199 285.59 U/mL
      • 2022-10-19 CA199 180.53 U/mL
      • 2022-09-13 CA199 156.34 U/mL
  • As SBP highly fluctuated between 136 and 231 under treatment with (patient-carried medication) Concor (bisoprolol), Zanidip (lercanidipine) and Hyzaar (losartan + hydrochlorothiazide), please monitor this closely. The drug Atanaal (nifedipine 5mg) 1# PRNQ6H might be considered in case where the blood pressure exceeds 200mmHg.

  • SBP flucturated at a wide range 136~231mmHg under patient-carried antihypertensive agents Concor (bisoprolol) and Hyzaar (losartan + hydrochlorothiazide), please keep a closer eye on it.

  • Pre-prandial blood sugar levels were higher than 170mg/dL for 2 days; metformin 500mg BID is recommended.

2022-10-25

  • The blood pressure remains high, around 185/100, since this hospital stay, despite the use of current antihypertensive medications: Concor (bisoprolol 5mg) 1.5# QD + Hyzaar (losartan 100mg + hydrochlorothiazide 12.5mg) 1# QD + Zanidip (lercanidipine 10mg) 1# QD + Atanaal (nifedipine 5mg) 1# PRNQ6H.
  • For severe asymptomatic hypertension, might consider hydralazine short-term use for blood pressure lowering (eg, over hours) if there is concern that severe blood pressure elevation will precipitate an acute cardiovascular event. Hydralazine initial: 10 mg 4 times daily for 2 to 4 days, then 25 mg 4 times daily for the remainder of the week followed by titration based on response to 50 mg 4 times daily; usual dosage range: 100 to 200 mg/day in divided doses.
  • Besides, minoxidil (not available in this hospital at present) is reserved for patients with resistant hypertension who do not respond adequately to an optimized 4-drug regimen, ideally consisting of a thiazide-like diuretic and a mineralocorticoid-receptor antagonist. Minoxidil is usually used in combination with a beta-blocker to prevent reflex tachycardia.

2022-08-31

  • The underlying diseases were managed with self-carried medications without the need for urgent adjustment. At the time of this hospital stay, blood pressure levels were 170(+-10)/90(+-10), blood sugar levels were 146~162, which were just slightly above normal ranges. The lab data on 2022-08-30 were generally normal.
  • Bevacizumab was last administered on 2022-06-13. The levels of CEA and CA199 have increased in the last three months.
  • CEA
    • 2022-08-10 CEA 31.80 ng/mL
    • 2022-07-12 CEA 21.34 ng/mL
    • 2022-06-10 CEA 17.51 ng/mL
    • 2022-05-03 CEA 10.98 ng/mL
    • 2022-03-29 CEA 10.39 ng/mL
  • CA199
    • 2022-08-10 CA199 171.05 U/mL
    • 2022-07-12 CA199 174.30 U/mL
    • 2022-06-10 CA199 162.79 U/mL
    • 2022-05-03 CA199 92.68 U/mL
    • 2022-03-29 CA199 92.15 U/mL

2022-08-02

  • The patient’s blood glucose level was approximately (140 +- 10) mg/dL, and his blood pressure was approximately (160 +- 20 ) / (95 +- 10) mmHg during this hospitalization.
  • Norvasc (amlodipine 5mg/tab) #1 QD for HTN is recommended.

2022-05-26

  • CT images taken on 2022-01-24 showed a regression, while CT images taken on 2022-03-31 showed the disease stable, which could hint a decline in the effect of the regimen or the tumor has acquired a certain degree of resistance, this is consistent with the slow rise in tumor markers in recent months.
  • Lab data
    • CEA
      • 2022-05-03 92.68 U/mL
      • 2022-03-29 92.15 U/mL
      • 2022-02-23 82.61 U/mL
      • 2022-01-18 72.41 U/mL
      • 2021-12-14 69.99 U/mL
    • CA199
      • 2022-05-03 10.98 ng/mL
      • 2022-03-29 10.39 ng/mL
      • 2022-02-23 8.55 ng/mL
      • 2022-01-18 6.69 ng/mL
  • In the event the disease progresses, since this patient is receiving irinotecan-based therapy without oxaliplatin, the next regimen candidates could be FOLFOX or CAPEOX.
  • Lab results on 2022-05-18 showed liver and kidney function, blood electrolytes were normal, however WBC 2700/uL (Neutrophil 61%) was relatively lower which should be addressed.
  • Since the evening of 2022-05-25, the SBP has risen up to 180mmHg, even with the use of bisoprolol, losartan, hydrochlorothiazide, and lercanidipine. Keeping a close eye on the blood pressure should be done to check if more intervention is necessary.

2022-03-31

  • According to latest CT images on 2022-01-06, the disease showed response to current regimen which has been introduced since 2021-08, compared with the images on 2021-10-25, 2021-06-21.
  • There has been an increase in biomarker readings since 2022 [CEA 10.39(2022-03-29) <- 8.55(2022-02-23) <- 6.69(2022-01-18); CA199 92.15(2022-03-29) <- 82.61(2022-02-23) <- 72.41(2022-01-18)], which is not consistent with the CT images that are updated not so frequently.
  • When the disease becomes resistant to current treatment, since this patient is on irinotecan-based therapy without oxaliplatin, the next regimen candidates might be FOLFOX or CAPEOX.

701090711

230706

[lab data]

2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.28 S/CO
2023-06-07 Anti-HBc Reactive
2023-06-07 Anti-HBc-Value 7.60 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 Anti-HBs 4.14 mIU/mL

[exam findings]

  • 2023-06-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 25 dB HL, LE 28 dB HL
    • bil normal to moderate SNHL
  • 2023-06-02 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
  • 2023-05-31 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic reaction, early bone mets or other nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-05-30 Patho - esophageal biopsy
    • Middle esophagus, 25 cm to 28 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Middle esophagus, 24 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections of both parts show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.
  • 2023-05-30 PET scan
    • Glucose hypermetabolism involving the middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes. Metastatic lymph nodes may show this picture.
    • Increased FDG in the colon, right kidney and right ureter. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-05-29 SONO - abdomen
    • Liver cysts
    • Liver calcification, S7
    • Renal cysts
    • R/o lymphadenopathy, near heptic hilum area
  • 2023-05-27 MRI - brain
    • No brain nodule or metastasis. Old right putamen lacunar infarcts. Mild cortical brain atrophy.
  • 2023-05-26 Patho - bronchus biopsy
    • Lung, left, bronchoscopic biopsy —- mild chronic inflammation
    • Section shows bronchial mucosa with mild chronic inflammation. No granuloma or malignancy is found.
    • The immunohistochemical stains of CK and p40 show no invasive tumor.
  • 2023-05-25 CXR
    • widening of Rt and Lt paratracheal stripes and prominent Rt supraclavicular soft-tissue due to paratracheal lymph node enlargement
    • Tortousity of thoracic aorta
  • 2023-05-17 CT - chest
    • Findings
      • Lungs: centrilobular nodular opacities at RLL and RUL, may be aspiration bronchiolitis. substantial subpleural paraseptal emphysema in both upper lobes and superior segment of LLL. partial atelectasis with focal fibrosis or subpleural paraseptal emphysema in RML
      • visible lowee neck, chest wall, mediastinum and hila: marked Rt medial wall thickening at M/3 of thoracic esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and Rt supraclavicular fossa(large left upper paratracheal LAP indents and displaces the trachea and adjacent greater vessels) RT vocal cord palsy.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Visible abdominal contents: multiple small low attenuations in the liver, may be hepatic cysts and metastatic lesions.
      • normal appearance of gall bladder..several RT and Lt renal cysts up to 3.7cm, unremarkable of the spleen, both adrenal glands, pancreas, and Lt kidneyno enlarged lymph node.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: M/3 esophageal cancer T4N3M1(E1)
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1(M_value) STAGE:____(Stage_value)

[MedRec]

  • 2023-07-05 SOAP Hemato-Oncology
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date: 20230627
        • cT4bN3M0 stage IVA => CCRT.
  • 2023-06-21 SOAP Hemato-Oncology
    • O
      • Cancer Treatment Chemoradiotherapy/Targeted Therapy Side Effects Assessment (20230621)
        • Vomiting: G1: 1-2 times within 24 hours
          • Vomiting [Treatment]: Observe
  • 2023-06-16 SOAP Radiation Oncology
    • P
      • Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx.
  • 2023-05-25 ~ 2023-06-14 POMR Hemato-Oncology
    • Discharge diagnosis
      • Squamous cell carcinoma of middle third of esophagus, cT4N3M0 stage IVA status post feeding jejunostomy and left port-A implantation on 2023/06/02
      • Hypertension
      • Anxiety disorder
      • Constipation, unspecified
      • Chronic viral hepatitis B without delta-agent
    • CC
      • suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.        
    • Present illness
      • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months.
      • According to the patient statement, he suffered from dysphagia with epigastric dull pain since 6 months ago. He didn`t pay much attention to it in the beginning.
      • In recent one month, he suffered from hoarseness and visited otolaryngology clinic for help. Nasopharyngoscopy showed left vocal palsy. Right supra-clavicular mass status post fine needle aspiration was done on 2023-05-16. The cytology report showed negative finding. Due to right eye ptosis for 2 months.
      • He visited ophthalmology clinic and Ach receptor Ab, chest CT were checked. It revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M1.
      • He was treferred to our chest surgery clinic for help. After discussing with the patient and his family about further treatment. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M1 stage IVB.        
    • Course of inpatient treatment
      • After admitted, Chest CT on 2023/05/17 showed M/3 esophageal cancer T4N3M1. Brain MRI on 2023/05/27 showed no brain nodule or metastasis, old right putamen lacunar infarcts and mild cortical brain atrophy. Abdominal echo on 2023/05/29 showed liver cysts, liver calcification, S7, renal cysts and R/O lymphadenopathy, near heptic hilum area.
      • PES on 2023/05/29 showed 1. Advanced esophageal cancer(Lesion B-25 28cm), middle esophagus, s/p biopsy(B) 2. Advanced esophageal cancer(Lesion A-24cm), middle esophagus, s/p biopsy(C) 3. Lugol voiding area, lower esophagus, s/p biopsy(D) 4. Reflux esophagitis LA Classification grade A 5. Gastric polyp, multiple, s/p biopsy(A). Middle esophagus, 25 cm to 28 cm pathology showed Squamous cell carcinoma, moderately differentiated and Middle esophagus, 24 cm pathology showed Squamous cell carcinoma, moderately differentiated.
      • Whole body PET scan on 2023/05/30 showed middle portion of the esophagus, compatible with primary esophageal malignancy with right lower paratracheal lymph node, confluent left upper paratracheal lymph nodes and confluent right supraclacular lymph nodes metastases. Whole body bone scan on on 2023/05/31 showed no bone metastases. Feeding jejunostomy and Left Port-A catheter implantation on 2023/06/02. PTA on 2023/06/07 showed reliability FAIR, average RE 25 dB HL // LE 28 dB HL.
      • Actein 600mg 1# po BID for sputum. Famotidine 1# po BID for GERD. Morphine 1# po Q8H, Panadol 1# po Q8H and Morphine 5mg IVD PRNQ6H for pain control. Radiotherapy for 45 Gy/ 25 fractions to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fractions from 2023/06/08~.
      • Chemotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2) on 2023/06/09~2023/06/13(C1). Primperan 1# po TIDAC and Primperan 1pc iv PRNQ6H for nausea and vomiting. NS 1000ml IVF Q8H Y-sited chemotherapy -> change NS 500ml IVF Q8H for bilateral hand edeam on 2023/06/12. Hypertension with Concor 1.25mg 1# po QD and Olmetec 20mg 1# po QD. Anxiety disorder with Ativan 1# po HS and Eurodin 1# po PRNHS for insomnia. Constipation with Bisadyl supp 1 pill RECT PRNQD and Lactulose 20ml po PRNBID. Chronic viral hepatitis B with Vemlidy 1# po QD. Xylocaine 2pc in NS 500ml for mouse rinse.
      • Patient tolerated the chemotherapy with nausea without vomiting. With the stable condition, he was discharged on 2023/06/14 and OPD followed up later.
    • Discharge prescription
      • Actein (acetylcysteine 600mg) 1# BID
      • Lactul (lactulose 666mg/mL) 20mL PRNBID
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg , lysozyme 90mg) 1# TID
      • Vemlidy (tenofovir alafenamide 25mg) 1# QD
      • Ulstop (famotidine 20mg) 1# BID
      • Promeran (metoclopramide 3.84mg) 1# TIDAC
      • morphine 15mg 1# Q8H
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Bisadyl supp (bisacodyl 10mg) 1# PRNQD RECT
      • Nincort Oral Gel (triamcinolone) PRNBID TOPI
      • Parmason Gargle Solution (chlorhexidine) BID GAR

[consultation]

  • 2023-06-07 Hemato-Oncology
    • Q
      • This 68-year-old man, a heavy smoker and alcoholism. He has suffered from dysphagia for solid material with epigastric dull pain for 6 months, associated with body weight loss 6-7 kg in recent 2 months. Chest CT revealed medial wall thickening at middle third of esopahgus (65mm in lenght) with luminal narrowing and invading adjacent mediastinal fat. Multiple metastatic lymphadenopathy in the visceral space and left anterior prevascular space, and right supraclavicular fossa. Impression: M/3 esophageal cancer T4N3M0. He was admitted for cancer work-up under impression of middle third esophageal cancer, cT4N3M0 stage IVA.
      • After admission, cancer work-up were done, the cancer staging revealed squamous cell carcinoma of middle third of esophagus cT4N3M0, stage IVA. We had well explaining with patient and his family about further treatment. Operation of port-A and feeding jejunostomy implantation was done on 2023-06-02. Now smooth digestion was presented after jejunostomy feeding, advanced diet to 1230 Kcal/day.
      • We need consult you for further chemotherapy. Thank you very much.
    • A
      • This 68 year old man is a case of squamous cell carcinoma of M/3 esophagus, c T4N3M0, stage IVA s/p port-A and feeding jejunostomy implantation was done on 2023-06-02. Initial presentation was dysphagia for solid material with epigastric dull pain for 6 months, associated with weight loss 6-7 kg in recent 2 months.      
      • We are consulted for CCRT.
      • Please check 24 urine CCR and arrange auditory test and check HBsAg, Anti HBc, Anti HBs, Anti HCV. Book 11A or 10B.
  • 2023-06-02 Radiation Oncology
    • A
      • He can still have porridge and drink water. CCRT is indicated. CT-simulation will be arranged on 6/5. Plan to deliver 45 Gy/ 25 fx to the bil. SCFs, U/3+M/3 esophagus and adjacent lymphatic drainage area. Then boost the esophageal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 6/7 or 8. Thank you very much.

[surgical operation]

  • 2023-06-02
    • Surgery
      • Feeding jejunostomy + port-A insertion.
    • Finding
      • 8.0 Fr. Polysite, left cephalic vein. cut-down method.
      • 18 Fr. silicon Foley catheter.

[chemotherapy]

  • 2023-07-05 - cisplatin 75mg/m2 100mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, Q4W, lower CDDP and 5-FU)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-09 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-06

According to the PharmaCloud database, this patient sporadically visits local clinics for his sleep disorder, chest pain, and acute upper respiratory infections. He has been given prescriptions with a duration of only three days, all of which are now invalid. The patient has sought medical attention multiple times due to his sleep disorder, and Eurodin (estazolam) is listed among his active medications. No reconciliation issues have been identified.

2023-07-05

Mild hyponatremia was observed in the patient on 2023-07-05, with a serum sodium level of 131 mmol/L. The planned administration of furosemide on 2023-07-06 (concurrent with the PF regimen) may exacerbate this condition, as furosemide may cause increased sodium excretion. Please continue to monitor the patient’s sodium levels closely to determine if further intervention is needed.

700938395

230705

[lab data]

2023-06-27 Urine-Creatinine 105.41 mg/dL
2023-06-27 U-Cr (24hr) 1633.9 mg/kg/24 hr
2023-06-27 Total Volume(24hr) 1550 mL
2023-06-27 C.C.R. 120.7 mL/min

2023-06-20 EBV DNA PCR 159 copies/mL

2023-06-14 Anti-HBc Nonreactive
2023-06-14 Anti-HBc-Value 0.06 S/CO
2023-06-14 Anti-HBs 0.40 mIU/mL

2023-06-07 RPR/VDRL Nonreactive
2023-06-07 HBsAg Nonreactive
2023-06-07 HBsAg (Value) 0.27 S/CO
2023-06-07 Anti-HCV Nonreactive
2023-06-07 Anti-HCV Value 0.11 S/CO
2023-06-07 HIV Ab-EIA Nonreactive
2023-06-07 Anti-HIV Value 0.07 S/CO
2021-08-17 RPR/VDRL Nonreactive

[exam findings] (not completed)

  • 2023-06-29 Pure Tone Audiometry, PTA
    • Reliabilty Fair
    • R’t : 59 dB HL, mild to severe mixed type HL
    • L’t : 21 dB HL, normal to mild SNHL.
  • 2023-06-09 Tc-99m MDP bone scan
    • Mildly increased activity in the skull base. Local hyperemia may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Mildly increased activity in some L-spines. Degenerative change may show this picture.
    • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, elbows, hips, knees and feet, compatible with benign joint lesions.
  • 2023-06-08 SONO - abdomen
    • Fatty liver, moderate
    • Gallbladder polyps
    • Renal cyst, right kidney
  • 2023-06-07 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:1(T_value) N:2(N_value) M:0(M_value) STAGE:III(Stage_value)
  • 2023-06-06 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-05-30 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tumor, left nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated subtype
    • Microscopically, the sections show a picture of squamous cell carcinoma, non-keratinizing, undifferentiated subtype of the nasopharyngeal tissue characterized by tumor cells with ovoid vesicular nuclei, prominent nucleoli, and indistinct cell borders arranged in syncytial pattern, infiltrate in the inflamed stroma.
    • Immunohistochemistry shows CK(+) and P63(+) for tumor.

[consultation]

  • 2023-06-06 Oral and Maxillofacial Surgery
    • Q
      • This is a 46 y/o male with history of GERD
      • This time, he was admitted to our ward for Nasopharyngeal cancer survey. Under the impression of NPC, radiotherapy is indicated. We need your expertise on dental evaluation before radiotherapy.
    • A
      • After the exam of this 46 y/o male
      • O:
        • Fair oral hygiene
        • Caries over tooth 27 was noted
      • Pano finding:
        • Missing: 18 28 38 48
        • Crown and bridge: 35X37
        • Impaction: Nil
      • There is no tooth extraction is indicated now, radiotherapy can be delivered safely.
      • Suggest restoration of 27 caries after him discharge

[chemotherapy]

  • 2023-06-30 - docetaxel 75mg/m2 140mg NS 250mL D1 + cisplatin 75mg/m2 150mg NS 500mL D2 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr (after CDDP) + furosemide 20mg NS 30mL 10min (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL D2-5 (TPF Q3W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + NS 250mL D1-2 + aprepitant 125mg PO D1-3

==========

2023-07-05

[bedside visit: poor appetite. patient education: docetaxel, cisplatin, fluorouracil]

  • I visited the patient at about 13:15 on 2023-07-05. He was lying on his bed with his eyes closed, and I saw that the medications on his IV stand had been changed to KCl and Nako No.5, indicating that his chemotherapy had ended.
  • I gently woke him up, gave him the patient medication information for docetaxel, cisplatin, and fluorouracil, and highlighted the serious side effects of each drug with a colored marker.
  • I advised him to stay hydrated to maintain kidney function. I asked if he had any family or friends to take care of him while he was in the hospital, and he said he was alone.
  • I asked if he was feeling unwell in any way and he replied that he had a poor appetite. I told him that the medication he was taking included an appetite stimulant and suggested that we wait a few days to see if his appetite improved.

701344079

230705

[lab data]

2021-11-10 ROS1 FISH NOT detected

2021-11-09 EGFR G719X not detected
2021-11-09 EGFR Exon19 del detected
2021-11-09 EGFR S768I not detected
2021-11-09 EGFR T790M not detected
2021-11-09 EGFR Exon20 ins not detected
2021-11-09 EGFR L858R not detected
2021-11-09 EGFR L861Q not detected

2021-11-08 PD-L1 (28-8) TC <1%
2021-11-03 PD-L1 (22C3) TPS<1%

2021-11-03 ALK IHC Negative

2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.05 Ratio
2021-10-27 Aspergillus Ag Negative
2021-10-27 Aspergillus Ag Value 0.08 Ratio

2021-10-25 Mycoplasma IgM Negative Index
2021-10-25 Mycoplasma IgM Value 0.1 Index

2021-10-22 Anti-HBs 11.64 mIU/mL

2021-10-22 HBsAg Nonreactive
2021-10-22 HBsAg (Value) 0.47 S/CO

2021-10-22 Anti-HBc Nonreactive
2021-10-22 Anti-HBc-Value 0.31 S/CO

2021-10-22 Anti-HCV Nonreactive
2021-10-22 Anti-HCV Value 0.04 S/CO

2021-10-22 HIV Ab-EIA Nonreactive
2021-10-22 Anti-HIV Value 0.06 S/CO

[exam findings] (not completed)

  • 2023-06-29 CXR
    • Scoliosis of the T-spine with convex to right side.
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-06-27 Patho - stomach biopsy
    • Stomach, PW of low body, biopsy — Hyperplastic polyp. No H.pylori present
  • 2023-06-26 SONO - abdomen
    • suspected liver parenchymal disease (incomplete exam of liver)
    • bilateral renal cysts
    • pancreas obscured
  • 2023-06-26 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade D
    • Hiatal hernia
    • Atrophic gastritis, s/p CLO test
    • Gastric polyp, PW of low body, s/p biopsy
  • 2023-06-23 MRI - brain
    • Indication: Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
    • IMP: No evidence of brain metastasis. General brain atrophy.
  • 2023-05-28 CXR
    • Known a case of Lung cancer with bone mets.
    • Tortuosity of the aorta with atherosclerotic change.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2023-05-28 KUB
    • No definite opaque stone detected.
    • Degenerative joint disease of lumbar spine with marginal osteophytes.
    • Scoliosis of L-spine.
    • There is fecal materials impaction in the course of colons.

[MedRec]

  • 2023-06-07 SOAP Urology
    • S
      • hematuria today
      • chronic frequency
    • A: r/o UTI
    • P: RTC with report
    • Prescription
      • Transamin (tranexamic acid 250mg) 1# BID 3D
      • cephalexin 500mg 1# TID 7D
      • Harnalidge (tamsulosin 0.4mg) 1# QD 7D
  • 2023-05-23 SOAP Nephrology
    • Prescription
      • Pentop (pentoxifylline 400mg) 0.5# HS
  • 2023-05-18 SOAP Hemato-Oncology
    • Plan: Request visit ER if SBP < 80
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 28D
  • 2023-03-30 SOAP Hemato-Oncology
    • P: Chest CT on 2022-10-20 -> 2023-01-20 -> 2023-04-10, Bone scan on 2022-10-18 -> 2023-01-18 -> (May consider non-contrast Chest CT due to impaired renal funciton)
  • 2023-03-02 SOAP Hemato-Oncology
    • Plan: On 2023-02-02 and 03-02, request salt intake again and again
  • 2023-02-02 SOAP Hemato-Oncology
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 28D
      • Norvasc (amlodipine 5mg) 1# QL 28D
  • 2022-12-08 SOAP Hemato-Oncology
    • Chest CT on 2022-10-20 -> 2023-01-20, Bone scan on 2022-10-18 -> 2023-01-18 (May consider non-contrast Chest CT due to impaired renal funciton)
  • 2022-09-16 SOAP Nephrology
    • O
      • 2022/09/15 Creatinine = 2.17 mg/dL;
      • 2022/09/15 eGFR = 31.02;
      • 2022/07/21 Creatinine = 1.60 mg/dL;
      • 2022/07/21 eGFR = 44.09;
  • 2022-09-01 SOAP Neurology
    • O
      • 2022/08/29 NCV: This abnormal NCV study suggested bilateral lumbosacral rdiculopathy.
    • Prescription
      • Saline (nicametate citrate 50mg) 1# TID 28D
  • 2022-08-18 SOAP Neurology
    • S
      • P’t is a case of lung CA and received tagrisso treatment.
      • P’t noted left leg pain about 2 years ago and noted lung CA with L-spine meta. After treatment, condition statioanry but bilateral feet numbness was noted about 1 year but in recent numbness ascent to bilateral lower leg.
    • Prescription
      • Saline (nicametate citrate 50mg) 1# TID 14D
  • 2022-08-18 SOAP Hemato-Oncology
    • Plan: Refer to Neuro for numbness
  • 2022-01-06 SOAP Hemato-Oncology
    • Plan: May consider XGEVA after bone scan in 2022-01
  • 2021-12-08 SOAP Hemato-Oncology
    • Plan
      • Shift Estengy (Amlodipine / Valsartan 5/80 mg) 1# QD to Diovan (160) 0.5# QD
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 15D
      • Diovan (valsartan 160mg) 0.5# QD 15D
  • 2021-11-25 SOAP Hemato-Oncology
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD 13D
  • 2021-10-21 ~ 2021-11-11 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of unspecified part of unspecified bronchus or lung
      • Lung cancer with lymph node, pleural and bone metastases, T2N2M1, Stage IVB
      • Acute respiratory failure, unspecified whether with hypoxia or hypercapnia
      • Pleural effusion in other conditions classified elsewhere
      • Chronic obstructive pulmonary disease, unspecified
      • Enlarged prostate with lower urinary tract symptoms
    • Present illness
      • This 82y/o male was a case of denied any majort systemic disease or operation history.
      • According to the statement of the patient families and ER medical record. This time, he had suffered from dyspnea for 4 days, the symptoms became to serious and visited frist to Cardinal Tien Hospital. Due to massive amount left pleraul effusion and bed adjustment mechanism, referred to our hospital.
      • At MER, O2 therapy and the chest films disclosed left massive plerual effusion. Chest CT was arranged and the conculsion of severe left pleural effusion with suspected left hilar lung mass. However, elevation of breathing work with paradoxical movement were also note, then emergency intubation was done. Empiric antiboltic with Rocephin was perscribed.
      • Under the impression of acute respiratory failure s/p intubation and severe left plerual effusion, R/I lung cancer. He was admitted to our ICU for further observation and management.
    • Course of inpatient treatment
      • After admitted, Left pigtail insertion on 2021/10/21 and keep left pigtail drainage for Left massive amount plerual effusion. Chest CT on 2021/10/21 showed severe left pleural effusion with suspected left hilar lung mass, R/O lung cancer, T2N2M0, suggest contrast enhanced study, enlarged prostate and infra-renal aortic aneurysm. 2D echo on 2021/10/25 showed 1. Thickened AV with mild AR 2. Thickened and calcification of MV, no MR 3. LV septal hypertrophy 4. Preserved LV and RV systolic function 5. Moderate PR, mild TR, normal IVC size. Explain his condition to his family.
      • Acetin 1pk po BID and Cough mixture 10ml po HS for cough with sputum. Brain MRI on 2021/10/29 showed no evidence of brain metastasis, general brain atrophy, hydrocephalus and cervical spondylosis. Whole body bone scan on 2021/10/29 showed the scintigraphic findings suggest multiple bone metastases. Chest CT on 2021/10/30 showed left lower lobe lung cancer with left malignant pleural effusion and extensive lymphadenopathy. A family meeting was held to explain his condition and therapy to patient and his family on 2021/11/01. Consult rahabilitation department for bedside rehabilitation exercises on 2021/11/01. Remove NG tube on 2021/11/02. Target therapy with Iressa 1# po QD from 2021/11/02. Remove left pigtail on 2021/11/08. Explain his deta and condition to his family on 2021/11/09. Major illness was applied on 2021/11/11.
      • Foster 4puff INHL BID and Spiriva 2puff INHL HS for Chronic obstructive pulmonary disease. Urief F.C 0.5# po QD for BPH. With the stable condition, he was discharged on 2021/11/11 and OPD followed up later.
    • Discharge prescription
      • Cough Mixture (platycodon) 10mL HS
      • Urief (silodosin 8mg) 0.5# QD
      • Actein (acetylcysteine) 1pk BID
      • Iressa (gefitinib 250mg) 1# QD

[treatment]

  • 2021-11-25 ~ undergoing - Tagrisso (osimertinib 80mg) 1# QD

  • 2021-11-11 ~ 2021-11-24 - Iressa (gefitinib 250mg) 1# QD

==========

2023-07-05

  • I visited the patient around 11:10 on 2023-07-05 with the osimertinib medication pamphlet. The patient was lying in bed and his son was on a bench against the wall.

  • I explained to the patient and his son that he has been using osimertinib for a relatively long period of time and based on the pamphlet, I described the potential side effects to watch for during the use of this drug. The patient’s son said that the main issue was digestive tract symptoms, but other than that, everything else felt fine, and the tumor has been controlled for a good period of time, they are still satisfied with the efficacy. I left the contact information for the hospital’s pharmacy counseling window, so the patient and his family can call when needed.

700561643

230703

[exam findings]

  • 2023-07-01 CXR
    • Tortous aorta with calcification is noted.
    • Superior mediastinum mass like lesion is found. Suggest CT.
    • Osteopenia of the bony structure is noted.
  • 2023-07-01 CT - chest
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Confluent soft tissue mass at superior, anterior mediastinum and middle mediastinum is found. The SUPERIOR VENA CAVA is compressed. Lymphoma or germ cell tumor is suspected and lymphoma is most likely.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Confluent soft tissue mass at mediastinum with SUPERIOR VENA CAVA compression. Lymphoma is favored.

[MedRec]

  • 2023-07-01 Hemato-Oncology VS note on admission day
    • She experienced troublesome cough and it could be exaggerated by lying down.
    • CT revealed mediastinum tumor with compression of trachea and SVC, Tissue proof will be done on 2023-07-03.

[consultation]

  • 2023-07-01 Hemato-Oncology
    • Q
      • Productive cough and orthopnea for 2 months
      • Face edema was told by daughter
      • Past history: anxiety, HTN
      • Allergy: NKA
      • Surgical hx: thyroid s/p OP now under eltroxin
    • A
      • This 73 year old woman is a case of anterior mediastinum tumor r/o lymphoma. We are consulted for further evaluation.
      • Please arrange admission for CT guide biopsy. Add steroid for r/o lymphoma related SVC syndrome. Thanks for your consultation.
  • 2023-07-01 Thoracic Surgery
    • Q
      • Productive cough and orthopnea for 2 months
      • Face edema was told by daughter
      • Past history: anxiety, HTN
      • Allergy: NKA
      • Surgical hx: thyroid s/p OP now under eltroxin
    • A
      • The patient had dyspnea. CT scan showed huge mediastininal tumor with SVC compression
      • Lymphoma, small cell lung cancer was suspected
      • Please consult oncologist for treatment

==========

2023-07-03

  • As per the PharmaCloud database, this patient frequently visits RenJi Hospital (last visit on 2023-06-19) and routinely refills his prescription at a local pharmacy. The prescription includes sennoside, ubidecarenone, bisoprolol, valsartan, pitavastatin, levothyroxine, alprazolam, carbinoxamine, and dextromethorphan.

  • Except for carbinoxamine (a first-generation antihistamine used to treat allergic rhinitis and vasomotor rhinitis), all other drugs are included in the active medication list. However, no current diagnosis or active medical problems relating to allergic rhinitis or vasomotor rhinitis have been identified. Thus, there is no evidence of discrepancies in medication reconciliation.

701031265

230630

[present illness] - 2023-03-20 admission note

  • This 92-year-old male had history of
    • Benign prostate hyperplasia
    • Hypothyroidism
    • Hypertension
    • status post left total knee replacement about 10 years ago
    • Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
  • He was under regular follow up at CRS/Meta/Uro OPD.
  • Liver metastasis after RFA on 2023/02/03. On 2023/03/04 whole abdominal CT showed suspect of three new liver metastasis.
  • Under the impreession of colon cancer with liver metastases, he was admitted for port-A and palliative chemotherapy after further advanced evalaution on 2023/03/20.

[past history]

  • Benign prostate hyperplasia
  • Hypothyroidism
  • Hypertension
  • status post left total knee replacement about 10 years ago
  • Adenocarcinoma of ascending colon, pT2N0M0 stage I status post Single-incision laparoscopic right hemicolectomy on 2021/11/03
  • Liver metastasis after RFA on 2023/02/03         

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-06-19 CT - abdomen
    • Findings
      • Lobulated low density lesion at S5 of liver measuring 2.38cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2023-03-04, the lesion regressed. Another low density lesion at dome up to 1.68cm is noted. stable.
      • Enlarged prostate up to 5.68cm is found.
      • One hepatic cyst at S6 of liver measuring 1.3cm is noted.
      • s/p RAR.
      • Calcified right posterior pleura is found.
      • Senile fibrotic change is noted at lung fields.
      • Interstitial change at bilateral lower lobes is found.
    • Imp:
      • s/p RAR.
      • Liver meta at dome. Stationary. S5 meta, in regression.
  • 2023-05-15, -03-24, -03-20 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-04-26 KUB + L-spine Lat
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4 and L4-5 (more severe on L4-5).
    • Spondylolisthesis of L5-S1 (< Grade I) is noted.
  • 2023-03-23 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Borderline dilated LV; Adequate LV systolic function with normal resting wall motion
      • Dilated aortic root; mild to moderate AR
      • Trivial MR, mild to moderate TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
  • 2023-03-22 Spirometry
    • normal lung volume and ventilatory function
  • 2023-03-20 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
  • 2023-03-04 CT - abdomen
    • Indication: refer from CRS a case of colon cancer R/O single liver metss/p RFA on 2023-02-03 no AE. now CT 1 m F/U
    • With and without contrast enhancement CT of abdomen shows:
      • Colon CA, s/p operation. No local recurrent tumor.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Right posterior segment liver metastasis, s/p RFA. Three poor enhancing lesions in right hepatic lobes: 1.4cm in S7, 0.8cm and 1.0cm in S5.
      • No ascites, nor extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • Colon CA, s/p operation
      • Suspect three new liver metastasis. Suggest sonography correlation.
  • 2023-02-03 RFA
    • Indication: colon ca with single mets for RFA
    • Procedure
      • Metastatic liver tumor (1.8 cm) s/p RFA (2 sessions; 2 cm active tip)
    • Course
      • By sono-guided, RFA probe was inserted to the tumor (stop after 3 pauses; 2 sessions). The patient tolerated the procedure. Iv anesthesia was performed during the procedure.
    • Findings
      • A 1.8 cm mass at rt post seg near liver surface.
  • 2023-02-02 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-01-11 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 71 dB HL
      • L’t : 66 dB HL
      • Bil mild to profound SNHL.
  • 2022-12-28 SONO - abdomen
    • Diagnosis
      • Chronic liver parenchymal disease
      • Hepatic tumor C/W single metastatic tumor
      • Calcified spot of liver
      • Liver cyst
    • Suggestion
      • RFA if needed
  • 2022-12-21 ENT Hearning Test
    • Tymp:
      • Bil type B.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE >101 dB HL; LE 70 dB HL.
      • RE moderately severe to profound MHL.
      • LE moderate to profound SNHL. (BC masking dilemma)
  • 2022-11-28 CT - abdomen
    • A colon cancer s/p SILS right hemicolectomyp T2N0M0 on 20211103
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • s/p RAR.
      • Low density lesion at S6 of liver up to 1.1cm is found. In comparison with CT dated on 2021-10-09, the lesion is new. New liver meta is suspected.
      • Enlarged prostate up to 5.9cm is found.
      • Ground glass opacity over right lower lobe is found.
    • IMp:
      • s/p RAR.
      • new low density lesion at S6 of liver. 1.1cm, suspected liver meta.
  • 2022-09-28 Nerve Conduction Velocity, NCV
    • Findings
      • Decreased amplitudes and slowed NCVs in bilateral peroneal and tibial CMAP.
      • Decreasd amplitudes and slowed NCVs in bilateral sural SNAPs.
      • Prologed F-wave latencies followed bilateral peroneal and tibial nerve stimulations.
      • Prolonged H-reflex latencies followed right tibial nerve stimulations.
    • Conclusion
      • This abnormal NCV study suggested mix-type sensorimotor polyneuropathy may superimposed polyradiculopathy
        • note ChatGPT: Polyneuropathy refers to damage or disease affecting multiple peripheral nerves throughout the body. Sensorimotor polyneuropathy involves both sensory and motor nerves, which can cause symptoms such as numbness, tingling, weakness, and pain. Polyradiculopathy refers to damage or disease affecting multiple spinal nerve roots, which can cause similar symptoms.
  • 2022-05-19 SONO - abdomen
    • Diagnosis
      • Suspected liver cyst,right
      • Suspected liver calcification,right
      • Pancreas not shown
      • Suboptimal examination of liver due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
  • 2022-04-23 Bladder Sonography
    • PVR: 23.89 mL
  • 2022-04-23 Uroflowmetry
    • Q max: low
    • flow pattern: obstructive
  • 2021-11-03 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, well differentiated, arising from tubulovillous adenoma
      • Resection margins: free
      • Lymph node, mesocolic, dissection — Negative for malignancy (0/22)
      • Lymph node, IMA / SMA, dissection — N/A.
      • Terminal ileum, laparoscopic right hemicolectomy — Negative for malignancy
      • Appendix, appendectomy — Negative for malignancy
      • Pathology stage: pT2N0(if cM0); AJCC stage I
    • MACROSCOPIC EXAMINATION
      • Operation procedure: laparoscopic right hemicolectomy
      • Specimen site: ascending colon
      • Specimen size: colon: 30 cm in length ; Terminal ileum: 8 cm
      • Tumor size: 11x 8x 5 cm
      • Tumor location: 12 cm away from the closest resection margin
      • Depth of invasion grossly: muscularis propria
      • Mucosa elsewhere: Not remarkable
      • Representative sections and labeled: A1:appendix, A2-3:bilateral marfins, A4-7:LNs, A8:non-tumor part, A9-15:tumor
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: well differentiated
      • Depth of invasion: muscularis propria
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified.
      • Discontinuous extramural tumor extension: Not identified.
      • Circumferential (radial) margin of rectum: Serosal margin status of colon: Uninvolved
      • Lymph node metastasis, mesocolic: 0 / 22
      • Lymph node metastasis,, IMA / SMA: N/A.
      • Extranodal involvement: N/A.
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT)
          • pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN)
          • pN0: No regional lymph node metastasis
        • Distant Metastasis (pM)
      • Type of polyp in which invasive carcinoma arose: Tubulovillous adenoma.
      • Additional pathologic findings: None identified.
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2021-10-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (133 - 36) / 133 = 72.93%
      • M-mode (Teichholz) = 72
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH without outflow tract obstruction; impaired LV relaxation.
      • Normal RV systolic function.
      • Aortic valve sclerosis with no AS, mild to moderate AR; mild MR; mild TR; mild PR.
      • Atherosclerosis of aorta with mildly diated aortic root and ascending aorta.
  • 2021-10-19 Patho - colon biopsy
    • Clinical Finding
      • One huge tumor with partial obstruction was noted A-colon, s/p biopsy
    • PATHOLOGIC DIAGNOSIS
      • Colon tumor, ascending colon, biopsy — Villotubular adenoma with high grade dysplasia
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show a picture of villotubular adenoma, composed of colonic mucosal tissue with atypical glands lined by low grade dysplastic columnar cells, in tubular, fused glandular or cribriform arrangement. No convincing stromal invasion present in the limited specimen. Repeat biopsy is advised for further evaluation is advised, if malignancy is suspected clinically. Closely follow up
  • 2021-10-19 Colonoscopy
    • Diagnosis
      • Highly suspect colon cancer with partial obstruction, A-colon, s/p biopsy
      • Mixed hemorrhoids
    • Suggestion
      • F/U pathology report
    • Complication
      • No immediate complication
  • 2021-10-14 Bronchodilator Test
    • probably normal screening
    • negative BDT
    • Inadequate tracing
  • 2021-10-09 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Huge soft tissue mass up to 7.69cm in largest dimension at ascending colon with dilatation of the cecum is found. Colon cancer is favored. Two tiny lymph nodes are found.
      • Mild consolidation over right lower lobe and left lower lobe is found.
      • Borderline heart size is found.
      • Tiny subpleural nodule at right middle lobe up to 0.cm, in largest dimension is found.
      • Bula formation at bilateral upper chest is found.
      • Hepatic cyst at S6 of liver up to 1.25cm in largest dimension is found. S (CVP line placement Im63).
      • Very enlarged prostate up to 5.67cm in largest dimension is found.
    • Imp:
      • Suspected huge Colon cancer at ascending colon.
      • Consolidation over bilataral basal lungs.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2021-07-10 Bladder Sonography
    • PVR: 8.32 mL
  • 2018-07-20 Renal Echo
    • Bilateral parenchymal renal disease
    • Calcification lesion, left kidney
    • Enlarged prostate
  • 2018-03-22 Pure Tone Audiometry & Tymanometry
    • Tymp: bil type A.
    • PTA:
      • reliability: fair
      • R’t mild to severe SNHL, average 66 dB HL.
      • L’t mild to profound SNHL, average 60 dB HL.
      • Audiogram: bil BC 2k and 4k Hz at 70 dB HL NR.
  • 2017-11-09 Barium Enema Double Contrast study of LGI series
    • Findings:
      • The contrast medium passage from anus to the cecum smoothly without obstruction.
      • Normal contour, haustration and peristalsis of the colon.
      • Redundant of sigmoid colon.
    • IMP:
      • Redundant of sigmoid colon.
        • note ChatGPT: “Redundancy of sigmoid colon” is a condition in which the sigmoid colon, which is the last part of the large intestine, is abnormally long and twisted. This results in the sigmoid colon being bunched up or looped on itself, which can cause constipation, bloating, and abdominal pain.

[consultation]

  • 2021-10-12 Dermatology
    • A
      • This patient suffered from multiple erythematous papules on trunk and limbs for months
      • Imp: Asteatotic dermatitis
      • Suggestion:
        • Zaditen 1 / Bid
        • Clobetasol x 6 tubes/bid

[surgical operation]

  • 2021-11-03
    • Surgery
      • SILS right hemicolectomy        
    • Finding
      • Villotubular adenoma with high grade dysplasia of ascending colon, cT2N1M0
      • Anastomosis by GIA 75/4.8mm x2
      • One JP drain in pelvic area
      • Close abdomen by surgical assister

[chemotherapy]

  • 2023-08-31 - FOLFOX

  • 2023-08-04 - FOLFOX

  • 2023-07-20 - FOLFOX

  • 2023-06-29 - FOLFOX

  • 2023-06-07 - FOLFOX

  • 2023-05-15 - oxaliplatin 85mg/m2 110mg D5W 250mL 2hr + leucovorin 400mg/m2 760mg NS 250mL 2hr + fluorouracil 2800mg/m2 3735mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 770mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-24 - oxaliplatin 85mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 775mg NS 250mL 2hr + fluorouracil 2800mg/m2 3800mg NS 500mL 46hr (FOLFOX Q2W, Oxa and 5FU 30% off for his senior age)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

Refillable prescriptions for patients with chronic illnesses - ref: https://www.nhi.gov.tw/Glossary/Glossary.aspx?page=6

==========

2023-09-01

Our neurologist prescribed Saline (nicametate) on 2023-07-05, our endocrinologist prescribed Eltroxin (levothyroxine), and our urologist prescribed Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide) on 2023-07-08. These drugs are included in the list of active medications and reconciliation issues found.

2023-06-30

  • Our Urology department issued refillable prescriptions for the patient with chronic illnesses for Betmiga (mirabegron), Eurodin (estazolam), Harnalidge (tamsulosin), Minirin (desmopressin), Norvasc (amlodipine), and Uretropic (furosemide), on 2023-04-08. These medications have been accurately incorporated into the current medication list, hence no issues were encountered during the medication reconciliation process.

2023-06-08

  • The patient has exclusively sought medical care at our hospital, with the exception of a visit to a local clinic for low back pain on 2023-04-28, where he was prescribed mephenoxalone for a duration of 5 days. Since low back pain isn’t mentioned in the admission note or in the current list of medical problems, there appear to be no medication reconciliation issues.

2023-05-16

  • Subclinical hypothyroidism is biochemically characterized by a normal serum free thyroxine (T4) concentration along with an elevated serum thyroid-stimulating hormone (TSH) concentration. Our endocrinologist has previously prescribed a refillable dose of Eltroxin (levothyroxine). This drug is currently listed in the patient’s active medication regimen. However, the patient continues to have normal free T3 and free T4 levels, while there is a significant increase in TSH levels (approximately doubled every 2 months this year). Therefore, it may be prudent to consult with the endocrinologist to determine if an adjustment in levothyroxine dose is necessary.
    • 2023-05-05 TSH 35.330 uIU/mL
    • 2023-03-21 TSH 19.587 uIU/mL
    • 2023-01-12 TSH 9.573 uIU/mL
    • 2022-09-12 TSH 7.507 uIU/mL
    • 2023-03-22 Free T3 2.5 pg/mL
    • 2023-03-22 Free T4 1.085 ng/dl

2023-03-25

  • The FOLFOX regimen has been adjusted by reducing the dose of oxaliplatin and fluorouracil by 30% due to the patient’s advanced age.
  • According to the TPR panel, the patient’s blood pressure and serum glucose levels are well controlled with the appropriate medications based on his age.
  • No issues have been identified with the patient’s active prescriptions.

700523705

230629

[exam findings]

  • 2023-06-28 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increase soft tissue density of the left lower neck is suspected. Please correlate with sonography or CT for further evaluation.
    • Several Compression fracture of the T-spine S/P vertebroplasty.
  • 2023-06-28 ECG
    • Normal sinus rhythm
    • CCWR
    • Minimal voltage criteria for LVH, may be normal variant
    • T wave abnormality, consider anterior ischemia
  • 2023-06-22 T-spine AP + Lat
    • S/P VP.
    • Compression fracture of spine.
  • 2023-06-22 KUB + L-spine Lat
    • S/P VP.
    • Non-specific small bowel and colon gas pattern.
    • A calcification at pelvic cavity.
  • 2023-06-07 Tc-99m MDP bone sccan with SPECT
    • No evidnece of bone lesion at the left shoulder and left scapula.
    • Suspected benign lesions in both rib cages, maxilla, sternum, some T- and L-spine, left sternoclavicular junction, bilateral shoulders, S-I joints, and hips.
  • 2023-06-05 CXR
    • No active lung lesion
    • No pleural lesion
    • Borderline enlarged cardiac sihoutte
    • Tortuous thoracic aorta with intimal calcification
    • General osteoporosis
    • Multilevel compression fracture of T-L spine
  • 2022-12-17 SONO - nephrology
    • Left borderline small kidney with chronic parenchymal changes.
  • 2022-12-17 Bladder sonography
    • PVR: 10.1 ml
  • 2022-10-15 Bladder sonography
    • PVR: 10.8 ml
  • 2022-10-13, -07-21, -04-02 Gynecologic ultrasonography
    • Uterine myoma
  • 2021-08-28 Bladder sonography
    • PVR: 1.52 ml
  • 2019-07-13 Colonoscopy
    • Diagnosis
      • There was no abnormal mucosa or mass up to the ileocecal valve
      • Mixed hemorrhoids,minimal
    • Suggestion
      • CRS OPD follow up
      • Repeated colon scopy was suggested for follow-up in 1-2 yrs
      • Small lesion may be masked by semifluid like feces
  • 2019-05-08 L-spine Lat (including sacrum)
    • Gr.I spondylolisthesis of L5/S1
    • Facet degeneration of lumbar spine
    • Disc space narrowing of L2-S1
  • 2019-04-01 CTA - abdomen
    • No evidence of ischemic colitis.
  • 2019-03-31 CXR
    • Increase bilateral lung markings.
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.

==========

2023-06-29

  • According to PharmaCloud records, the patient had visited JingMei Hospital for a wedge compression fracture of the first lumbar vertebra on 2023-05-31. She was given short-term prescriptions for dexamethasone (1 day), tramadol (7 days), and mephenoxalone (7 days), all of which have now expired and are therefore invalid.
  • Currently, intravenous formulations of Limadol (tramadol) and morphine have been prescribed for pain management since her admission date of 2023-06-28. Based on the information available, there are no apparent medication reconciliation issues found.

701474048

230628

[exam findings]

  • 2023-04-18 PD-L1 (22C3)
    • Block No: S2023-04371
    • RESULTS:
      • Combined Positive Score (CPS) assessment: CPS >= and <10
      • Combined Positive Score (CPS): X
  • 2023-04-01, -03-20 SONO - abdomen
    • moderate fatty liver (suboptimal exam of liver)
    • fatty infiltration of pancreas
    • suspected right renal cysts or focally dilated right renal pelvis
  • 2023-03-21 MRI - breast
    • Clinical history: 72 y/o female patient with left breast cancer.
    • With and without enhancement MRI of breast (axial T1, T1FS, sagittal T2, T2FS, axial and sagittal T1FS contrast, dynamic study):
      • Large irregular tumor, up to 6cm in right subareolar region with periareolar skin thickening, prominent heteregeneous enhancement, c/w breast malignancy.
      • There are multiple enlarged lymph nodes in bilateral axillary regions (mainly in right side, up to 2.2cm), r/o lymph nodes metastasis.
    • IMP:
      • Right breast malignancy with skin invasion and bilateral axillary lymph nodes metastasis.
    • BI-RADS:
      • Category 6 - proven malignancy.
  • 2023-03-20 ECG
    • Normal sinus rhythm
    • Increased R/S ratio in V1, consider early transition or posterior infarct
  • 2023-03-13 PET
    • Glucose-hypermetabolism in the right breast with nipple and skin of the anterior chest wall involvement, in the right axillary lymph nodes, and in a right SCF lymph node, highly suspected breast cancer with regional lymph nodes metastases.
    • Increased FDG uptake in a level II lymph node of the right neck and in a left axillary lymph node, highly suspected cancer with distant metastases.
    • Right breast cancer, cT4N3cM1, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-03-10 Patho - lymphnode biopsy
    • Labeled as “right axillary lymph node”, core needle biopsy — invasive carcinoma.
    • Section shows lymph node with invasive carcinoma.
  • 2023-03-10 Patho - breast biopsy
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (-, 0%), PR(-, 0%), Her2/neu: negative(score=1+), Ki-67(25 %), p63 (-).
  • 2023-03-10 SONO - breast
    • Right breast tumors with enlarged axillary lymph nodes, suggest biopsy.
    • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.
  • 2023-03-10 Mammography
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • Diffuse increased density in right breast with periarolar skin thickening, r/o malignancy.
      • No periareolar skin thickening.
      • Enlarged right axillary lymph nodes.
    • Impression:
      • Dense breast. R/O right breast malignancy with lymph nodes metastasis, suggest biopsy.
    • BI-RADS: Category 5 - highly suggestive of malignancy - appropriate action should be taken.

[chemotherapy]

  • 2023-06-21 - docetaxel 75mg/m2 120mg NS 250mL 1hr (D, Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-31 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 955mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
  • 2023-05-03 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + famotidine 20mg + NS 250mL
  • 2023-04-12 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-21 - liposome doxorubicin 35mg/m2 56mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 960mg NS 500mL 1hr (AC(lipo), Q3W)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

2023-06-27 G-CSF (filgrastim 150ug) SC ST 2023-06-21 Granocyte (lenograstim 250ug) SC QD 3D

==========

2023-06-28

  • The pathology results from the breast biopsy performed on 2023-03-10 confirmed that the patient has triple-negative breast cancer (TNBC) with HER2-low characteristic (ER negative, PR negative, and Her2/neu score=1+).

  • Following this diagnosis, the patient underwent four cycles of liposomal doxorubicin with cyclophosphamide (AC) on 2023-03-21, 2023-04-12, 2023-05-03, and 2023-05-31. Docetaxel was then administered on 2023-06-21.

  • Leukopenia episodes were observed on the 20th day after the 3rd AC administration and the 6th day after the 1st docetaxel administration, with WBC levels marked with an asterisk (*) representing WBC < 2K/uL and double asterisks (**) representing WBC < 1K/uL.

    • 2023-06-27 WBC 0.93 x10^3/uL **
    • 2023-06-27 WBC 0.79 x10^3/uL **
    • 2023-06-20 WBC 3.02 x10^3/uL
    • 2023-05-30 WBC 5.99 x10^3/uL
    • 2023-05-23 WBC 1.74 x10^3/uL *
    • 2023-05-02 WBC 4.50 x10^3/uL
    • 2023-04-12 WBC 4.29 x10^3/uL
    • 2023-03-08 WBC 7.64 x10^3/uL
  • To manage the episodes of leukopenia, filgrastim 150ug was given on 2023-06-27 and lenograstim 250ug was given consecutively for 3 days starting from 2023-06-21. Following these interventions, the patient’s WBC level has begun to show signs of improvement. Regular monitoring is essential to ensure this upward trend continues and to ensure the patient’s safety during further chemotherapy treatments.

  • The NHI in Taiwan approves the use of G-CSF for patients with non-hematologic malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL after chemotherapy. As the patient meets these criteria, the use of G-CSF is covered by NHI.

  • The patient received G-CSF with the chemotherapy regimen on 2023-06-21. For primary and secondary prophylaxis, G-CSF administration should typically begin 24 to 72 hours after completion of chemotherapy.

  • If the current chemotherapy regimen becomes less effective, Enhertu (fam-trastuzumab deruxtecan-nxki) may be used. This medicine is indicated for adult patients with unresectable or metastatic HER2 low (IHC 1+ or IHC 2+/ISH-) breast cancer who have received prior chemotherapy in the metastatic setting or who have experienced disease recurrence within six months of completing adjuvant chemotherapy. However, Enhertu is currently not covered by NHI in Taiwan.

700769074

230627

[exam findings]

  • 2023-06-05 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (135 - 54) / 135 = 60.00%
      • M-mode (Teichholz) = 60
    • Conclusion:
      • Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Mildly dilated LV with preserved LV and RV systolic function.
      • Mildly dilated aortic root.
  • 2023-05-24 Patho - soft tissue debridement
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, partial mastectomy — Invasive carcinoma of no special type, recurrent
      • Resection margin, breast, left, simple mastectomy — Free
      • Lymph node, left axilla sentinel, SLNB — Negative for malignancy (0/6)
      • AJCC 8 th edition, Pathology stage: rpT1c(m)N0(sn); Anatomic stage IA; Prognostic stage IA if cM0
      • Specimen labeled “capsule”, left breast, release constracture — Chronic inflammation, fibrosis and foreign body reaction
    • MACROSCOPIC EXAMINATION
      • Breast Size: 6.5 x 4.1 x 1.8 cm
      • Skin Size: 6.2 x 1.1 cm
      • Nipple: Not included
      • Tumor Size: Two tumors, 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x 1.0 x 0.8 cm (8’ tumor) , respectively
      • Resection Margin: Free, 0.4 cm from the deep margin
      • Lymph node: Axilla sentinel
      • Specimen labeled “capsule, left breast”: two pieces, measuring up to 3.5 x 2.8 x 0.4 cm.
      • Representative parts are taken for section and labeled: F2023-00239FS A1= 12’ 3’, 6’’ margins, FSA2= 9’ and deep margins, FSB1-FSB2= left axilla sentinel lymph nodes, A= skin, A2-A4= 9’ tumor, A5-A6= 8’ tumor, A7= non-tumor. S2023-10135= capsule, left breast
    • MICROSCOPIC EXAMINATION
      • Histology
        • Histologic type: Invasive carcinoma of no special type (both 9’ and 8’ tumors)
        • Size of invasive carcinoma: 1.5 x 1.0 x 0.8 cm (9’ tumor) and 1.0 x .0 x 0.8 cm (8’ tumor)
        • Histologic grade (Nottingham histologic score): Grade 2 (score= 7, both tumors)
        • Skin involvement: Absent
        • Ductal carcinoma in situ: Absent
      • Margins: Negative, Closest margin ( 4 mm from deep margin)
      • Nodal status: Negative (0/6)
        • number of lymph node examined: 6 (sentinel)
        • number with macrometastases (> 2mm): 0
        • number with micrometastases (> 0.2~2mm and/or > 200 cells): 0
        • number with isolated tumor cells (<= 0.2mm and <= 200 cells): 0
      • Treatment Effect: Not applicable
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Specimen labeled “capsule, left breast”: Chronic inflammation, fibrosis, and foreign body granuloma
    • IMMUNOHISTOCHEMICAL STUDY (S2023-08643)
      • 8’ tumor, left breast
        • ER: Positive (+, 100%, strong intensity),
        • PR: Positive (+, 100%, strong intensity)
        • HER-2/Neu: Negative (score=1+)
        • Ki-67: 10%
      • 9’ tumor, left breast
        • ER: Positive (+, 80%, strong intensity)
        • PR: Positive (+, 80 %, strong intensity)
        • Her2/neu: Positive (score=3+)
        • Ki-67: 10 %
  • 2023-05-22 MRI - breast
    • Clinical history: 45 y/o female patient with left breast cancer and right breast tumor.
    • With and without enhancement MRI of breast
      • S/P left breast mammoplasty.
      • There is spiculated tumor in 9’region of left breast, 2.4x2.2cm, around the implant, with prominent enhancement, malignancy considered.
      • Irregular tumor, 1.4cm in 8’region of left breast, malignancy considered.
      • Right subareolar oval shaped tumor, 1.3cm.
      • There are stipple enhancement in right breast, r/o fibrocystic disease.
      • No periareolar skin thickening.
      • There are bilateral axillary lymph nodes.
      • Prominent internal mammary lymph nodes, left side.
    • IMP:
      • S/P left breast mammoplasty, recurrent tumors (8’region and 9region).
      • Right subareolar tumor.
      • Bilateral axillary lymph nodes.
      • Prominent left internal mammary lymph nodes, metastasis?
    • BI-RADS:
      • Category 6 - proven malignancy.
  • 2023-05-15 Tc-99m MDP bone scan
    • Two hot spots in the sternal body, the nature is to be determined (bone mets, post-traumatic change or other nature ?), suggesting PET scan for investigation and follow-up with bone scan in 3 months.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, hips, knees, and feet.
  • 2023-05-05 Patho - breast biopsy (no need margin)
    • Breast, left, 8’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 100%, strong intensity), PR(+ , 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(10 %), E-cadherin (+).
    • Breast, left, 9’clock, core biopsy — Invasive carcinoma, no special type, NST. IHC stains: ER (+, 80%, strong intensity), PR(+, 80 %, strong intensity), Her2/neu: positive(score=3+), Ki-67(10 %), E-cadherin (+).
  • 2023-04-25 SONO - breast
    • Right breast subareolar tumor, suggest biopsy.
    • S/P left mammoplasty. Irregular hypoechoic lesion in left 9’region, post-op scar or recurrence. Suggest further study.
    • BI-RADS 4b

[consultation]

  • 2023-05-23 Hemato-Oncology
    • Q
      • This is a 45 years old woman patient. Due to left breast cancer and right breast tumor, she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. However, Hb:5.6 was noted. Anemia over 3 years without follow up by this patient told. We need your help for anemia assessment. Thank you so much!!
    • A
      • This 45 year old woman is a case of Lt breast ca s/p op at Cathay General Hospital in 2010-12, Lt breast ca recurrence proved by CNB on 2023-05-05 and Rt intraductal papilloma. she was admitted for surgery of left partial mastectomy + SLNB and right tumor excision on 2023/05/23. We are consulted for anemia.
      • 2023-05-23 did not encounter the patient during visitation.
      • For microcytic anemia, please check Hb electrophoresis, Ferritin, Fe/TIBC, stool OB (if positive, please arrange colonoscopy and panendoscopy to rule out GI bleeding).
      • Please add Foliromin 1 tab QD (or HS) and increase vitamin C intake. Arrange our OPD after discharge. Thanks for your consultation.

[immunochemotherapy]

  • 2023-06-27 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-06-06 - trastuzumab 600mg SC 5min + docetaxel 75mg/m2 132mg NS 250mL 1hr + carboplatin AUC 4 600mg NS 250mL 2hr (DCH)
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Regimen Reference Order - BRST - DCH — ref: https://www.cancercare.mb.ca/export/sites/default/For-Health-Professionals/.galleries/files/treatment-guidelines-rro-files/regimen-reference-orders/breast/BRST-DCH.pdf — Updated: June 14, 2023

  • Planned Course: DCH every 21 days for 6 cycles, followed by trastuzumab every 21 days for 12 cycles
  • Indication for Use: Breast Cancer Adjuvant; HER2 positive

==========

2023-06-27

  • The patient received two cycles of the DCH regimen on 2023-06-06 and 2023-06-27. However, lab data shows that there was already a noticeable decrease in HGB levels before the initiation of the regimen, with the lowest record on 2023-05-22 at 5.6g/dL. Subsequently, multiple blood transfusions were conducted on 2023-05-22, 2023-06-05, and 2023-06-27.

    • 2023-06-27 HGB 7.4 g/dL
    • 2023-06-12 HGB 9.2 g/dL
    • 2023-06-05 HGB 8.1 g/dL
    • 2023-05-24 HGB 6.8 g/dL
    • 2023-05-23 HGB 6.6 g/dL
    • 2023-05-22 HGB 5.6 g/dL
  • Trastuzumab has been associated with a low occurrence of anemia, affecting approximately 4% of patients, with less than 1% experiencing a severe (grade 3) form, according to UpToDate. However, both docetaxel and carboplatin, which are part of the patient’s treatment regimen, are known to significantly increase the risk of anemia. Docetaxel can cause anemia in 65% to 97% of patients, with 8% to 9% experiencing severe anemia (grades 3/4). Carboplatin can cause anemia in a wide range of 21% to 90% of patients. Therefore, these drugs could be contributing to the patient’s current anemia.

  • MCV is at the lower end of the normal limit, and both MCH and MCHC are below the lower limit of normal, suggesting possible iron deficiency. This is further supported by the ferritin level measured on 2023-05-24, which was significantly below the lower limit of normal. It may be necessary to further investigate and address this possible iron deficiency.

    • 2023-06-27 MCV 82.3 fL
    • 2023-06-27 MCH 21.8 pg
    • 2023-06-27 MCHC 26.5 g/dL
    • 2023-05-24 Ferritin 4.9 ng/mL

700402514

230626

[exam findings]

  • 2023-05-09 Pure Tone Audiometry
    • PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 19 dB HL.
    • RE normal to moderately severe SNHL.
    • LE normal to moderate SNHL.
  • 2023-05-06 MRI - brain
    • Venous angioma in right frontal lobe. No evidence of brain metastases.
  • 2023-05-05 Patho - colon biopsy
    • Colon, descending, 40 cm above anal verge, polypectomy — tubulovillous adenoma with low grade dysplasia
    • Colon, descending, 30 cm above anal verge, biopsy — tubular adenoma with low grade dysplasia
    • Colon, transverse, 50 cm above anal verge, polypectomy — Hyperplastic polyp
    • Colon, transverse, 60 cm above anal verge, biopsy — tubulovillous adenoma with low grade dysplasia
    • Colon, hepatic flexure, biopsy — Hyperplastic polyp
  • 2023-05-05 Miniprobe endoscopy ultrasound
    • Indication: for staging
    • Symptoms: for staging
    • Pre-EUS diagnosis: Eso adeno Ca
    • Endoscopic findings
      • With white light endoscopy, a easily touch-bleeding elevated lesion was noted at EC junction. With NBI-ME, focal JES-IPCL B3 pattern. Chromoendoscopy was performed with lugol-solution and showed no LVLs above EC junction. A few sessile polyps were scattered at remnant stomach.
    • EUS findings
      • With UM-DP20-25R, it showed 6.5x7.7mm hypoechoic lesion, invading to 4th layer of esophageal wall. At least two hypoechoic lesions up to 4.3mm were noted at paraesophageal space.
    • Diagnosis
      • Esophageal adenocarcinoma, EC junction, EUS staging at least cT2N1
      • Gastric polyps, remnant stomach.
  • 2023-05-04 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower T-spines and some L-spines. Degenerative change is more likely.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, left wrist, bilateral hips, knees, ankles and feet, compatible with benign joint lesions.
  • 2023-05-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (107 - 47) / 107 = 56.07%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR and trivial TR
      • Preserved RV systolic function
  • 2023-05-03 PET
    • Increased FDG uptake in the lower third of esophagus, near E-G junction, compatible with the primary esophageal cancer.
    • Increased FDG uptake in a focal soft tissue in the right supraclavicular fossa, the nature is to be determined (esophageal cancer with regional lymph nodes metastases, the other primary cancer, or other nature ?), suggesting biopsy for investigation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • Highly suspected lower esophageal cancer with regional lymph nodes metastases, cTxN1-2M0, stage IIIA-B (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-04-20 CT - chest
    • IMP: Esophageal tumor at EG junction. 1.6cm.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-04-10 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Adenocarcinoma in situ, at least
    • Microscopically, it shows adenocarcinoma in situ composed of high-grade atypical neoplastic glands admixed with necrotic tissues and stromal fibrosis.
  • 2023-04-10 Esophagogastroduodenoscopy, EGD
    • Gastric A2 ulcer, anastomosis site, s/p biopsy (A)
    • Esophageal erosion, EC junction, s/p biopsy (B)
    • Remnant gastritits
    • Post subtotal gastrectomy with Billroth II anastomosis
  • 2023-05-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 24) / 79 = 69.62%
      • M-mode (Teichholz) = 69.9
    • Conclusion:
      • Normal chamber size
      • Septal hypertrophy
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Mild MR
      • No regional wall motion abnormalities
  • 2021-03-31 Patho - appendix (non-incidental)
    • Appendix, L.A. — Early appendicitis and myxoid degeneration of appendix wall
  • 2021-03-30 CT - abdomen
    • Mild dilatation of appendix, r/o acute appendicitis, suggest clinical correlation.
    • S/P gastrectomy.
    • Left renal cysts.
  • 2020-05-25 ENT Hearing Test
    • Tymp: Bil type A.
    • ART:
      • R’t ipsi 4k Hz reduced, and contra 2-4k Hz elevated and absent.
      • L’t ipsi 4k Hz and contra 4k Hz absent.
    • PTA
      • Reliability: fair
      • Average: R’t 33 dB HL, L’t 25 dB HL.
      • Bil normal to moderately severe SNHL. (4k Hz notch)

[consultation]

  • 2023-05-09 Radiation Oncology
    • A
      • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Biopsy at EC junction revealed adenocarcinoma in situ, at least. The PET revealed the right supraclavicular lymph node metastasis. PET and EUS clinical staging revealed at least cT2N1-2M0,stage IIIA-B.
      • Neoadjuvant CCRT is indicated. CT-simulation will be arranged on 2023/05/15. Plan to deliver 45 Gy/ 25 fx to the lower half esophagus, the adjacent lymphatic drainage area, and Rt SCF. Then boost the esophageal tumor, LAPs, and Rt SCF LAP to 50.4 Gy/ 28 fx. RT will start around 2023/05/17 or 18. Thank you very much.
  • 2023-05-08 Hemato-Oncology
    • Q
      • For lower third esophageal maglignancy further evlauation and mangement.
      • This 46 years old male has history of subtotal gastrectomy, alcohol(+), smoke(+). He was admitted to our GI ward due to tarry stool. Panendoscope was done and tissue biopsy at anastomosis revealed ulcer,no H.pylori present. However, biopsy at EC junction revealed adenocarcinoma in situ, at least. Thus, he was admitted to our chest surgery ward for furteher cancer survey and pre-operative evaluation. However, the PET reported his right supraclavicular lymph node metastasis, PET and EUS clinical staging revealed at least cT2N1M0,stage IIIA-B.
      • Thus, we need your expertise for the patient’s further evaluation and further managment, thanks a lot!
    • A
      • This 46 year old man is a case of EG junction cancer, cT2N1M0,stage III, biopsy show adenocarcinoma in situ with initial presentation epogastric pain. He had history of HTN, GU, obesity s/p subtotal gastrectomy. He was admiited for cancer work up. We are consulted for pre-op CCRT.
      • Please arrange port A insertion. Please arrang auditory test and 24 urine CCR and check Anti HBc, Anti HBs, HBsAg, Anti HCV. We will arrange chemotherapy concurrent with RT. Please consult Radio-oncologist. Thanks for your consultation

[chemotherapy]

  • 2023-06-23 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-22 - cisplatin 75mg/m2 150mg NS 500mL 24hr D1 (Y-sited 5-FU) + MgSO4 10% 20mL NS 100mL 1hr D2 (after CDDP) + furosemide 20mg NS 30mL 10min D2 (after CDDP) + fluorouracil 1000mg/m2 2000mg NS 500mL 24hr D1-4 (PF, CCRT, Q4W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-26

  • According to the PharmaCloud database, our hospital is the sole provider of all medical services and medications required by the patient in recent months. Therefore, no medication reconciliation issues have been identified.

700856655

230621

[exam findings]

  • 2023-06-05 SONO - abdomen
    • Hepatic hemangiomas, right lobe
    • Renal stone, RK
  • 2023-06-02 Tc-99m MDP bone scan
    • No definite evidence of bone metastasis.
    • Increased activity in the lower L-spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral hips and right foot, compatible with benign joint lesions.
  • 2023-06-01 MRI - nasopharynx
    • Oralcavity
      • Impression (Imaging stage) : T:4a N:0 M:0 STAGE:
  • 2023-05-17 Patho - gingival/oral mucosa biopsy
    • Oral cavity, left tongue, incisional biopsy — Squamous cell carcinoma, moderately differentiated
    • Section shows squamous mucosal tissue with infiltration of nests of neoplastic squamous cells.

[immunochemotherapy]

  • 2023-06-19 - cetuximab 400mg/m2 600mg 2hr + docetaxel 40mg/m2 60mg NS 150mL 2hr + cisplatin 40mg/m2 60mg NS 500mL 3hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr (longer infusion taxel and platin)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-06-09 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 1000mg/m2 1600mg NS 1000mL 22hr + leucovorin 100mg/m2 160mg in 5-FU 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-06-21

  • The patient’s medical history, as recorded in the HIS5 database, shows previous episodes of leukopenia and thrombocytopenia in 2018-01. No chemotherapy was administered at that time.

  • More recently, in mid to late May 2023, the patient was diagnosed with SCC of the left tongue margin. The patient then received TPF chemotherapy on 2023-06-09 and a combination of TPF and cetuximab on 2023-06-19. Leukopenia, defined here as a WBC count of less than 3K/uL, was observed on 2023-06-16. To treat this, 3 doses of Granocyte (lenograstim 250ug) were administered on 2023-06-16, 2023-06-17, and 2023-06-21.

    • 2023-06-19 WBC 5.80 x10^3/uL
    • 2023-06-16 WBC 2.26 x10^3/uL *
    • 2023-06-01 WBC 3.57 x10^3/uL
  • Given that the WBC count prior to the 2nd dose of TPF was higher than that prior to the 1st dose, and given that G-CSF was administered 2023-06-21 morning, the likelihood of severe leukopenia following the 2nd round of chemotherapy is expected to be reduced. However, the patient’s blood counts should continue to be monitored closely.

[reconciliation]

  • The patient regularly visits a local psychiatric clinic to manage her episodic paroxysmal anxiety. The prescribed medications for this condition are clonazepam, fludiazepam, estazolam, and escitalopram. These medications have all been integrated into the patient’s current medication list, and no reconciliation issues have been identified. Please ensure the patient is adhering to her psychiatric medication regimen, as disruptions could potentially exacerbate her anxiety symptoms.

701243929

230620

{esophageal SCC moderately differentiated T3N2M1 with lung mets}

[exam findings]

  • 2023-05-17, -04-17, -04-14, -02-23, -01-31 CXR
    • Multiple metastases on both lungs.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2023-04-14 Patho - lung wedge biopsy
    • Lung, left, CT-guide biopsy — squamous cell carcinoma, moderately differentiated, consistent with metastatic
    • Sections show dysplastic keratinized squamous cell carcinoma infiltrating in a fibrotic stroma. The morphology is consistent with metastatic squamous cell carcinoma. Please correlate with the clinical presentation.
  • 2023-03-21 CT - chest
    • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
    • Comparison was made with previous CT dated on 2022/12/08
      • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
      • multiple randomly distributed nodules/masses of varing sizes in both lungs, increase in size and number of these lesions as compared with previous CT on2022/12/8. interlobular septal thickening in Rt lung and LUL.
      • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, enlarged LNs in visceral space and Rt hilum.
      • mild pericardial effusion.
    • Impression
      • bilateral lung metastases and mediastinal and hilar metastatic LAP, in progression as compared with previous CT study on 2022/12/08
  • 2022-12-08 CT - chest
    • Indication: Esophageal cancer of squamous cell carcinoma, moderately differentiated T3N2M1 with lung mets progression, stage IV
    • Chest CT with and without IV contrast ehnancement shows:
      • Soft tissue mass at both lungs up to 6.7cm at left lower lobe and right upper lobe up to 4.67cm is found. Lung mets is considered. In comparison with CT dated on 2022-08-17, the lesios enlarged.
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p esophagectomy and gastric tube reconstruction.
    • Imp: Lung meta at both lungs. In progression.
  • 2022-12-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83 - 32) / 83 = 61.45%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR, trivial TR and trivial PR
    • Minimal pericardiac effusion
    • Preserved RV systolic function
    • left pleural effusion
  • 2022-12-07 CXR
    • S/P port-A implantation.
    • Multiple metastases on both lungs.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - Lung/Mediastinum/Pleura
    • Findings
      • Lungs:
        • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
        • multiple nodules in both lungs, some with intrinsic cavitations slightly inecrease in size of these nodules as compared with previous CT on 2022/5.17
      • Mediastinum and hila: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
    • Impression
      • bilateral lung metastases, sligthly in progression as compared with previous CT study on 20220517
  • 2022-05-17 CT - Lung/Mediastinum/Pleura
    • Findings
      • Lungs:
        • post op change with staple lines in LLL. left upper lobe medial fibrotic change, related to treatment.
        • multiple nodules in both lungs, some with intrinsic cavitations slightly decrease in size as compared with previous CT on 20220208
      • Mediastinum: s/p esophagectomy and gastric conduit in middle mediastinum, no enlarged LN or mass..
      • Hila: no enlarged LN.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: minimal effusion.
      • Chest wall and visible lower neck: no LAP.
      • Visible abdominal-pelvic contents:
        • distended U-bladder filled with urine.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. no enlarged lymph node. no ascite.
    • Impression:
      • bilateral lung metastases, sligthly in regression as compared with previous CT study on 2022-02-08
  • 2022-02-08 CT - Lung/Mediastinum/Pleura
    • Impression: bilateral lung metastases, sligthly in regression as compared with previous CT study on 2021-12-08.
  • 2021-12-08 CT - Lung/Mediastinum/Pleura
    • Impression: bilateral lung metastases, in progression as compared with previous CT study on 2021-08-20.
  • 2021-02-08 Patho - Lung wedge biopsy
    • Diagnosis: Lung, left, upper lobe, wedge resection - Squamous cell carcinoma, moderately differentiated, consistent with metastatic esophageal tumor
    • The HER2/NEU In-Situ Hybridization Test is NEGATIVE. There is NO amplification of HER2 detected.
    • IHC: Her-2/neu (Ab) equivocal(2+).
  • 2020-09-25 Patho - Esophageal biopsy
    • Esophagus, middle, 32cm to 34cm below incisor - squamous cell carcinoma, moderately differentiated
    • IHC: CK(+), p63(+)
  • 2020-07-09 Patho - Esophageal biopsy
    • Esophagus, middle, 25cm below incisor - squamous cell carcinoma, moderately differentiated
    • IHC: p63(+), CD56(focal +)

[consultation]

  • 2020-07-08 Radiation Oncology
    • A
      • History:
        • This 48 year-old male patient denied the systemic disease or specific medical history before. He has suffered from dysphagia and food stuck in the chest for 1-2 months. He can tolerate regular food now. Upper G- I panendoscopy showed esophageal ulcerative lesion, favor malignancy. Biopsy pathology showed squamous cell carcinoma. Esophageal cancer, middle to lower third, was diagnosed at the Yeezen General Hospital in TaoYuan. EUS on 2020078 and Chest CT on 20200709 were arranged for further survey.
        • Previous RT: denied.
        • Other disease: denied.
        • Family history: denied.
        • Habit: Alcohol, 1 bottle/day for 20 yr; smoking: 1/2 PPD for 20 yr; betel nuts: 20#/day for 20 yr.
        • Married, 3 sons (grade 5, kindergarten middle class, baby class). Caregiver: his wife. Job: worker and driver. Mild economic stress at least. Lives in XinWu Dist. TaoYuan City.
        • Language: Mandarin, Taiwanese.
        • Religion: Buddhism
      • Objective:
        • General Condition-ECOG: 1.
        • PE, 20200709: No palpable neck LNs.
        • Pathology, 202007: esophagus, squamous cell carcinoma.
        • Images:
          • Chest CT, 20200710: pending.
          • EUS, 20200710: pending.
          • CXR, liver echo, 20200706: negative.
      • Diagnosis: Esophageal cancer, middle to lower third, squamous cell carcinoma, fresh case, ECOG = 1.
      • Plan: Staging workup as your order. CCRT (5040cGy/28 fx) will be indicated if upfront surgery is not favored by the surgeon. Please contact us later to arrange CT simulation later. Diet education, psychological and spiritual support is given.

[surgical operation]

  • 2021-02-05
    • Surgery
      • VATS, LUL wedge + LLL wedge resection
    • Finding
      • mutiple lung nodule suspected esophageal cancer metastasis s/p LUL wedge (a solid nodule about 6mm x1); LLL wedge (two soft nodules about 7mm and 4mm)
      • a 14 Fr. pigtail inserted in 7 ICS
      • blood loss: minimal
  • 2020-10-05
    • Surgery
      • VATS esophagectomy + gastric tube reconstruction.
    • Finding
      • Esophageal tumor was noted over middle third esophagus, adhesion to left main bronchus, s/p CCRT.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS.
      • 18 Fr. Foely catheter as jejunostomy tube.
  • 2020-07-10
    • Surgery
      • Port-A + feeding jejunostomy
    • Finding
      • 18 Fr. Foley as jejunostomy tube
      • 8 Fr. polysite, left cephalic vein, cut-down method.

[radiotherapy]

  • 2020-08 ~ 2020-08 CCRT 5040cGy/28fx

[chemotherapy]

  • 2023-06-19 - oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + irinotecan 150mg/m2 245mg NS 500mL 90min + leucovorin 400mg/m2 655mg NS 250mL 2hr + fluorouracil 2800mg 4590mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-05-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 675mg NS 250mL 2hr + fluorouracil 2800mg 4745mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-18 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + irinotecan 150mg/m2 250mg NS 500mL 90min + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg 4765mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-20 - gemcitabine 1000mg/m2 1735mg NS 250mL 30min + leucovorin 200mg/m2 345mg NS 250mL 2hr + fluorouracil 2000mg/m2 3475mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-24 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-01 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-27 - gemcitabine 1000mg/m2 1775mg NS 250mL 30min + leucovorin 200mg/m2 355mg NS 250mL 2hr + fluorouracil 2000mg/m2 3550mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-05 - gemcitabine 1000mg/m2 1770mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3540mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-14 - gemcitabine 1000mg/m2 1800mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3600mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-24 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-29 - gemcitabine 900mg/m2 1600mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 2000mg/m2 3570mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-07 - gemcitabine 900mg/m2 1400mg NS 250mL 30min + leucovorin 200mg/m2 350mg NS 250mL 2hr + fluorouracil 1800mg/m2 3000mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-17 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-07-26 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + carboplatin AUC 5 300mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-27 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-06-06 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-05-16 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-04-19 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-03-30 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-03-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-02-09 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-01-24 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-01-03 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2021-12-08 - paclitaxel 120mg/m2 210mg NS 250mL 3hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + fluorouracil 1000mg/m2 3400mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2021-11-22 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-11-08 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-10-15 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-09-16 - irinotecan 150mg/m2 200mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg
  • 2021-09-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-08-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/2 4700mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-08-03 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-07-20 - oxaliplatin 85mg/m2 147mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4840mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-06-30 - oxaliplatin 85mg/m2 146mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-06-10 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-05-27 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4850mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-05-11 - oxaliplatin 60mg/m2 100mg 2hr + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/2 4860mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 69mg 2hr + fluorouracil 2000mg/m2 3450mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-04-27 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-03-25 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3380mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-03-11 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3340mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2021-02-23 - docetaxel 40mg/m2 60mg 1hr + cisplatin 40mg/m2 60mg 2hr + fluorouracil 2000mg/m2 3390mg 46hr
    • doxamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2020-08-24 - cisplatin 50mg/m2 84mg 2hr + fluorouracil 1000mg/m2 1700mg 22hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2020-07-27 - cisplatin 50mg/m2 87mg 2hr + fluorouracil 1000mg/m2 1750mg 22hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-06-20

The patient has been prescribed Bafen (baclofen 5mg) 1# PRNQ12H for hiccups. Metoclopramide is also included in the active medication list. Both baclofen and metoclopramide are regarded as first-line therapy for hiccups. However, it’s advisable to note that there have been numerous cases reported in the literature indicating neurotoxicity due to oral baclofen accumulation in adult patients with varying levels of renal impairment. Additionally, abrupt discontinuation of oral baclofen has been linked to altered mental status. While the current dosage seems unlikely to cause these adverse reactions, it’s worth mentioning as a precaution.

2022-12-27

  • The elevated serum uric acid level (8.1 mg/dL on 2022-11-22) has returned to normal levels (5.6 mg/dL on 2022-12-27).
  • First-line chemotherapy for advanced esophageal squamous-cell carcinoma results in poor outcomes. The monoclonal antibody nivolumab has shown an overall survival benefit over chemotherapy in previously treated patients with advanced esophageal squamous-cell carcinoma (for PD-L1 expression of 1% or greater). ref: Doki Y, Ajani JA, Kato K, et al. Nivolumab Combination Therapy in Advanced Esophageal Squamous-Cell Carcinoma. N Engl J Med. 2022;386(5):449-462. doi:10.1056/NEJMoa2111380

2022-12-06

  • CT scan on 2022-08-17 revealed bilateral lung metastases that were slightly in progress compared to previous CT scans on 20220517, after which the current regimen was initiated in September 2022. A CT update in this hospital stay has been arranged.

2022-06-07

2022-05-17

  • CT image might be updated. The progression was seen to have slowed in last CT dated on 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
  • As of 2022-05-16, lab data showed that liver functions, serum electrolytes were generally normal. However, there were elevated blood creatinine 1.41 mg/dL, elevated Neutrophil 85% and decreased blood magnesium 1.3 mg/dL. Estimated creatinine clearance based on Cockcroft-Gault is 60 L/min. Kintzel 1995 recommended administration 75% of cisplatin dose for CrCl 46 to 60 mL/minute patients.
  • On 2022-05-16, high stool frequency was observed (5 times). There has been a decline in blood magnesium levels over the last 12 months, which may be a result of diarrhea depleting magnesium levels. Magnesium sulfate has been prescribed. Some loperamide might also be helpful.

2022-04-20

  • The progression was seen to have slowed in the most recent CT dated 2022-02-08, which implies that the present [5-FU + Cisplatin + Paclitaxel] regimen, which begins in December 2021, has had an effect.
  • As of 2022-04-19, lab data showed that liver and kidney functions, serum electrolytes, and blood cell counts were grossly normal.
  • No PD-L1, NTRK, MSI/MMR, TMB results found. HER2 overexpression is not evident, trastuzumab might not be applicable.
  • There has been a slight decline in blood magnesium levels (<1.9mg/dL) that might be asymptomatic for at least 12 months. Magnesium depletion is more prevalent as a result of diarrhea than vomiting in general. The causal relationship could be further clarified if clinically needed.

2022-02-23

  • the on going progression slightly slowed down according to CT findings on 2022-02-08, it seems that the current 5-FU + Cisplatin + Paclitaxel regimen since Dec 2021 showed certain effect.
  • ANC ~ 1.23 x 0.85 (based on 2022-02-23 lab data) is just above 1 with fluctuation which should be monitored.

2022-01-25

  • in progresstion, several subsequent therapies have been tried.
  • HER2 overexpression is not evident, trastuzumab might not be applicable.
  • PD-L1, NTRK, MSI/MMR, TMB test might be ordered optionally.
  • no drug allergy recorded in database, no issue with current medication.

700096683

230619

[lab data]

2023-06-16 Anti-HBc Reactive
2023-06-16 Anti-HBc-Value 8.30 S/CO
2023-06-16 Anti-HBs 0.91 mIU/mL
2023-06-16 Anti-HCV Nonreactive
2023-06-16 Anti-HCV Value 0.10 S/CO
2023-06-16 HBsAg Nonreactive
2023-06-16 HBsAg (Value) 0.27 S/CO
2021-06-10 HBsAg (NM) Negative
2021-06-10 HBsAg Value (NM) 0.359
2021-06-10 Anti-HCV (NM) Negative
2021-06-10 Anti-HCV Value (NM) 0.00292

[exam findings]

  • 2023-05-24 Patho - liver biopsy needle/wedge
    • Liver, needle biopsy — Metastatic colonic adenocarcinoma
    • The sections show a picture of metastastic colonic adenocarcinoma, composed of liver tissue with nests of columnar neoplastic cells arragned in cribriform pattern with dirty necrosis.
    • IHC, the neoplastic cells shows: CK7(-), CK20(+) and CDX2(+).
  • 2023-05-22 SONO - abdomen
    • Diagnosis:
      • Hepatic hypoechoic lesion, S6/7, nature?
      • Fatty liver, moderate
    • Suggestion:
      • Lesion could be masked due to fatty liver background.
      • Correlated with triphase CT and tumor markers
  • 2023-04-17 CT - abdomen
    • Indication: Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 2021/06/10, pT2N0M0(0/12), stage I
    • Abdominal CT with and without enhancement revealed:
      • s/p single incision laparoscopic right hemicolectomy
      • Low density lesion at S6 of liver up to 0.93cm is found. In comparison with CT dated on 2022-05-16, the lesion is new. Metastatic tumor cannot be excluded.
      • The GB is well distended without soft tissue lesion
      • Enlarged prostate up to 5.3cm is found.
    • Imp:
      • Cecal cancer s/p operation.
      • New low density lesion at S6 of liver. 0.93cm, r/o meta.
      • Enlarged prostate.
  • 2023-04-17 Colonoscopy
    • No definite mucosal lesion was seen.
  • 2022-05-16 CT - abdomen
    • Cecal cancer s/p operation. No evidence of tumor recurrence.
  • 2022-05-16 Colonoscopy
    • C/W colon cancer s/p right hemicolectomy
    • Internal hemorrhoid
  • 2021-06-10 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Tumor, cecum, SILS R’t hemicoloectomy — Adenocarcinoma
      • Resection margins, bilateral, ditto — Free from tumor invasion
      • Lymph nodes, mesocolic, dissection — Free from metastasis (0/12)
      • Appendix, ditto — Free from tumor, periappendiceal congestion
      • AJCC pathologic stage — pT2N0, if cM0, stage I
    • MACROSCOPIC EXAMINATION
      • Operation procedure: SILS right hemicolectomy
      • Specimen site: ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 10.5 cm in length, 3.2 cm in diameter, (b) Terminal ileum: 1.7 cm in length, 3.7 cm in diameter and (c) Appendix: 6.3 cm in length, 0.5 cm in diameter
      • Tumor size: 3.2 x 2.8 cm
      • Tumor location: 2.2 and 7.2 cm away from bilateral resection margins
      • Tumor appearance: elevated mass
      • Depth of invasion grossly: muscular propria
      • Representative sections as follows: A1: bilateral margins, A2: appendix, A3-A7: tumor, A8-A12: lymph nodes
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: G2: moderately differentiated
      • Depth of invasion: muscular propria
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: not present
      • Circumferential (radial) margin of rectosigmoid: not involved
      • Lymph node metastasis, mesocolic: free from metastasis (0/12)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: N/A
      • Pathological TNM Stage: pT2N0, stage I
      • Type of polyp in which invasive carcinoma arose: N/A
      • Additional pathologic findings: N/A
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
    • IMMUNOHISTOCHEMISTRY
      • SMA highlights muscle tissue
  • 2021-05-25 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 24.1) / 96.3 = 74.97%
      • LVEF (%) = 80
      • M-mode (Teichholz) = 75.0
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Mild PR, mild TR, normal IVC size
  • 2021-05-06 CT - abdomen
    • History and indication: A flat and depressed 2cm tumor at cecum, R/O cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Focal wall thickening of cecum.
      • Grade 5 fatty liver.
      • Right renal cyst (6mm).
      • Enlargement of prostate.
      • Atherosclerosis of aorta, iliac arteries.
      • Several cysts (5-6mm) at RUL.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-05-03 Patho - colon biopsy
    • Large intestine, cecum, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2021-05-03 Colonoscopy
    • Suspect early colon cancer, cecum, s/p biopsy
    • Mixed hemorrhoid

[MedRec]

  • 2023-06-01 SOAP Hemato-Oncology
    • P: Arrange Neoadjuvant chemtoehrapy with FOLFOX +/- targeted therapy
  • 2021-06-09 ~ 2021-06-14 POMR Colorectal Surgery
    • Discharge diagnosis
      • Adenocarcinoma of cecum status post single incision laparoscopic right hemicolectomy on 110/06/10, pT2N0M0(0/12),G2, LVI(+), PNI(+), CRM(-), stage I
      • Malignant neoplasm of cecum
      • Type II diabetes mellitus
    • CC
      • for preoperative preparation and surgical treatment for cecal cancer.
    • Present illness
      • This 62 years old male patient has the history of 1) colon polyp s/p polypectomy at Wanfang Hospital in MK 102; 2) mixed hemorrhoids s/p hemorrhoidectomy on 2015-09-22; 3) DM under OHA control for 5-6 years.
      • He received health examination and FOBT revealed postive. He denied abdominal discomfort, bowel habit change, bloody stool passage and body weight loss. He visited CRS for help and colonoscopy revealed suspect early colon cancer, cecum, s/p biopsy. Pathology proved adenocarcinoma. Abdominal CT revealed cecal ctumor, cT2N0M0, stage: I. This time, he admitted to our ward for preoperative preparation and surgical treatment.
    • Course of inpatient treatment
      • After admission with ward routine and pre-op study were done. After well explain the risk of surgery including heart, lung complications and risk of leakage. Operation of SILS right hemicolectomy under general anesthesia were performed on 2021-06-10. NPO and adequate IV fluid supplement. His wound pain is acceptable by Dynastat. Early activity is encouraged. Chewing cookies, toast, rice with gum was started at op day. The wound healing well and no erythema change. He had flatus passage and abdominal wound pain subsided. So he started to take oral diet well and no abdominal discomfort after meal. He had passed stool with normal bowel movement. Oral intake with soft diet is tolerated well. Drain is clear ascites and removal of JP drain at post-op day 4. His abdominal wound pain had got much better. In stable condition, he was discharged on 2021/06/14 and will receive OPD follow up next week.

[surgical operation]

  • 2021-06-10
    • Surgery
      • SILS Right-hemicolectomy        
    • Finding
      • Cecal tumor, cT2N0M0 stage I
      • Anastomosis by GIA 75/4.8mm x2
      • TISSEL 4ml at anastomosis site and wound clot
      • One 15# JP drain at Morison’s pouch

==========

2023-06-19

  • There’s no available data from PharmaCloud, possibly due to the patient not providing consent for access.

  • Based on the records from our hospital, the patient has visited the departments of Colorectal Surgery, General and Digestive Surgery, and Hematology-Oncology in the past three months. No prescriptions were issued by the first two departments, hence, no medication reconciliation issues were found.

  • Several data points have indicated that the patient’s fasting plasma glucose levels are exceeding 200mg/dL, even while being under medication with Januvia (sitagliptin 100mg) 0.5# BID and Uformin (metformin 500mg) 1# BID. There are no HbA1c readings available in the HIS5 data. It is recommended to obtain an HbA1c reading to get an understanding of the average blood glucose levels over the past two to three months.

  • Additionally, the patient has also been prescribed Zulitor (pitavastatin 4mg) 0.5# QD, an HMG-CoA reductase inhibitor used to lower lipid levels and reduce the risk of cardiovascular disease. However, there are no diagnoses, medical problems, or lab data related to dyslipidemia. The status of the patient’s dyslipidemia might need to be checked and clarified.

700421458

230619

==========

2023-06-19

  • Vitacal (CaCl2) 120mL IVD ST is just prescribed. It is recommended in HIS5 not to exceed 100mL in each administration. The most recent lab data on 2023-05-15 showed normal calcium and chloride readings. It is prudent to check the use of CaCl 120mL.
  • This patient is a stem cell donor. If calcium supplementation is required, particularly during hematopoietic stem cell (HSC) harvesting where citrate-based regional anticoagulation is used, it might be advisable to utilize a sliding scale for the continuous infusion of calcium chloride. This would help maintain systemic ionized calcium levels between approximately 3.6 to 5.2 mg/dL (~0.9 to 1.3 mmol/L). Regular monitoring of systemic ionized calcium levels, ideally every 6 hours or more frequently when necessary, is also recommended under these circumstances.

In continuation of the previous pharmacist note.

  • I just had a phone conversation with the patient’s nurse practitioner. She indicated that for the HSC harvesting procedure, 120mL of CaCl2 is commonly used, and calcium levels are regularly monitored both before and after the procedure. Therefore, it doesn’t seem to present any issues at present.

701097074

230619

[MedRec]

  • 2022-02-18 ~ 2022-05-10 POMR Hemato-Oncology
    • Discharge diagnosis
      • Multiple myeloma, IgG kappa, ISS stage IIIA
      • Type 1 diabetes mellitus with unspecified complications
      • Nausea with vomiting, unspecified
      • Diabetes mellitus without mention of complication, Type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled
    • CC
      • Nausea with vomit for 2 days, right shoulder and back pain over month    
    • Present illness
      • This 53-year-old female has history of
        • Type 1 diabetes mellitus since age of 19
        • Hypertension
        • Secondary hypoparathyroidism
        • Sacrum and right ilium fracture after fell down in 2021/06
        • Osteoporosis with BMD: T score -4.2.
        • Right Scapula fracture
      • This time, she suffered from persistent back pain for over one month and nausea with vomit for 2 days. According to the patient’s statement, she had been to our Ortho. OPD for help on 2021/12/15, when KUB + L-spine Lat was revealed compression fractures at L5, L4, L2, L1 and T12 vertebral bodies, mild decreased disc spaces in the upper L-spine discs.
      • Due to above symptoms, she came to our ER for help. At ER, tachycardia with BP 153/73 were noted. Physical examination showed tenderness at bilateral flank and T-L spinal process. Laboratory data revealed hypercalcemia of Calcium: 3.17 mmol/L. T-L spine X-ray revealed compression fracture of L1 and L2. Under the impression of 1) Hypercalcemia, 2) Right Scapula and back pain, she was admitted for pain control and further management on 2022/02/18.    
    • Course of inpatient treatment
      • This 53 y/o female has history of type 1 diabetes mellitus since age of 19, anemia, hypertension, secondary hypoparathyroidism, sacrum and right ilium fracture after fell down in 2021/06, osteoporosis with BMD: T score -4.2, and retinal hemorrhage OU s/p OP. She suffered from persistent back pain for about one month. Under the impression of T7, T8 compression fracture and old compression frature of T12, L1/2/4/5, the patient was admitted.
      • After admitted, she received pain killer and IV fluid supplement for compression fracture pain control. During hospitalization, she had nausea with vomit and hyperglycemia with diabetic ketoacidosis were noted on 2022/02/21. The laboratory data revealed hyponatremia, favor hyperglycemia related. The endocrinologist was consulted, RI pump (2/21~22), 0.298 KCL were perscribed and titrate insulin dose. The Oncologist was consulted for hypercalcemia with low PTH, suspect multiple myeloma. Blood test and urine Protein EP/IFE/Free Light Chain κ/λ were performed by Oncologist advice and they arrange bone marrow examination on 3/2. She will transfer to oncologist ward for further management.
      • Due to bone marrow report showed MM IgG kappa, stage IIIB. Major illness and family conference were done this week. RT was consulted and positioning on 3/8. Feburic F.C 80mg 1# qd for hyperuricemia and rechecked level decerased well. This week, the bone marrow for FISH test was done and we gave Thalidomide 2# qn and dexamethasome 40mg qw. Painful condition got improvement. Sugar poor control and we comfirm Meta for adjust Apidra and Tresiba. RT (2022-03-10 ~ 2022-03-23): 2000cGy/10 fractions (6MV photon) of the upper T spine and peripheral area. Chemotherapy as VTd (C1 Velcade since 2022/3/29, weekly) and XGEVA on 2022/3/30. Hypocalcemia and Hypomagnesemia were correct during hospitalization. Nutritional assessment for DM diet with energy and protein requirement during hospitalization. RT again for bilateral hip pain (2022-4-12 ~): at 600cGy/3 fractions (6MV photon) of the right hip to upper femur.
      • Under the stable condition, VTD (C1 on 2022/3/29, C2 on 4/6, C3 on 4/13, C4 on 4/20, C5 on 4/27, C6 on 5/4, C7 on 5/9). Pain control with Neurontin 100mg/cap (Gabapentin) 1# bid, Celebrex 200mg/cap (Celecoxib) 1# q12h,Muaction 100 mg/SR tab (Tramadol) 1# hs.
      • With the relatively stable condition,she was discharged on 2022/05/10 and will OPD follow up later
      • VTD regimen
        • Days 1,8,15,22: Bortezomib 1.3mg/m2 subcutaneous
        • Days 1-21: Thalidomide 50-200mg (usual dose range) orally once daily at bedtime
        • Days 1-2, 8-9, 15-16, 22-23: Dexamethasone 40mg orally once daily
        • Repeat cycle every 3 weeks
    • Discharge prescription
      • Limeson (dexamethasone 4mg) 5# QN 5/9-5/10
      • Thado (thalidomide 50mg) 2# QN 5/9-30, take 3 weeks, skip 1 week
      • Muaction (tramadol 100 mg) 1# HS
      • Concor (bisoprolol 1.25mg) 1# QD      
      • Tresiba FlexTouch 16 Unit QD SC (If F/S HS < 140, eat something before go to bed, Tresiba should not be stopped)
      • Apidra 8 Unit TIDAC SC (As correction scales)
      • Celebrex (celecoxib 200mg) 1# Q12H
      • Neurontin (gabapentin 100mg) 1# BID
      • Stogamet (cimetidine 300mg) 1# TID
      • Through (sennoside 12mg) 2# HS
      • Pentop (pentoxifylline 400mg) 1# BID

[chemotherapy]

  • 2023-04-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-04-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-03-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-10 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-02-03 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-01-27 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-01-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2023-12-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-12-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-11-11 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-11-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-28 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-21 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-14 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-10-07 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-30 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-23 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-16 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-09-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-12 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-08-05 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-15 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-08 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-01 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-07-24 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-17 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-06-02 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-26 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-09 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-05-04 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-25 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-19 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-13 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-04-06 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC
  • 2022-03-29 - Velcade (bortezomib) 1.3mg/m2 1.75mg SC

==========

2023-06-19

  • The patient had an appointment at TaiAn Hospital on 2023-05-16, where she was prescribed oral Pentop (pentoxifylline) and several eye drops for a 28-day course, which has now concluded. If the patient continues to experience eye symptoms, it might be advisable to consult our ophthalmologist for reevaluation.

700394537

230616

[exam findings]

  • 2023-06-07 MRI - brain
    • no evidence of brain metastasis.
  • 2023-06-06 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spines, sternum, bilateral multiple ribs, left scapula, pelvic bones, right humerus, and left femur.
    • IMPRESSION: As compared with the previous study on 2023-02-15, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
  • 2023-06-05 CXR
    • Osteoblastic metastasis in spine
  • 2023-06-05 CT - chest
    • Indication: Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis
      • Malignant neoplasm of upper lobe, right bronchus or lung
    • Comparison was made with previous CT dated on 2023/02/13
      • Lungs: the small spiculated nodule at posterior RUL is still visible. interval regression of miliary and small nodules in both lungs, and resolution of septal thickening and peribronchovascular bundle thickening as compared with CT on 2023/2/13
      • Mediastinum and hila: no more enlarged LNs.
      • Vessels: the great vessels in the hila and mediastinum are normal in caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: minimal residual bilateral effusions
      • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
      • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
      • Visualized bones:
        • multiple marginal spurs of vertebrae.
        • blastic metastatic change spine and sternum.
    • Impression: RUL cancer T4M1c, in regression as compared with CT on 2023/02/13
  • 2023-03-22 Shoulder Lt
    • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
    • A small focal hyperdense osteoblastic metastasis at medial humeral neck?
  • 2023-03-22 MRI - C-spine
    • spinal canal stenosis at the imddle and lower C-spine
    • herniated discs in the C4/5 and C5/6 discs.
    • multiple bone metastasis in the visible T-spine and L-spine.
  • 2023-02-23 MRI - brain
    • no evidence of brain metastasis.
  • 2023-02-21 EGFR
    • Two mutations were detected at exon 19 (Del) and exon 20 (T790M) of EGFR gene in this specimen.
  • 2023-02-16 Patho - lung transbronchial biopsy
    • Lung, side ?, CT-guide biopsy —adenocarcinoma, moderately differentiated
    • Sections show acinar, papillary, and micropapillary tumor cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(focal +), and CD56(-). The results are supportive for the diagnosis.
  • 2023-02-15 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, left scapula, bilateral multiple pelvic bones, right humerus, and right acetabulum.
    • IMPRESSION: Some of above-mentioned bone lesions including sternum, several T-spine, and left rib cage come to more evident, while other lesions such as left scapula, left iliac bone and right acetabulum become less prominent compared with the previous study on 2022-11-30, indicating dissociated response to current therapy.
  • 2023-02-13 CT - chest
    • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1
    • Comparison was made with previous CT dated on 2022/11/21
      • Lungs: the smallm spiculated nodule at posterior RUL is readily identified. miliary and small nodules throughout both lungs, and septal thickening and peribronchovascular bundle thickening visible, due to lung to lung metastases. dependent atelectasis over both lower lobes.
      • Mediastinum and hila: residual small and enlarged LNs in visceral and left anterior perivascular spaces.
      • Vessels: the great vessels in the hila and mediastinum are normal in caliber. minimal left pericardial effusion.
      • Heart: normal in size of cardiac chambers.
      • Pleura: small bilateral effusions, increase in volume.
      • Chest wall and visible lower neck: no enlarged LNs at supraclavicular fossae
      • Visible abdominal contents: distended gallbladder. unremarkable of the spleen, liver, adrenal glands, pancreas, and both kidneys. no enlarged lymph node
      • Visualized bones: multiple marginal spurs of vertebrae. blastic metastatic change spine and sternum, .
      • CECT of brain shows no brain metastasis
    • Impression: RUL cancer T4M1cN2, in progression as compared with CT on 2022/12/21
  • 2022-11-30 Tc-99m MDP bone scan
    • All of above-mentioned bone lesions are old and most of them show less evident compared with the previous study on 2022-7-14, indicating partial response to current therapy.
  • 2022-11-21 CT - chest
    • Impression: RUL cancer T4M1c, stationary as compared with CT on 2022/8/8
  • 2022-10-27 Cardiopulmonary Exercise Testing
    • Conclusion
      • maximal exercise
      • low exercise capacity (VO2 39%, WR 51%)
      • normal stroke volume response during exercise
      • normal ventilatory function (FEV1/FVC 78 , FVC 81%, FEV1 77%)
      • low expiratory muscle strength (MIP 100%, MEP 50%)
      • Health-related quality of life, CAT= 4
    • Suggestions:
      • treat underlying condition
      • suggest exercise training
  • 2022-08-08 CT - chest
    • Impression: RUL cancer T4N3M1c, with new bony metastasis as compared with CT on 2022/03/01 and resolution of patchy consolidations in both lungs compared with CT on 2022-04-28
  • 2022-07-14 Tc-99m MDP bone scan
    • The scintigraphic findings suggest multiple bone metastases. In comparison with the previous study on 2022/03/07, some new bone lesions are noted and some previous bone lesions are more evident. However, some previous bone lesions in the lower L-spines, sacrum and bilateral S-I joints are a little less evident.
  • 2022-04-28 CT - chest
    • Pneumonic patch at both lungs with bilateral pleural effusion.
  • 2022-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (96.3 - 25.8) / 96.3 = 73.21%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Mild dilated aortic root
      • Septal hypertrophy
      • Adequate LV and RV systolic function
      • Mild MR, AR, TR and PR
      • No regional wall motion abnormalities
  • 2022-03-18 Spirometry
    • mild obstructive combine restrictive lung defect with significant reversibility
    • FEV1/FVC=81%, FVC= 70% FEV1= 69%
    • small airway disease FEF25-75% = 44%
  • 2022-03-09 Patho - pleural/pericardial biopsy
    • Lymph node, right neck, dissection — adenocarcinoma, moderately differentiated, metastatic, consistent with lung origin (8/10)
    • Sections show 10 lymph nodes with metastatic acinar and papillary glandular tumor cells in 8 lymph nodes. Extranodal extension is seen. The morphology is consistent with metastatic adenocarcinoma from lung.
  • 2022-03-09 CXR
    • Diffuse miliary lesions in both hypoinflated lungs due to lung to lung metastases
    • superior mediastinal widening due to lymph node enlargement,
    • Blunting of left costophrenic angle, pleural effusion?
  • 2022-03-07 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • S2022-3466
      • Tumor type: adenocarcinoma
      • Tumor location: supraclavicular fossa lymph node
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-07 Tc-99m MDP bone scan
    • Highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
  • 2023-03-07 MRI - brain
    • No evidence of brain metastasis.
  • 2023-03-04 PET
    • Glucose hypermetabolism in a focal area in the upper lobe of right lung. Primary lung malignancy may show this picture. Please correlate with other clinical findings.
    • Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
  • 2022-03-03 Patho - lymphnode biopsy
    • Soft tissue, supraclavicular fossa lymph node, sono-guiding biopsy — Metastatic adenocarcinoma, consistent with lung origin
    • Sections show solid nests and acinar glandular tumor cells infiltrating in a fibrotic stroma. No lymphoid tissue is seen. The morphology is consistent with S2022-3326. The immunohistochemical stains are done in S2022-3326.
  • 2022-03-02 Patho - bone marrow biopsy
    • Bone marrow, iliac crest, biopsy — Metastatic adenocarcinoma, consistent with lung origin
    • Sections show 20-30 % cellularity. The M/E ratio is about 3/1 - 4/1. Megakaryocytes are found about 2-8/HPF. No increase of blasts is noted. There are no granulomas. Nests of papillary and acinar tumor cells are seen.
    • The immunohistochemical stains reveal CK(+) and TTF-1(+). The results are consistent with metastatic adenocarcinoma from lung. Please correlate with the clinical presentation and image study.
  • 2022-03-01 CT - chest
    • Imaging Report Form for Lung Carcinoma
  • 2022-02-21 MRI - L-spine
    • History
      • PH: no DM; no HTN
      • OP hx: nil
      • 20220215: LBP, esp ant banding; buttock/ thigh radiaiton for 2 months; walk level < 30 mins; ineffective to L-traction/ hot packing/ pain killer for 1 month; relief by lying down
    • Thoraco-lumbar spine (including sagittal T2WI of cervical spine) MRI without IV Gd-DTPA administration shows:
      • Multiple bone destructing lesions in TL spine, esp. at L1-2-3 levels, including posterior parts of L2-3.
      • Multiple bone destructions at bil. pelvic bones.
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
      • Normal cord size and signal intensity.
    • IMP: Multiple bone metastases, or multiple myelomas?
      • C-spine: Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression.
  • 2022-02-21 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.

[consultation] (not completed)

  • 2023-06-05 Dermatology
    • Q
      • for herpus around anus and abdominal
      • This 49-year-old man who with past history of gastric ulcer. 1) Gastric ulcer. 2) Right upper lung cancer, adenocarcinoma, T4N3M1c, stage IVB with  lung to lung, liver, bone metastasis, ECOG 1, NGS LAPs: EGFR - amplification, exon 19 deletion (E746_A750del).
        • The lung cancer treatment regimen as below:
          • First TKI with Giotrif 30mg on 2022-03-18 to 2023-03-08, changed to Tagrisso on 2023-03-08.
          • Angiogenesis inhibitor C1 Ramucirumab since 2022-03-22.
          • Radiotherapy 3000cGy/10 fx to T12-sacrum, SI, Rt iliac crest 2022/03/08 to 2022/03/02
          • Radiotherapy 3000cGy/10 fractions (6 MV photon) to left upper femur, 2022/06/08 to 2022/06/21.
          • Radiotherapy 3500cGy/10 fractions (6 MV photon) to Lt sternum, scapula and Lt humerus, 2022/12/15 to 2022/12/28; 2450cGy/7 fractions (6 MV photon) to Rt iliac and ischial bone; 1050cGy/3 fractions (6 MV photon) to Rt iliac bone, 2022/12/29 to 2023/01/06.
        • Tracing back the past history, his complained low back pain since 2021-11, especially anterior banding, buttock, and thigh radiaiton, he can only walk less than 30 minutes, relief by lying down.
          • He first went to the clinic to receive anti-inflammatory and pain-relieving injections and oral medication, which were ineffective; then he was transferred to the orthopaedic clinic, where suggested rehabilitation.
          • He received rehabilitation treatment with traction and hot packing for about a month, but it was also ineffective, then he was referred to our neurosurgery clinic in 2022-02. Neurosurgery Clinic on 2022/02/15, the neurological assessment revealed consciousness E4V5M6, JOMAC and cranial nerves examinatin were intact, pupil right 3.0(+), left 3.0(+), muscle power upper limbs 5+, lower limbs 5-, deep tendon reflex upper limbs 2-3+, right lower limb 2+, left lower limb +, negative result of Hoffmann sign and Spurling sign, there were left shoulder pain and suspect numbness, and bilateral thigh hypesthesdia, limited of gait, normal coordination and finger-nose-finger test, continence of sphincter.
          • The impression was cervical and lumbar spine spondylosis. Pain-killers with Celebrex and Sketa were prescribed to him back home, a magnetic resonance imaging of lumbar spine was arranged and it revealed multiple bone destructing lesions in TL spine, especially at L1-2-3 levels, including posterior parts of L2-3, multiple bone destructions at bil. pelvic bones, bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression, and bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression. Suspect metastasis?
          • He was was referred to the Department of Hematology and Oncology for follow-up survey. He is hospitalized on 2022/02/28. After admission, check tumor marker CEA=20.78ng/ml, kept pain-killer for symptoms relief, arranged Chest CT on 2022/03/01, which revealed a 13 mm spiculated solid nodule at posterior RUL consistent with a primary lung cancer, with innumerable small nodules and miliary nodules randomly distributed throughout both lungs due to lung to lung metastases. Mediastinum and hila: extensive metastatic lymphadenopathy in the visceral aand anterior prevascular spaces. Impression: RUL cancer T4N3M1c.
          • Arranged bone marrow and biopsy was done and smoothly on 2022/03/02 and show Metastatic adenocarcinoma, consistent with lung origin. Due to primary lung cancer, sona guide biopsy was done that reveal metastatic adenocarcinoma, consistent with lung origin. Sent EGFR, PD-LI and ALK, that report EGFR mutation Exon 19 detect. Painless of endoscopy was complete that show Reflux esophagitis LA grade A. Superficial gastritis. Gastric erosions, mid body, LC and GC, s/p biopsy. Pursue pathology report. Check sputum and TB culture data in negative finding. Brain MRI reveal no evidence of brain metastasis. Bone scan was complete that show highly suspected cancer with multiple bone metastases in multiple C-, T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, S-I joints, right humerus, and left femur.
          • Consult oncology of radiotherapy that suggest radiotherapy to L1-2 and pelvic bone metastasis for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on March 07 08:30 and treatment will be started after pathological proof is available. Xgeva 120mg was administrated. PET disclose 1.Glucose hypermetabolism in a focal area in the upper lobe of right lung. 2.Glucose hypermetabolism in the right lower neck lymph nodes, bilateral supraclavicular lymph nodes, right axillary lymph nodes, bilateral pulmonary lymph nodes and bilateral mediastinal lymph nodes, compatible with metastatic lymph nodes. 3.Glucose hypermetabolism in some small focal areas in bilateral lung fields, in some small focal area in the liver and in multipe bones as mentioned above, suggesting lung to lung metastases and multiple liver and bone metastases.
          • Vemidy was prescribed for Hepatitis B and abd echo was done that reveal Fatty liver, mild hepatic tumor, S5, r/o metastatic lesion. Neck lymphnode dissection and a minivac in placed on 2022-03-09 post consult CS. TKI with Giotrif 30mg was presribed on 2022-03-18. Arrange agiogenesis inhibitor C1 Cyramza 500mg on 2022-03-22 was done smoothly. This time he was admitted to our ward on 20230530 for C15-3 Ramu 500, C2 Durva (1+1) CEA, BT with PLT 2ph.
      • We sincerely need your professional assistance!!!
    • A
      • This patient suffered from multiple grouped vesicles on L’t trunk for days and graulation on R’t thumb for days.
      • Imp:
        • Herpes Zoster
        • Pyogenic granuloma
      • Suggestion:
        • Lyrica x1 /bid
        • Serenel x1 /hs
        • ZnO x1 tube/bid
        • Arrange He-Na laser
        • Liq N2
  • 2023-02-17 Radiation Oncology
    • A
      • Diagnosis: Lung cancer, RUL, adenocarcinoma, with military lung to lung & multiple bone metastasis, cT4N3M1c; EGFR mutation: L858R(-), exon 19(+), under Afatinib since 2022/03/12, Ramicurimab since 2022/3/22 & multiple RT course to bone, last on 2023/01/13 with disease progression; ECOG:1.
      • Plan: RT to T3-11 spines and possible left scapula for 3000cGy/10 fractions is suggested for pain control. Possible treatment toxicity is told. CT simulation was arranged on Feb 20 14:30 and treatment will be started on Feb 22 or 23. Diet education & psychological support is done.
  • 2022-06-07 Dermatology
    • Q
      • A 48-year-old man with a past medical history of 1) asthma, 2) gastric ulcer, 3) Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis, ECOG 1, under TKI with Giotirf, chemotherapy and radiotherapy treatment.
      • Due to left hand erythematous rash, so we sincerely need your help for evaluation. Thanks a lot!!!
    • A
      • This patient suffered from erytheamtous papules-with scaling for wks
      • Imp: Subacute dermatitis
      • Sugestion:
        • please check ANA, TSH, IgE
        • Xyzal x 1 /Hs
        • Topsym cream x 5 tubes/bid
  • 2022-05-05 Psychosomatic Medicine
    • Q
      • this consultation is for depression management.
      • This 48-year-old man had past history of gout. He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. Since then he became depressed and need hypnotic agent. He was admitted to our ICU for desaturation noted at chest ward. He had extubation on 2022/05/02 and he had no SOB under n/c use. We planned to transfer him back to chest ward on 2022/05/05. However, he claimed that he became more depressed and had insomnia. No suicidal ideation or decreased appetite were noted. Due to above reason, we sincerely need your expertise for depression management. Thanks!
    • A
      • Impression: Major depressive disorder
      • Clincial course and symptoms:
        • This is a 48-year-old man had past history of gout. No psychiatric history.
        • He was diagnosed with lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis on March, 2022. We were consulted for his depression and insomnia recently.
        • Upon visit, he said he had depressed mood, insomina, negative thought, decreased appetite, lack of reward sensation, since 2022/03, and he kept crying during the interview, intermittent suicide ideation was noted.
        • The patient has been diagnosed with cancer after this March, and recently he has often crying and feeling down, with insomnia. He has lost 5kg in 2 months. He feels guilty and apologetic to his family. In the past few days, he has had suicidal thoughts, but currently, he is not planning to commit suicide due to his daughter.
        • And he had no depresive episode or psychiatric history before.
      • Suggestion:
        • Use mirtazapine 15mg HS firstly for his depression, if no oversedation tomorrow, please tirtrated to 30mg HS
        • please arrange our OPD follow up after he dsicahrge.
  • 2022-05-03 Dermatology
    • Q
      • Dear doctor, this consultation is for skin lesion management.
      • This 48-year-old man had past history of
        • Lung cancer, adenocarcinoma, T4N3M1c, stage IVB with lung to lung, liver, bone metastasis.
        • asthma
        • gastric ulcer
      • He was admitted to ICU due to OHCA and acute respiratory failure s/p ETT s/p extubation 2022/05/02.
      • A skin lesion over his left knee was noted. We ever prescribed biomycin but in vain. He denied painful sensation. There was no swelling or discharge from the wound. Due to above reason, we sincerely need your expertise for skin lesion management. Thanks!
    • A
      • This patient suffered from ulceration w’d on L’t thigh for months.
      • Imp: Chronic wound
      • Suggestion:
        • ZnO x1 tube/bid
        • Fucidin cream x2 tubes/bid

[immunochemotherapy] (not completed with small molecular targeted therapeutics)

  • 2023-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-05-02 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr + durvalumab 240mg NS 100mL 1.5hr D2
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-04-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-02-14 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2023-01-16 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-12-19 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-11-21 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-10-24 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-09-26 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-08-09 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-07-10 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-06-06 - ramucirumab 10mg/kg 500mg NS 250mL 1.5hr
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-04-18 - ramucirumab 10mg/kg 500mg NS 250mL 90min
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL
  • 2022-03-22 - ramucirumab 10mg/kg 500mg NS 250mL 90min
    • dexamethasone 8mg + diphenhydramine 30mg + NS 50mL

==========

2023-06-16

  • This year, there have only been 2 episodes of leukopenia with a WBC count less than 3K/uL, occurring on 2023-01-14 and 2023-04-06. The injectable Cyramza (ramucirumab) has been used since 2022-03-22. Oral TKI treatment was divided at 2023-03-15: before this date, the patient was taking Giotrif (afatinib), and after this date, the patient was taking Tagrisso (osimertinib). The relationship between the usage of these drugs and the WBC level is shown in the table below, with asterisks indicating the dates when the WBC count was less than 3K/uL.

    • 2023-06-05 WBC 3.33 x10^3/uL 2023-05-02 ramucirumab osimertinib
    • 2023-04-27 WBC 4.95 x10^3/uL osimertinib
    • 2023-04-06 WBC 2.88 x10^3/uL * 2023-04-06 ramucirumab osimertinib
    • 2023-04-03 WBC 3.35 x10^3/uL osimertinib
    • 2023-03-30 WBC 3.72 x10^3/uL 2023-02-14 ramucirumab osimertinib
    • 2023-02-11 WBC 6.33 x10^3/uL 2023-01-16 ramucirumab afatinib
    • 2023-01-14 WBC 2.88 x10^3/uL * afatinib
    • 2022-12-19 WBC 4.24 x10^3/uL 2022-12-19 ramucirumab afatinib
    • 2022-11-21 WBC 5.87 x10^3/uL 2022-11-21 ramucirumab afatinib
    • 2022-10-24 WBC 6.04 x10^3/uL 2022-10-24 ramucirumab afatinib
    • 2022-09-26 WBC 6.75 x10^3/uL afatinib
  • The administration time of ramucirumab does not appear to directly correlate with the episodes of leukopenia. However, all three drugs mentioned above have been reported to be associated with leukopenia. For ramucirumab, neutropenia has been reported in 5% to 24% of patients, with grade >=3: 8%. Afatinib has been associated with lymphocytopenia in 38% of patients, with grades 3/4: 9%, and decreased white blood cell count in 12% of patients, with grades 3/4: 1%. Osimertinib has been reported to cause leukopenia in 54% of patients, neutropenia in 26% to 41% of patients, with grades 3/4: <= 3%. (ref: UpToDate)

  • In conclusion, it is difficult to determine whether leukopenia is caused by a specific drug or a combined effect of all drugs.

  • As per the reimbursement guidelines of Taiwan’s NHI, the administration of G-CSF is approved for patients with non-hematological malignancies who demonstrate a WBC count of less than 1000/uL or an ANC of less than 500/uL following chemotherapy. In this particular patient’s case, the specific criteria are not fulfilled, which means that the use of G-CSF is not covered by the NHI, if G-CSF is desirable.

700532802

230616

[diagnosis]

  • 2023-04-23 discharge note
    • Metachronous adenocarcinoma transverse colon cancer with lung metastasis, cT4aN1bM1a stage IVA, status post right hemicolectomy on 2022/12/21, pT3N2aM0, stage IIIB, s/p chemothearpy with FOLFOX from 2023/02/21
    • Chronic viral hepatitis B without delta-agent
    • Tuberculosis of lung
    • Insomnia, unspecified
    • Idiopathic gout, unspecified site
  • 2023-02-20 admission note
    • Malignant neoplasm of transverse colon
    • Chronic persistent hepatitis, not elsewhere classified
    • Tuberculosis of lung
    • Functional dyspepsia
  • 2023-01-03 discharge note
    • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2aif cM0, stage IIIB.
    • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
    • Chronic persistent hepatitis

[past history]

  • The patient had no systemic diseases, including endocrine, CNS, CV, and infection
  • Tuberculosis of lung under treatment from 2023/01/13 (AKuriT-4 (RIF 150mg/INH 75mg/PZA 400mg/EMB 275mg)/tab)
  • History of operation: Ascending colon s/p right hemi 15 years ago.
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid): OK。
  • Regular medications or herb: no  

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings] (not completed)

  • 2023-03-10 CXR
    • Atherosclerotic change of aortic arch
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
  • 2023-03-01 SONO - abdomen
    • Liver cirrhosis
    • GB polyp
    • Splenomegaly, mild
  • 2023-02-09 CXR
    • Tortous aorta with calcification is noted.
    • Faint aveolar opacity over left central lung is found.
    • Emphysematous change over both lungs.
  • 2023-01-02 Cepheid Xpert MTB/ RIF Test
    • Result: Positive
  • 2022-12-23 CXR
    • Ground glass opacity in LLL.
  • 2022-12-22 Patho - lung wedge biopsy
    • Diagnosis
      • A: Lung, LUL, wedge resection —- fibrotic nodules with surrounding granulomatous inflammation
      • B: Lung, LLL, wedge resection —- necrotizing granulomatous inflammation
      • C: Lymph node, left, group 7, dissection —- negative for malignancy (0/3)
      • D: Lymph node, left, group 9, dissection —- negative for malignancy (0/1)
      • E: Lymph node, left, group 10, dissection —- negative for malignancy (0/3)
      • F2022-00622 Lung, LLL, biopsy —- necrotizing granulomatous inflammation
  • 2022-12-22 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, transverse colon, anastomosis of small intestine and colon, colectomy —- Adenocarcinoma, moderately differentiated
        • Omentum, omentectomy —- Negative for malignancy
        • Peritoneum ?, excision —- Negative for malignancy
      • Resection margins: free
      • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (4/17)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: pStage IIIB, pT3N2a(if cM0) or pStage IVA, pT3N2a(if cM1a)
    • Gross Description:
      • Operation procedure: colectomy, s/p right hemicolectomy
      • Specimen site: transverse (anastomosis of small intestine and colon)
      • Specimen size: small intestine and colon: 15.5 cm in length; omentum: 21 x 8 x 1.5 cm; peritoneum ?: 1.7 x 0.7 cm
      • Tumor size: 6.5 x 4 cm, annularly ulcerated
      • Tumor location: 6.5 cm and 2.5 cm away from the two resection margins
      • Depth of invasion grossly: mesocolic soft tissue
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4: omentum; A5-8: tumor (A5 and A8 with peritoneum ?); A9-12: lymph node, mesocolic.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved, Distance of tumor from margin: 1 mm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: not applicable
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 4/17
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM): if cM0 or cM1
      • Additional Pathologic Findings (select all that apply): None identified
  • 2022-12-14 CT - abdomen
    • History: A-Colon cancer, s/p right hemicolectomy. now 1 yr F/U, Hb 8.2,
      • 20221130 colonoscopy:One huge ulcerative mucosa lesion, probable at transverse colon to hepatic flexure, s/p biopsy
    • Findings:
      • S/P right hemicolectomy.
        • There is asymmetrical wall thickening at the proximal transverse colon with irregular fuzzy contour that is c/w newly-developed adencarcinoma (T4a).
        • In addition, three enlarged nodes in the adjacent mesocolon are noted that are c/w metastatic nodes (N1b).
      • There are three soft tissue nodules in LLL of the lung that are c/w lung metastases (M1a).
      • There are several calcification in LUL of the lung that are c/w old granulomas.
      • Several hepatic cysts in both lobes are noted and the largest one 0.8 cm in size at S2/3.
      • There is minimal ascites in the cul-de-sac.
  • 2022-12-01 Patho - colon biopsy
    • Colorectum, probable at transverse colon to hepatic flexure, biopsy — Adenocarcinoma.
    • IHC stains: CK20 (+), CD56 (-), EGFR (+); PMS2 (-), MSH6 (+), MSH2(+), MLH1 (-).
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
  • 2022-11-30 Colonoscopy
    • Highly suspect colon cancer, probable transverse colon to hepatic flexure, s/p biopsy
  • 2022-10-19 SONO - abdomen
    • Diagnosis
      • Liver cirrhosis
      • GB polyp
      • Splenomegaly, mild
      • R/O colon leison
    • Suggestion
      • suggest colonoscopy

[MedRec]

  • 2023-03-07 SOAP Hemato-Oncology
    • A/P
      • Check TB PCR first -> If negative, then C/T with FOLFOX. -> Because the lung nodules are TB, the stage would be pT3N2aM0, Stage IIIB -> Adjuvant FOLFOX would be given.
      • Port-A insertion on 2023-02-14
      • Admission on 2023-02-20.
  • 2023-02-02 SOAP Gastroenterology and Hepatology
    • Prescription: Baraclude (entecavir 0.5mg) 1# QDAC 28 days
  • 2023-01-13 SOAP Infectious Disease
    • Diagnosis: A15.0 Tuberculosis of lung, confirmed by sputum microscopy with or without culture or confirmed molecularly.
    • A/P; check blood tests, begin anti-TB regimen
    • Prescription
      • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 274mg) 4# QDAC 14 days
      • Vit B6 (pyridoxine 50mg) 1# QD 14 days
  • 2023-01-10 SOAP Hemato-Oncology
    • A/P:
      • Check TB PCR first -> If negative, then C/T with FOLFOX
      • Refer to GS for Port-A insertion
      • RTC 3 weeks
  • 2023-01-09 SOAP Infectious Disease
    • A/P: collect sputum for TB
  • 2023-01-09 SOAP Colorectal Surgery
    • S
      • Colon cancer, A colon. s/p. OP, 200712
      • Loss follow up for years and then a newly found tumor at T-colon
      • 20221221 Right hemicolectomy, Colon cancer, metachronous pT3N2aM0
      • Lung nodule: necrotizing granulomatous inflammation
    • A/P
      • Suggest post-op chemotherapy
      • Refer to Infection due to R/O TB
  • 2022-12-20 ~ 2023-01-03 POMR Colorectal Surgery
    • Discharge Diagnosis
      • Metachronous transverse colon cancer with lung nodule suspect metastasis status post right hemicolectomy on 2022/12/21, pT3N2a if cM0, stage IIIB.
      • Left lung nodule status post video-assisted thoracoscopic surgery left lower lobe and left upper lobe wedge lymph node dissection on 2022/12/21.
      • Chronic persistent hepatitis
    • CC: Accidentally finding of local recurrence of ascending colon carcinoma during OPD follow up.
  • 2022-12-15 SOAP Thoracic Surgery
    • S: for consultation about lung nodules.
    • O:
      • 20221214 Abd CT showed LUL and LLL nodules,
      • suggest VATS for tissue proof and culture.
      • 20221221 VATS LLL wedge followed by CRS
  • 2022-12-15 SOAP Colorectal Surgery
    • O
      • 20221214 Abd CT done
    • A/P
      • Enhanced Recovery After Surgery, ERAS
  • 2022-12-08 SOAP Gastroenterology and Hepatology
    • S
      • colon cancer, recurrence
      • Hb 8.2
      • refer for CRS
  • 2022-11-30 SOAP Gastroenterology and Hepatology
    • S
      • colonoscopy R/O colon cancer
      • dizziness R/O anemia
  • 2022-11-03 SOAP Gastroenterology and Hepatology
    • S
      • Colon cancer, A colon. s/p. now 1 yr F/U
      • CH-B. LC. HBeAg (-).
      • start ETV on 20110421
      • Now ETV tx for 12 yrs 7 m. HBV DNA (-) (1 yr, 3 yr, 4 yr, 7, 8 yrs). normal AFP.
    • O
      • US 20221019:
        • Liver cirrhosis, GB polyp, Splenomegaly, mild
        • R/O colon leison
    • Diagnosis
      • Malignant rectosigmoid junction neoplasm [C19]
      • Chronic persistent hepatitis [K73.0]
  • 2017-03-01 SOAP Gastroenterology and Hepatology
    • S
      • Colon cancer, A colon.
      • CH-B. LC. HBeAg (-). anti-HBe (+). Splenomegaly mild. check HBV DNA 1.21E+4 IU/mL (20110413)
      • start ETV on 20110421 (ETV = Endoscopic Third Ventriculostomy)
      • Now ETV tx for 6 yrs 4 m. HBV DNA (-) (1yr, 3 yr, 4 yr). normal AFP.
    • Diagnosis
      • Malignant rectosigmoid junction neoplasm [C19]
      • Chronic persistent hepatitis [K73.0]
      • Dyspepsia & other specified disorders of function of stomach [K30]
      • Acute upper respiratory infection, unspecified [J06.9]

[surgical operation]

  • 2022-12-21
    • Surgery
      • Right hemicolectomy        
    • Finding
      • Metachronous T-colon cancer
  • 2022-12-21
    • Surgery
      • 3D VATS LLL and LUL wedge + LND.
    • Finding
      • Multiple solid lung nodules over LUL and LLL, size about 0.7 to 1.0cm.
      • Frozen section: benign
      • One 24 Fr. straight chest tube was inserted via left 8th ICS.

[chemotherapy]

  • 2023-06-15 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL D1-3 + aprepitant 125mg PO D1-3 + lorazepam 1mg IVD D1-3
  • 2023-05-26 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2000mg 3000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-31 - oxaliplatin 75mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa, skip 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-10 - oxaliplatin 65mg/m2 90mg D5W 250mL 2hr + leucovorin 300mg/m2 430mg NS 250mL 2hr + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX, lower Oxa and LV, skip 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-21 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg 3400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-06-16

  • On 2023-06-15, the patient commenced the 6th cycle of FOLFOX chemotherapy. In this cycle, the dosage of oxaliplatin was reduced to 65mg/m2, leucovorin to 300mg/m2, and infusional 5-FU to 2000mg/m2. This dosage reduction was a continuation from the 5th cycle (2023-05-26). It’s also worth noting that the bolus 5-FU was excluded from the regimen from the 2nd cycle (2023-03-10) onwards.
    • 2023-06-15 WBC 2.58 x10^3/uL *
    • 2023-06-07 WBC 4.31 x10^3/uL
    • 2023-05-26 WBC 3.76 x10^3/uL
    • 2023-05-04 WBC 3.23 x10^3/uL
    • 2023-04-12 WBC 3.56 x10^3/uL
    • 2023-03-28 WBC 3.39 x10^3/uL
    • 2023-03-10 WBC 2.38 x10^3/uL *
    • 2023-02-20 WBC 3.89 x10^3/uL
    • 2023-02-09 WBC 4.43 x10^3/uL
    • 2023-01-13 WBC 5.21 x10^3/uL
  • The patient’s WBC level does not yet meet the criteria for G-CSF reimbursement under Taiwan’s NHI rules. However, considering that the WBC level was already below the LLN just before the administration of this regimen cycle, it might be beneficial to administer G-CSF on a self-pay basis. The G-CSF administration is recommended to be started at least 24 to 72 hours after the end of this regimen cycle.

[optional addition of antiemetics]

  • Even though premedication with palonosetron and aprepitant was administered prior to the dose-reduced FOLFOX regimen, the patient is still experiencing grade 2 vomiting (3-5 instances within 24 hours) today. If the administration of Imperan (metoclopramide) PRNQ6H is found to be ineffective, it might be worth considering the addition of olanzapine or prochlorperazine. However, this would require careful monitoring for signs of extrapyramidal reactions or neuroleptic malignant syndrome. (Dexamethasone is already in use.)

2023-04-25

  • Vital signs are relatively stable during this hospitalization, and the most recent lab data on 2023-04-12 showed grossly normal readings.
  • On 2023-03-10, the patient’s WBC level was at 2.38K/uL, which led to a reduction of oxaliplatin from 85mg/m2 to 65mg/m2 and the skipping of the 5-FU bolus in the FOLFOX regimen. Oxaliplatin has since been titrated back to the standard dose, and no instances of WBC levels below 3K/uL have been observed up to this point.
  • Underlying conditions including HBV and TB are properly managed with Baraclude (entecavir), Epbutol (ethambutol) and Rina (rifampicin, isoniazid).

700209819

230615

  • 2023-06-13 Patho - esophageal biopsy
    • Esophagus, lower, 33 cm to 37 cm belwo incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections of a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Rare keratin formation is noted.
  • 2023-06-10 CT - brain
    • CC: General weakness for daysDizziness and headache. Cough, throat pain, abdominal pain, nausea.
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • Extensive encephalomalacic change in left frontal and temporal lobes.
      • Diffusely prominent cerebral fissures, cisterns & sulci.
      • Moderate dilated lateral & 3rd ventricles most severe on Lt.
      • Atrophy of the left cerebral peduncle and anterolateral of pons.
      • No evidence of acute intracranial hemorrhage.
      • Hypodensity in the periventricular white matter of bilateral frontal and parietal lobes.
      • No mid-line structure deviation.
      • s/p large Lt and Rt craniotomies.
    • IMP:
      • No evidence of intracranial hemorrhage.
      • Moderate brain atrophy. Extensive encephalomalacic change in left frontal and temporal lobes. Wallerian degeneration of brain stem,
  • 2023-06-10 CXR
    • focal increased opacity over Lt lower lung zone with obscuring costophrenic angle
    • old fracture of Rt distal clavicle
  • 2023-06-10 KUB
    • large amount of fecal material filled nondilated colon
    • fracture of left pubic rami old
  • 2019-04-12 EEG
    • Normal, no focal cortical dysfunction or epileptic form discharges were recorded.
  • 2017-10-06 CT - brain
    • Clinical history: 39 y/o
      • 2017-09-18_TBI s/p op (Left F-T-P craniotomy) in Dec 2016 at Hua-Lien TCH. Alcoholism. Facial abrasions. Two episodes of convulsions and upward gaze. Unsteady gait. Poor memory.
      • 2010_right traumatic SDH s∕p craniotomy, double vision.
    • Without enhancement CT of brain:
      • Encephalomalacic change in left temporal lobe.
      • Soft tissue swelling over right periorbital region.

==========

2023-06-15

  • Upon reviewing the PharmaCloud database, no issues with medication reconciliation were found.

  • According to the records from the neurosurgery OPD, this patient has a long history of alcohol use. The patient also has a history of epilepsy, which is currently managed with Depakine (valproate). This medication is not typically recommended for use in patients with hepatic disease because its clearance is reduced in liver impairment. Therefore, it might be prudent to order comprehensive LFTs for further assessment.

701187733

230615

[past history] - 2023-03-23 admission note

  • ovarian cancer, pT2a N1a cM0, pStage: IIIA s/p ATH and BSO on 2019-07-31 and s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Carboplatin IV Q3W x 6 ceased in Oct 2021        
    • ChatGPT: The patient has a history of ovarian cancer with the pathological stage of pT2a N1a cM0, resulting in a pStage of IIIA. The patient underwent abdominal total hysterectomy (ATH) and bilateral salpingo-oophorectomy (BSO) on 2019-07-31. Post-operatively, the patient received adjuvant chemotherapy with Taxol and carboplatin intravenously every 3 weeks for a total of 6 cycles, which was completed in February 2020. The patient had a recurrent tumor in the abdominal wall in June 2021 and underwent second-line palliative chemotherapy with Avastin, Taxotere, and Carboplatin intravenously every 3 weeks for a total of 6 cycles, which was discontinued in October 2021.

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.    

[exam findings]

  • 2023-06-14 CXR
    • Several nodular opacity projecting in the both lung show stationary.
    • Spondylosis of the T-spine
  • 2023-03-24 CT - abdomen
    • Clinical history: Ovarian CA s/p Op on 7/31 19 by Pro Huang SiCheng. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    • IMP:
      • S/P HIPEC catheter implantation
      • Mild ascites in left subphrenic space, right subhepatic space and right paracolic gutter space is noted.
      • In addition, there are soft tissue nodules in the omentum that may be carcinomatosis.
  • 2023-01-19 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Tumor, midline abdominal wall, excision — Metastatic carcinoma
      • Peritoneum, RLQ, ditto — Metastatic carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of (A) one piece of tumor tissue measuring 9.8 x 6.5 x 2.8 cm in size without skin and (B) multiple small pieces of peritoneum tumor tissue measuring up to 6.5 x 3.3 x 1.7 cm in size respectively, fixed in formalin. Representatively embedded for sections as A1-A4: abdominal wall tumor and B1-B2: peritoneum tumor.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Midline abdominal wall tumor: a poorly-differentiated carcinoma arranged in nest or papillary pattern with necrosis and tumor emboli, compatible with metastaic carcinoma.
        • Peritoneum tumor: metastatic carcinoma
      • Immunohistochemistry (S2023-01270A2) show PAX-8(+), WT-1(+), CK7(+), TTF-1(-) and CDX-2(-), compatible with metastatic ovarian serous carcinoma
  • 2023-01-18 ECG
    • Septal infarct, age undetermined
  • 2022-11-07 CT - abdomen
    • Indication
      • Malignant neoplasm of left ovary
      • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
    • Imp:
      • Herniation with intestines at anterior abdominal wall is found. In comparison with CT dated on 2022-02-22, the lesion is stationary in extension.
      • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
  • 2022-02-22 CT - abdomen
    • s/p ATH and BSO. No evidence of recurrent/residual tumor in the study.
  • 2022-02-14, 2021-11-22 CT - abdomen
    • S/P hysterectomy. No evidence of tumor recurrence.
    • Ventral hernia.
  • 2021-06-01 CT - abdomen
    • Clinical history: 52 y/o female patient with CA 125:592.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P bilateral oophorectomy.
      • Irregular soft tissue (1.8x1.5cm) in the abdominal wall (surgical scar region), r/o abdominal wall recurrence.
      • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
      • Presence of ascites in the pelvic cavity.
    • Impression:
      • S/P hysterectomy and oophorectomy.
      • R/O recurrent tumor in the abdominal wall (surgical scar region).
      • Ascites in the pelvic cavity, progression.
  • 2021-02-16 CT - abdomen
    • s/p ATH and BSO. No evidence of abnormal soft tissue mass in the study.
  • 2020-09-02 CT - abdomen
    • Clinical history: Ovarian CA s/p Op on 7/31 19. Papillary serous adenocarcinoma. pT2a N1a cM0, pStage: IIIA
    • IMP: S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2020-04-14 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95.4 - 23.0) / 95.4 = 75.89%
      • M-mode (Teichholz) = 75.9
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with mild MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, trivial TR, normal IVC size
  • 2019-07-31 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, salpingo-oophorectomy — Papillary serous adenocarcinoma.
        • IHC stains: ER +, 90%, strong intensity); PR: (+, 80%, strong intensity), WT-1 (+), PAX-8 (+), Napsin-A (-).
      • Ovary, right, salpingo-oophorectomy — Free.
      • Fallopian tube, left, salpingectomy — Free.
      • Fallopian tube, right, salpingectomy — Seeding.
      • Uterus, corpus, total hysterectomy — Atrophic endometrium and myomas
      • Uterus, cervix, total hysterectomy — Free.
      • Omentume, omentectomy — Free.
      • Lymph node, bilateral pelvic and paro-aortic, dissection — Metastatic adenocarcinoma (1/27)
      • Appendix, appendectomy —- Not received.
      • pT2a N1a (if cM0); pStage: IIIA1i
    • MICROSCOPIC EXAMINATION
      • Histologic type: papillary serous adenocarcinoma.
      • Histologic grade: high grade
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: present (in peri-tubal soft tissue)
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus : abscent
      • Peritoneal/Ascitic Fluid: see N2019-2801Results pending
      • Regional Lymph Nodes: A1-2: left external iliac LNs (0/7); B: left obturator lymph nodes (0/4); C: right iliac lymph nodes (1/3); D1-2: right obturator lymph nodes (0/6); E: left para-aortic lymph nodes (0/3); F: right para-aortic lymph nodes (0/4).
        • No lymph nodes submitted or found: 27
        • Positive for metastasis: 1, see above. (size: 0.5 x 0.1 cm)
        • Negative for metastasis: 27 see above
      • Other organs or specimens involvement: absent

[MedRec]

  • 2021-10-04 SOAP Hemato-Oncology
    • S: 52 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020 & recurrent tumor in the abd wall in June 2021 s/p 2nd line palliative C/T wt Avastin/Taxotere/Cisplatin IV Q3W x 6 since 6/11 21.
  • 2020-02-25 SOAP Hemato-Oncology
    • S: 50 y/o female, a pt of Ovarian CA, pT2a N1a cM0, pStage: IIIA s/p Op on 7/31 19 by Pro Huang SiCheng & s/p post-Op adjuvant C/T wt Taxol / carboplatin IV Q3W x 6 finishing in Feb 2020.
  • 2019-07-25 SOAP Obstetrics and Gynecology
    • O
      • 2019-07-25 sona
        • EM 5.5 mm, Pelvis mass: 311 x 137 mm, RI: 0.26
      • R/O OV tumor
    • Diagnosis
      • Abdominal pain, unspecified site [R10.9]
      • Irregular menstruation, unspecified [N92.6]
      • Malignant neoplasm of right ovary [C56.1]

[MultiTeam]

  • 2023-04-25 Social Services
    • Consultation Date: 2023-04-24
    • Reason for Consultation: Other: Low-income household
    • Case Status: No Case Opened
    • Reason for not opening case: 2023.04.24 - Conversation with client and review of past case records
    • Family Situation:
      • The client is 54 years old, an ethnic Chinese from Indonesia, divorced with three sons, and has been unemployed in recent years due to illness. The client is registered as a low-income family in Taipei City but does not receive any subsidies. The client has no labor insurance or private medical insurance.
      • The eldest son is 28 years old, unmarried with a daughter (11 years old), and recently returned to vocational high school (weekend classes), thus only engaging in part-time work; the second son is 24 years old, studying at Chung Hua University in the Department of Multimedia and working as a part-time employee in a health food store, earning over 20,000 NTD per month; the youngest son is 22 years old, currently working as a mobile phone tester. The sons are now jointly helping to cover the family’s expenses.
      • The granddaughter, 11 years old, has been raised by the client since childhood. The client stated that because the sons have found jobs recently, the family now qualifies as a low-income household, and the granddaughter receives a monthly subsidy of over 4,000 NTD.
      • The family lives in Nangang social housing with a monthly rent of 11,000 NTD.
      • The client’s parents have passed away, and they have seven sisters and four brothers, with the client being the ninth child. The eldest sister is deceased, the younger sister and brother have both moved to Taiwan, and the remaining family members still live in Indonesia. Both the younger sister and brother are married with two children each and have occasional contact with the client.
    • Assessment and treatment:
      • The client is automatically referred as a low-income family in Taipei City, exempt from part of the health insurance burden and able to bear medical expenses independently. This time, the client was provided with related welfare consultation, but the client stated that the sons are currently employed, so they may not meet the application criteria. However, the family’s current living situation is still manageable. Additionally, the client expressed concern about the impact of her treatment on her granddaughter and was provided with emotional support by the social worker. It was also suggested that the client seek resources such as the school counseling office for the granddaughter, which the client accepted.
      • This consultation provided the above treatment, and it was noted that the client has experienced discomfort and vomiting after chemotherapy in the past. The team is advised to pay attention to this issue.

[surgical operation]

  • 2023-01-19
    • Surgery
      • excision of intraabdominal tumor, malignancy
      • excision of abdomianl wall tumor, malignancy
    • Finding
      • firm mass over lower abdominal wall, favor malignancy
      • multiple seeding tumors over whole peritoneal cavity, total PCI: 26/39
      • UOQ 3
      • epigastria 1
      • LUQ 1
      • right flank 1
      • central 3
      • left flank 0
      • RLQ 3
      • inferior 3
      • LLQ 3
      • small bowel PCI: 1 + 2 + 2 + 3 = 8
  • 2019-07-31
    • PreOP Dx: Malignant neoplasm of ovary and other uterine adnexa
    • PostOP Dx: Malignant neoplasm of ovary and other uterine adnexa
    • PCS code: 80418B
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, small military nodules over right vesicouterine fold
      • Adnexa:
        • LOV: 30x20 cm, capsule intact, intra-op rupture(-)
        • ROV: 4x3 cm, capsule intact,
        • Fallopian tube: bilateral grossly normal
      • CDS: no adhesion
      • Ascites: yellowish and clear, about 200 ml
      • Bilateral pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: no nodules noted
      • Liver: grossly normal & smooth
      • Bilateral peritonium: miliary tumor seeding(+), bean sized
      • Appendix: grosslt normal.
      • After the operation, optimal debulking surgery was achieved.
      • Residue tumor: multiple tumors, maximal diameter smaller then 1 cm, over peritoneal wall and bladder base
    • Estimated blood loss: 300ml
    • Blood transfusion: nil
    • Complication: nil

[chemoimmunotherapy]

  • 2023-06-14 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + topotecan 0.35mg/m2 0.6mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-04-24 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-23 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-17 - topotecan 0.35mg/m2 0.5mg NS 30mL 30min D1-3 + NS 500mL 2hr (before cisplatin) + cisplatin 25mg/m2 40mg NS 500mL 2hr + NS 500mL 2hr (after cisplatin) + [docetaxel 40mg/m2 65mg + cisplatin 40mg/m2 65mg + gentamycin 40mg + sodium bicarbonate 2800mg + NS 500mL] IP 1hr (Q3W x 6)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-10-25 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-10-04 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-09-06 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-02 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 75mg/m2 120mg NS 250mL 1hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-08 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-11 - bevacizumab 7.5mg/kg 500mg NS 250mL 90min + docetaxel 60mg/m2 100mg NS 250mL 1hr + NS 500mL 2hr (before cisplatin) + cisplatin 60mg/m2 100mg NS 500mL 2hr + NS 500mL (after cisplatin) 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-02-13 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
  • 2020-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 3 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO
  • 2019-12-19 - ditto
  • 2019-11-26 - ditto
  • 2019-11-05 - ditto
  • 2019-10-15 - ditto

==========

2023-07-13

  • For the past three months, this patient has used only the outpatient and inpatient hemato-oncology services at our hospital. No medication reconciliation issues have been identified.

2023-06-15

  • According to the PharmaCloud database, all of this patient’s prescribed medications for the past 3 months have been provided exclusively by our hospital’s hemato-oncology department. There are no identified medication reconciliation issues.

2023-04-25

  • Since the last episode of leukopenia (2.81K/uL) on 2023-03-10, the patient’s WBC count has remained consistently above 4K/uL. However, the patient has experienced post-chemotherapy discomfort with the feeling of wanting to vomit. A short-term prescription of Emend (aprepitant) at 1# QD may help alleviate these symptoms.

2023-03-24

  • On 2023-01-19, the patient underwent surgery to remove malignant intra-abdominal and abdominal wall tumors and subsequently began receiving the topotecan/cisplatin regimen on 2023-02-17. Approximately 2 weeks after starting the regimen, an episode of leukopenia was observed with a WBC count of 2.81K/uL on 2023-03-10. It is recommended that the patient’s blood counts continue to be monitored as usual.

700154194

230614

[lab data]

  • 2020-12-17 ROS1 Not detected
  • 2020-12-11 EGFR G719X Not detected
  • 2020-12-11 EGFR Exon19 Del Detected
  • 2020-12-11 EGFR S768I Not detected
  • 2020-12-11 EGFR T790M Detected
  • 2020-12-11 EGFR Exon20 Ins Not detected
  • 2020-12-11 EGFR L858R Not detected
  • 2020-12-11 EGFR L861Q Not detected
  • 2020-12-11 ALK IHC Negative
  • 2020-12-09 PD-L1 (22C3) TPS <1%

[exam findings]

  • 2023-06-08 MRI - L-spine

    • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
    • Scoliosis of L-spine.
    • Spondylolisthesis of L5 on S1, grade I.
    • Severe narrowing of right L5/S1 neural foramen, caused by protusion disc. Compression of right L5 nerve root.
  • 2023-05-20 MRI - brain

    • no evidence of brain metastasis.
  • 2023-05-19 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.
  • 2023-05-19 ECG

    • Unusual P axis, possible ectopic atrial tachycardia
    • Abnormal ECG
  • 2023-04-24 Patho - colon biopsy

    • Colorectum, sigmoid colon, (15 cm from anal verge) , Specimen: A — HIGH grade dysplasia.
    • Section shows fragment(s) of polypoid colonic mucosal tissue with proliferative tubular mucinous glands lined by cells containing hyperchromatic, elongated nuclei with HIGH grade dysplasia. The possibility of a more advanced lesion cannot be excluded.
  • 2023-04-21 Patho - soft tissue nontumor/mass/lipoma/debridement (Y2)

    • Labeled as “left shoulder”, core needle biopsy — carcinoma, poorly differentiated.
    • Section shows soft tissue infiltrated by andulated irregular nests of carcinoma.
    • IHC stains: WT-1(-), Napsin-A (-), TTF-1 (-), GATA-3 (+), TRPS-1 (-), CK20 (-), vimentin (+).
  • 2023-04-21 CT - abdomen

    • History: LUL lung adenocarcinoma, cT4N2M1, stage: IV.
      • 20200613 CT: Mass in Lt pelvis, 6.1cm with left hydronephrosis. S/P left pelvic mass resection and left ureteronephrectomy.
        • Patho: metastases (endometrioid cancer) with ureter invasion
      • 20210908 CT: Few metastases in left pelvis retroperitoneal space?
        • S/P CT guided biopsy: metastatic adenocarcinoma
      • 20210908 CT: multiple liver tumors, R/O mets. B (-), C (-), s/p biopsy. patho: adenocarcinoma. refer back to chest doctor.
        • R/O lung ca with liver mets or multiple CCC
      • 20210802 tumor marker: SCC:7.23 ng/ml (normal: < 2.7),
        • CA125: 55.55 U/ml (normal: < 35), CEA and CA199: normal
    • Findings: Comparison prior chest CT dated 2022/07/08.
      • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
      • There are two newly developed soft tissue mass 1.1 cm and 2.2 cm in the retroperitoneal space of left lower abdomen and left upper pelvis that are c/w metastasis.
        • In addition, there is a third newly developed rim enhancing soft tissue mass 2.1 cm in the mesentery of right upper pelvis that is also c/w metastasis.
      • S/P left nephrectomy.
      • S/P hysterectomy
    • Impression:
      • Prior CT identified several poor enhancing lesions on both hepatic lobes are noted again, increasing in size that is c/w Metastases S/P C/T with progressive disease.
      • Two Metastasis in the retroperitoneal space of left lower abdomen and left upper pelvis, and one metastasis in the mesentery of right upper pelvis.
  • 2023-04-21 Bone densitometry - spine + hip

    • L-spines BMD performed by DXA revealed:
      • AP L-spines, BMD of L1-4 1.175 gms/cm2, about 1.2 SD above the peak bone mass (112%) and 3.0 SD above the mean of age-matched people (162%).
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.582 gms/cm2, about 2.4 SD below the peak bone mass (69%) and 0.2 SD above the mean of age-matched people (102%).
    • Impression
      • Osteopenia
  • 2023-04-17 CT - chest

    • LUL cancer T4M1c, stationary of primary tumor and hepatic metastases as compared with previous CT on 2023/01/07
  • 2023-03-14 Whole body PET scan

    • Glucose hypermetabolism in the anterior aspect of the upper lobe of left lung. Residual or recurrent malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Multiple glucose hypermetabolic lesions in the pelvic cavity, compatible with metastatic lesions.
    • Glucose hypermetabolism in some lymph nodes in the right aspect of the mediastinum, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in the posterior aspect of right 4th rib, in a focal area in the soft tissue in the anterior aspect of proximal portion of left humeral shaft, in multiple focal areas in the right lobe of the liver and in a focal area in the left buttock. Metastatic lesions in the bone, liver and soft tissues may show this picture.
  • 2023-02-08 Tc-99m MDP

    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed a faint hot area in the post. aspect of the right 4th rib, and increased activity in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees in whole body survey.
    • IMPRESSION:
      • A faint hot area in the post. aspect of the right 4th rib is new compared with the previous study on 2022-03-28; the nature is to be determined (post-traumatic change or other nature?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-01-17 MRI - upper abdomen

    • History and indication:
      • Endometrial cancer with liver mets
      • Lung cancer
    • IMP:
      • Poor enhancing tumors (up to 1.4cm) in right hepatic lobe.
      • Absence of left kidney.
      • Partial consolidation at left lingual lung.
  • 2023-01-07 CT - chest

    • Indication: reuse Tagrisso (osimertinib) due to the liver lesion was endometrial cancer with liver meta (not from lung after pathologist revision)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Left hilar mass with encasing left lobe bronchus, causing collapsed left lingula lobe is found. In comparison with CT dated on 2022-07-08, the lesion is stationary.
        • Enlarged lymph nodes at left axillary region are ofund.
        • S/p port-A placement with its tip at Superior vena cava.
        • Enlarged lymph nodes are found at right anterior chest wall is found.
      • Visible abdomen:
        • Hepatic cystic lesion at right lobe of liver are found. Stable.
        • Aortic wall thickening is found.
        • Scoliotic alignment of the thoracolumbar spine is noted.
    • Imp: Left hilar lung cancer with collapsed left lingula lobe, chest wall lymphadenopathy and probably liver lesions. Stationary.
  • 2022-11-09, -09-07 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart
  • 2022-07-08 CT - chest

    • Indication: Endometrioid carcinoma with ureter invasion with etastatic pulmonary adenocarcinoma, T3N0Mx, stage IIIB
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Consolidation over left upper lobe with air-bronchogram is found. In comparison with CT dated on 2022-03-25, the lesion is stationary in size.
        • Mild pericardial effusion is found.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver up to 1.32cm in largest dimension. These lesions are stationary in size and numbers.
        • s/p left nephrectomy.
    • IMp:
      • Left upper lobe lung cancer, stationary in size.
      • Hepatic metastatic tumors at both lobes liver, stable.
  • 2022-05-18 Pure Tone Audiometry, PTA

    • Reliability FAIR
    • Average RE 31 dB HL // LE 41 dB HL
    • RE normal to moderately sevre SNHL
    • LE normal to severe SNHL
  • 2022-05-11 Pure Tone Audiometry, PTA

    • Tymp: Bil type C.
    • ART: Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 35 dB HL; LE 51 dB HL.
      • R’t normal to severe SNHL.
      • L’t normal to severe mixed type HL.
  • 2022-04-27, 2022-04-20 CXR

    • LUL atelectasis with increased density with obliteration of the hilum and adjacent mediastinal border, and compensatory overflation of LLL, with elevated hemidiaphgram and left shift of heart.
    • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
  • 2022-03-28, 2021-12-22 Tc-99m MDP whole body bone scan

    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the left 7th rib, maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2021-12-20 KUB

    • Compression fracture of L2 vertebral body
    • moderate dextroscoliosis of the L-spine
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, L-spine.
    • significant amount of fecal material filled nondilated colon
  • 2021-12-09 CT - lung/mediastinum/pleura

    • Left upper lobe lung cancer with stationary size.
    • Liver meta, in enlargement.
  • 2021-10-25 Patho - soft tissue biopsy, simple excision, non lipoma

    • left pelvic - Adenocarcinoma, metastatic.
    • IHC: CK7(focal positive), CK20(-), PAX8(+), PR(+), TTF-1(-), Napsin A(-), p40(-), and CD56(-).
    • The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).
  • 2021-10-21 CT - whhole abdomen, pelvis

    • Partial consolidation at left lingual region.
    • Tumors in liver, prevertebral region and LLQ tumor metastases.
  • 2021-09-08 CT - lung/mediastinum/pleura

    • LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021-06-02
  • 2021-09-08 CT - liver, spleen, biliary duct, pancreas

    • Metastases are highly suspected.
    • Multiple Cholangiocarcinomas are less likely.
  • 2021-07-16 Patho - liver biopsy

    • IHC: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component).
    • Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded.
    • Metastatic pulmonary adenocarcinoma is less likely in IHC result.
    • Additional IHC: ER(focal +), PAX8(focal +)
    • Comment: The IHC finding is compatible with metastatic endometroid carcinoma.
  • 2021-07-07 Tc-99m MDP whole body bone scan

    • A faint hot spot in the lateral aspect of the left 7th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
    • Suspected benign lesions in the maxilla, some C- and L-spine, bilateral shoulders, S-I joints, hips and knees.
  • 2020-12-17 ROS1 FISH not detected

  • 2020-12-11 EGFR, ALK IHC, PD-L1(22C3) S2020-18026 (bronchus biopsy)

    • EGFR
      • G719X (-)
      • Exon19 deletion (+)
      • S768I (-)
      • T790M (+)
      • Exon20 insertion (-)
      • L858R (-)
      • L861Q (-)
    • ALK IHC (-)
    • PD-L1 Tumor proportion score TPS < 1%
  • 2020-11-25 Patho - bronchus biopsy

    • CT-guide biopsy - adenocarcinoma, moderately differentiated
    • IHC: TTF-1(+).
    • The result is supportive for the diagnosis of malignant neoplasm of left bronchus or lung.
  • 2020-11-13 CT - lung/mediastinum/pleura

    • left upper lobe lung cancer with probably right lung meta. the primary left upper lobe lung cancer progressed.
  • 2020-08-12 CT - lung/mediastinum/pleura

    • LUL tumor involving mediastinum and hilum and Rt lung metastasis, in progression as compared with previous CT study on 20200320.
  • 2020-06-30 Patho - Ureter resection

    • pathologic diagnosis
      • Ureter, left, frozen section + open nephroureterectomy - Endometrioid carcinoma with ureter invasion
      • Kidney, left, ditto - Chronic pyelonephritis
    • IHC for tumor cells: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells
  • 2020-06-29 Patho

    • Tumor, urinary tract?, frozen section - Adenocarcinoma, uncertain origin
  • 2020-06-13 CT - whole abdomen, pelvis

    • S/P hysterectomy.
    • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis(TCC? GYN or GI tract). Suggest tissue study.
  • 2020-03-30 CT - lung/mediastinum/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20191230.
  • 2019-12-30 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190918.
  • 2019-09-18 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, stationary as compared with previous CT study on 20190612.
  • 2019-06-12 CT - lung/pleura

    • LUL tumor involving mediastinum and hilum, in regression as compared with previous CT study on 20190312.
  • 2019-04-11 MRI - L-spine

    • Lumbar spondylosis, canal stenosis and small L1/2 HIVD. No tumor or metastasis found.
  • 2019-03-15 MRI - brain

    • No evidence of brian metastasis.
    • Mild ventriculomegaly.
  • 2019-03-14 Surgical pathology Level IV

    • indication: Malignant bronchus and lung neoplasm, NOS;
    • diagnosis: Lung, ? side, needle biopsy - adenocarcinoma, moderately differentiated
    • IHC: TTF-1(+), Napsin A(+), and p63(-). The results are supportive for the diagnosis.
  • 2019-03-12 CT - lung/pleura

    • Progression of LUL lesion (6.1x7.1cm) with mediastinal LAP. TNM: T4N2Mx
    • Right tiny renal stones (1-2mm). Left hydronephrosis.
  • 2019-03-02 CT - brain

    • No brain lesion.
    • A 6.4mm dense calcification at left parasagittal region, calcified meningioma or benign parafalcal calcification.
  • 2018-06-06 Surgical pathology Level IV

    • indication: bilateral lung nodules
    • diagnosis: Lung, ? side, needle biopsy - Interstitial fibrosis with atypical pneumocytes
    • Sections show alveolar lung tissue with interstitial fibrosis and atypical pneumocytes proliferating along the alveolar wall. No stromal invasion is seen. The immunohistochemical stain of CK reveals no invasive tumor. The TTF-1 is positive. Please correlate with the clinical presentation and further examination is suggested.
  • 2018-05-31 Low-dose CT - lung cancer screening

    • A spiculated mass (4.2x6.1cm) at LUL suspected cancer.

[MedRec] (not completed)

  • 2022-02-09 SOAP Hemato-Oncology
    • A/P
      • On 2022-02-09. C/O Toxicity of C/T, e.g., four limbs numbness, especially left upper limb; decreased acuity of eye; fatigue and weakness. Already told the worse of prgnosis. Options are given e.g., change C/T regimen to NHI re-imbursement; rest for one week; continue current regiemen and C/T on 2022-02-09. They dedicde continue current C/T on 20220-02-09.
      • Admission 3rd course of C/T on 2022-02-09
      • Due to acnefirom skin rash over face, order clindaymicin gel.
      • Already told the C/T-irelated neuropathy, patient would like to try one more time on 2022-02-09. If not tolerated, may chnage to other regimen
  • 2022-01-05 SOAP Hemato-Oncology
    • O
      • Now on palliative C/T with TP, C1D1 on 2021-12-29
      • AEs: Fatigue
  • 2021-11-11 SOAP Chest Medicine
    • Prescription (part)
      • Navelbine (vinorelbine 20mg) 3# QW
  • 2021-11-05 SOAP Hemato-Oncology
    • A/P: She is receiving IO and navelbine for her lung ca by Dr Wu. (20211105)
  • 2021-09-01 SOAP Chest Medicine
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD
  • 2021-07-13 SOAP Hemato-Oncology
    • A
      • s/p local radiotherapy after operation for Lt nephrectomy and endometrioid ca with ureter invasion
      • Liver metastases noted in CT abdomen (20210713)
    • P
      • Suggest liver biopsy
  • 2021-06-04 SOAP Chest Medicine
    • A/P
      • 2021/05/28 chest CT with/without contrast suspected MET and/or c797 metastasis
      • biopsy of LUL by CS
      • She refused and hope to use qd Tagrisso
  • 2020-12-23 SOAP Chest Medicine
    • Prescription
      • Tagrisso (osimertinib 80mg) 1# QD (change)
      • Romicon-A 1# TID
      • Through (sennoside 12mg) 2# HS
      • Sketa 1# TID
  • 2020-10-14 SOAP Chest Medicine
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D
      • codeine phosphate 15mg 1# BID
      • Zalain External Gel (sertaconazole 2%) Q3D EXT
  • 2020-09-16 SOAP Chest Medicine
    • A/P
      • we discuss with patient and final decision was shifted to Iressa 1# Q3D
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D (longer interval)
      • Topsym (fluocinonide 0.05%) BID TOPI
  • 2020-08-19 SOAP Chest Medicine
    • A/P
      • we discuss with patient and final decision was shifted to Iressa 1# QOD => If after 3 months, on improve => Arrange rebiopsy
    • Prescription
      • Iressa (gefitinib 250mg) 1# QOD (shorter interval)
  • 2020-07-22 SOAP Chest Medicine
    • A/P
      • Iressa 1# Q3D
      • prepare to receive RT and C/T for endometrial ca
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D
      • Allegra (fexofenadine 60mg) 1# BID
  • 2020-04-16 SOAP Radiation Oncology
    • Plan
      • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 1200cGy/3 fractions to vaginal cuff mucosa surface by IVRT.
  • 2020-07-16 SOAP Obstetrics and Gynecology
    • Objective
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-16
        • Cancer staging: rypT3bNx(cM0), stage IIIB.
        • Treatment: Radiotherapy followed by Chemotherapy.
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2021-07-09
        • Wait for the pathology report to confirm if the primary cancer is endometrial cancer or cervical cancer.
        • Hematology doctor: Since the patient is old (70 years old) and has lung cancer (Lung adenocarcinoma, T4N0M1, stage IV, post Iressa since 2019-03), the significance of chemotherapy is not high. Suggest initial Local Radiotherapy.
  • 2020-02-04 SOAP Chest Medicine
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Cellulitis and abscess other specified sites [L02.811]
    • Prescription
      • Iressa (gefitinib 250mg) 1# Q3D (even longer interval)
      • Allegra (fexofenadine 60mg) 1# BID
      • Mosflow (moxifloxacin 400mg) 1# QDAC
  • 2019-06-25 SOAP Chest Medicine
    • Prescription
      • Iressa (gefitinib 250mg) 1# QOD (longer interval)
  • 2019-06-11 SOAP Dermatology
    • S
      • Multiple painful erythematous papule-nodules on face, trunk and 4-limbs
      • Heavy scaling over erythematous patchs on scalp, and eyelid and nasolabial fold with moderate itching
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Acne varioliformis [L70.2]
      • Other erythematosquamous dermatosis [L30.3]
      • Seborrheic dermatitis, unspecified [L21.9]
      • Type 2 diabetes mellitus without complications [E11.9]
      • Right eye hypertropia [H50.21]
    • Prescription
      • doxycycline 100mg 1# BID
      • Kefen (ketotifen fumarate 1mg) 1# BID
      • Mycomb BID TOPI
  • 2019-06-11 SOAP Chest Medicine
    • Plan:
      • change to Iressa due to severe adverse effect of giotrif, but adverse effect persist, so hold Iressa 2 weeks and wait CT result
  • 2019-05-28 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-05-28)
        • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
        • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
    • Plan
      • change to Iressa due to severe adverse effect of giotrif
    • Prescription
      • Iressa (gefitinib 250mg) 1# QD (new)
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mycomb Cream BID TOPI
  • 2019-05-14 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-05-14)
        • Skin rash: G1: Superficial rash or dry scales
        • Hand-foot syndrome: G3: Skin changes with pain, affecting daily life
        • Oral mucositis: G1: No lesions
    • Prescription
      • same as 2019-04-30
  • 2019-04-30 SOAP Chest Medicine
    • Objective
      • Assessment of Side Effects of Cancer Treatment (2019-04-30)
        • Diarrhea: G1: Up to 4 times per day
        • Skin rash: G2: Moderate rash, or single moist desquamation, mostly in skin folds and moderate edema
        • Oral mucositis: G2: Moderate pain, can eat, need to adjust diet
    • Prescription
      • Giotrif (afatinib 30mg) 1# QDAC (lower dose)
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Mycomb Cream BID TOPI
  • 2019-04-24 SOAP Chest Medicine
    • Objective
      • Conclusion of the Multidisciplinary Team Meeting for Cancer, Meeting Date: 20190326): Check PD-L1, EGFR and ALK status, if positive mutation is found, then initiate targeted therapy.
      • EGFR Exon 19 Del, PD-L1 5%, ALK negative
    • Prescription
      • Giotrif (afatinib 40mg) 1# QDAC
      • Ulstop (famotidine 20mg) 1# BID
      • Allegra (fexofenadine 60mg) 1# BID
      • Imolex (loperamide 2mg) 1# BID
  • 2019-03-27 SOAP Chest Medicine
    • Diagnosis
      • Lung cacer with adenocarcinoma, T4N0M1bx, ECOG 0. [C34.90]
      • Type 2 diabetes mellitus without complications [E11.9]
      • Right eye hypertropia [H50.21]
      • constipation [K59.00]
    • Prescription
      • Navelbine (vinorelbine 20mg) #3 QW
      • Sketa (acetaminophen 300mg + chlorzoxazone 250mg) 1# TID
      • Through (sennosides 12mg) 1# HS
  • 2019-03-08 SOAP Ophthalmology
    • Diagnosis
      • Senile cataract, unspecified [H25.9]
    • Prescription
      • ONSD (neostigmine methylsulfate) 0.01% 10mL eye drop BID
  • 2019-03-01 SOAP Neurology
    • Diagnosis
      • Disorder of binocular vision, unspecified [H53.30]
      • Sixth or abducens nerve palsy [H49.22]
    • Prescription
      • Compesolon (prednisolone 5mg) 1# BID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2018-06-01 SOAP Chest Medicine
    • Dx: bilateral lung nodules
  • 2017-03-24 SOAP Family Medicine
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Gout, unspecified [M10.9]
      • Urinary calculus, unspecified [N20.9]
      • Mixed hyperlipidemia [E78.2]
      • Constipation [K59.00]
    • Prescription
      • Uformin (metformin 500mg) 1# QD
      • Lipanthyl (fenofibrate 160mg) 1# QOD
      • Euricon (benzbromarone 50mg) 0.5# QOD

[consultation]

  • 2023-05-22 Oral and Maxillofacial Surgery
    • Q
      • She would like to receive Xgeva (denosumab)
      • We need your expertise and evaluation for her jaw because of propable MRONJ
    • A
      • After intraoral dental examination, no dental decay or mobile teeth was noticed.
      • Xgeva could be used safely.
  • 2023-05-22 Radiation Oncology
    • Q
      • This 72-year-old woman with underlying histories of
        • LUL adenocarcinoma, Stage= T4N2M1 stage IV with probably right lung metastasis
        • Malignant tumors in the pelvic cavity, up to 6.1cm in left side with left hydronephrosis. Probably metastasis (endometrioid cancer)。
        • DM
        • hyperuricemia
        • Endometrioma sp ATH+BSO 2011
        • Abdominal benign mass lesion sp surgical removal x3 many years ago.
      • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation.
      • The patient complaint about her left arm pain and liver meta. She would like to receive radiotherapy
      • We need your expertise and evaluation for her treatment and symptoms control
    • A
      • History: This 72-year-old woman suffers from LUL adenocarcinoma, cT4N2M1 stage IV with probably right lung metastasis s/p Durvalumab and navelbine s/p Taxol/Carboplatin for 3 cycles in 2022/07 under Tagrisso now;
      • This time, she was admitted to ward for restaging of Brain MRI (no meta) and NGS evaluation. The patient complaint about left shoulder pain with movement limitation and progressive liver metastasis noted by CT on 2023/04/21.
      • Previous RT: Endometrial carcinoma of the uterus, s/p hysterectomy and BSO at ZhongShan Hospital in 2011, with recurrence and left ureter invasion, s/p operation (Nephrourterectomy with bladder cuff resection, left (open); Excision of retroperitoneal tumor, retrorectal tumor, left exteranl iliac LAP on 2020/07/06; stage rypT3bNx (cM0), stage IIIB, s/p adjuvant RT on 2020/09/11; RT to Rt posterior 4th rib for 3500cGy/10 fx on 2023/4/06.
      • Diagnosis: Metastatic soft tissue tumor over left shoulder (origin from lung cancer or endometrial cancer?); ECOG =1.
      • Plan: RT to left shoulder for 4000cGy/10 fx is suggested for pain control. Possible radiation toxicity (radiation dermatitis) is told to her. CT simulation will be arranged on May 30, 10:30.
  • 2021-12-21 Hemato-Oncology
    • Q
      • This 70 y.o female was a case with past history of (1) Endometrioid carcinoma with ureter invasion with Metastatic pulmonary adenocarcinoma is less likely in IHC result (2) DM.
    • A
      • This 70 year old woman had history of
        • s/p Hystectomy & BSO due to endometriosis in 2011 at ZhongShan Hospital.
        • LUL tumor involving mediastinum and hilum and Rt lung metastasis, NSCLC T4N0M1 stageIV adenocarcinoma, moderately differentiated s/p navelbine since 2019/03/27, Exon 19 Del, PD-L1 5%, ALK negative s/p afatinib since 2019/04/24, change to Iressa due to severe adverse effect of Giotrif (afatinib) since 2019/05, 2020/11 re biopsy, t790m mutation, shift to osimertinib 2020/12/23, 2021/02 CT: left upper lobe lung cancer with probably liver meta, s/p C1 Alimta 600mg on 2021/09/14 and C1 Durvalumab 240mg(1+1) on 2021/09/15.
        • Endometrioid carcinoma with ureter invasion status post retroperitoneal tumor s/p 1.excision of retroperitoneal tumor, LN. with enterolysis, 2.debulking, 3.ureterorenoscopic exam and DBJ insertion pT3N0M0 stage III on 2020-06-29: CK7(+); CK20 (-); ER(+); GATA-3(-), TTF-1(-), WT-1(-), PAX-8(+), P63(-) and CDX-2(+, focal) for tumor cells
        • 2021/07/16 liver biopsy: Adenocarcinoma with focal squamous differentiation, IHC shows following features: CK7(+), CK20(-), TTF1(-), Napsin A(-), and p40(focal + in squamous component). Primary liver adenocarcinoma (cholangiocarcinoma) can not be completely excluded. Metastatic pulmonary adenocarcinoma is less likely in IHC result. 2021-09-08 CT: 1. LUL cancer T4M1c, in progression of primary tumor and hepatic metastases as compared with previous CT study on 2021/06/02 2. There are multiple well-defined ring-enhancing masses on both heatic lobes, the largest one 3 cm in S7/8, at arterial phase images and contrast washout in portal and delayed phase images. Several larger lesions show central tunor necrosis. Metastases are highly suspected. Multiple Cholangiocarcinomas are less likely.
        • LLQ tumor seen in 2021/10/21 CT, biopsy:adenocarcinoma, metastatic, The morphology and immunohistochemical stains are consistent with S2020-8600 (Endometrioid carcinoma).
      • Impression:
        • Recurrent Endometrioid carcinoma (left lower quadrate mass biopsy result)
        • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p afatinib, s/p Gefitinib, s/p osimertinib, now under durvalumab
        • Liver lesions r/o lung meta or endometrioid meta, primary Cholangiocarcinomas are less likely
      • Suggestion:
        • Please contact pathologist for more IHC stain of liver biopsy to differentiate the possible origin from endometrioid cancer; in addition, may request pathologist to perform MMR, regarding the MSI-H or not.
        • As for the chemotherapy regimen, may consider palictaxel plus platinum to cover lung cancer and endometriroid cancer, if the final result of the possible cholangiocarcinoma is not coming out.
  • 2021-10-18 Gastroenterology
    • Q
      • This was a 70 y/o female with lung adenocarcinoma stage IVb, and she was admitted for immunotherapy (durvalumab). She complaint of constipation for long time. So MgO TID and sennoside 2 tab HS was given. Her constipation was relieved but she started to have LLQ pain since 20211014. So we stopped MgO and keep sennoside 1 tab HS. But she still have intermittant LLQ pain. The pain always exacerbated at night and could be relieved by Tramacet. Her colonscopy showed brownish pigmentation of mucosa on 2021/08/10. No bloody stool and watery diarrhea was noted.
    • A
      • 70F Phx:
        • Lung adenocarcioma, EGFR mutation, cT4N2M1c, cStage IVb, s/p Gefitinib, s/p osimertinib, now under durvalumab
        • Endometrial carcinoma of the uterus, s/p total hysterectomy with BSO 9 years ago
        • Pelvic malignancy tumor with left ureter invasion, s/p nephrourterectomy and tumor resction 1 year ago, followed by RT 4500cGy
        • DM, controlled with sitagliptin
      • S:
        • LLQ abdominal pain, raidating to LUQ and back since 2021/10/15. (Last durvalumab course)
        • Quality: dull with intermittent bloating
        • Do not relief after defecation nor flatulence
        • The pain would be precipitated at walking
        • Pain score: 3-5
      • O:
        • Abdomen:
          • soft and flat with multiple OP Scar
          • marked tenderness over LLQ, mild rebound tenderness, percussion tenderness (+)
          • knocking tenderness at left lower back
      • A
        • Acute LLQ abdominal pain,
        • r/o intraperitoneal or retroperitoneal inflammatory process
        • r/o colitis (immunotherapy related?)
      • P
        • Arrange KUB (standing)
        • Arrange abdominal echo
        • Check stool routine and urinanlysis
        • Consider CT scan if the aforementioned examinations are inconclusive
  • 2020-07-01 Infectious Disease
    • Q
      • This 69-year-old female wtih a known history of
        • Lung Ca s/p CM since March 2019
        • s/p Hystectomy & BSO due to endometriosis    
      • This time, she had Retroperitoneal tumor. Thus, excision of retroperitoneal tumor, retrorectal tumor, LN. with enterolysis were performed on 20200629. However, we found pneumonia, abdominal pain and leucocytosis (WBC 18680, CRP 9.38). We need your expertised for further evaluation and management. Thank you!!
    • A
      • Consultation for Tienam antibiotic.
        • 69-year-old lung cancer female patient received retroperitoneal tumor surgery two days ago.
        • There is post-operative fever that white count up to 18680 thismorning, with CRP level 9.38.
        • Mild elevated serum PCT level also noted.
        • CxR film this morning shows newly-developed infiltration patches over BLL and LUL, that postoperative pneumonia is the first impression.
        • Tienam is prescrbed.
      • Suggestion:
        • Continue Tienam for five days first.
        • Check blood and sputum culture report.

[surgical operation]

  • 2020-06-29
    • Operation
      • Excision of retroperitoneal tumor
      • Excision of retrorectal tumor
      • Ex of left exteranl iliac LN
      • Adhesionolysis
    • Finding
      • Moderate adhesion of small bowel and omentum of lower abdomen, no gross peritoneal seedings
      • A bulky tumor in pelvic retroperitoneal space and adjacent to left external iliac vessels and encasing left ureter
      • A rectal submucosa tumor in upper rectum, 3cm in diameter
      • Drain: 19Fr Blake drain x 2 in left retroperitoneal space
      • Washing cytology: 100cc normal saline irrigation for peritoneal cavity
      • Wound: treated with New Epi 5cc
  • 2020-06-09
    • Surgery
      • Nephrourterectomy with bladder cuff resection, left (open)
    • Finding
      • EBL: 1500cc
      • 300 cc during bladder cuff
      • 600 cc at renal pedicule
      • 6cm stone hard tumor at middle ureter –> after explanation of risk and alternative treatment, family member agreed nephroureterectomy
      • Frozen section: adenocarcinoma

[chemotherapy]

  • 2022-07-07 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-06-15 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-05-27 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-03-29 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-02-09 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-01-19 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 300mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-12-28 - paclitaxel 140mg/m2 180mg NS 500mL 3hr + carboplatin AUC 4 250mg D5W 250mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-11-25 - durvalumab 240mg NS 250mL
    • none
  • 2021-11-03 - durvalumab 240mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
  • 2021-10-12 - durvalumab 240mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 50mL
  • 2021-09-15 - durvalumab 240mg NS 250mL
    • none
  • 2021-09-14 - pemetrexed 600mg NS 100mL
    • dexamethasone 4mg + hydroxocobalamin 1mg + NS 50mL
  • 2021-11 ~ 2021-12 - vinorelbine
  • 2020-12 ~ ongoing - osimertinib (for NSCLC)
  • 2019-05 ~ 2020-11 - gefitinib
  • 2019-04 ~ 2019-05 - afatinib
  • 2019-03 ~ 2019-04 - vinorelbine

NCCN Non-Small Cell Lung Cancer Evidence Block 20220316 p89 — targeted therapy or immunotherapy for advanced or metastatic NSCLC

  • EGFR Exon 19 Deletion or L858R
    • First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib -Erlotinib + ramucirumab -Erlotinib + bevacizumabc (nonsquamous)
    • Subsequent therapy -Osimertinib9

-EGFR S768I, L861Q, and/or G719X - First-line therapy -Afatinib -Erlotinib -Dacomitinib -Gefitinib -Osimertinib - Subsequent therapy -Osimertinib9

  • EGFR Exon 20 Insertion Mutation Positive
    • Subsequent therapy -Amivantamab-vmjw -Mobocertinib
  • KRAS G12C Mutation Positive
    • Subsequent therapy -Sotorasib
  • ALK Rearrangement Positive
    • First-line therapy -Alectinib -Brigatinib -Ceritinib -Crizotinib -Lorlatinib
    • Subsequent therapy -Alectinib -Brigatinib -Ceritinib -Lorlatinib
  • ROS1 Rearrangement Positive
    • First-line therapy -Ceritinib -Crizotinib -Entrectinib
    • Subsequent therapy -Lorlatinib -Entrectinib
  • BRAF V600E Mutation Positive
    • First-line therapy -Dabrafenib/trametinib -Dabrafenib -Vemurafenib
    • Subsequent therapy -Dabrafenib/trametinib
  • NTRK1/2/3 Gene Fusion Positive
    • First-line/Subsequent therapy -Larotrectinib -Entrectinib
  • MET Exon 14 Skipping Mutation
    • First-line therapy/Subsequent therapy -Capmatinib -Crizotinib -Tepotinib
  • RET Rearrangement Positive
    • First-line therapy/Subsequent therapy -Selpercatinib -Pralsetinib -Cabozantinib
  • PD-L1 >=1%
    • First-line therapy -Pembrolizumab -(Carboplatin or cisplatin)/pemetrexed/pembrolizumab (nonsquamous) -Carboplatin/paclitaxel/bevacizumab/atezolizumab (nonsquamous) -Carboplatin/(paclitaxel or albumin-bound paclitaxel)/pembrolizumab (squamous) -Carboplatin/albumin-bound paclitaxel/atezolizumab (nonsquamous) -Nivolumab/ipilimumab -Nivolumab/ipilimumab/pemetrexed/ (carboplatin or cisplatin) (nonsquamous) -Nivolumab/ipilimumab/paclitaxel/carboplatin (squamous)
  • PD-L1 >=50% (in addition to above)
    • First-line therapy -Atezolizumab -Cemiplimab-rwlc

==========

2023-06-14

  • For the past 3 months, the patient has been receiving exclusive medical services, both outpatient and inpatient, from our hospital, in particular, from our departments of thoracic medicine and hemato-oncology. On 2023-06-02, our thoracic specialist prescribed a 14-day medication regimen that included acetaminophen, bisoprolol, megestrol, cortisone, osimertinib, sennoside, fentanyl patch, rabeprazole, and Romicon-A. These medications are accurately listed on the active prescription with no reconciliation issues identified.

2022-06-16

  • Audiometric test of pure tones indicated recovery to some degree in hearing loss (2022-05-18 Average RE 31 dB HL and LE 41 dB HL <- 2022-05-11 Average RE 35 dB HL and LE 51 dB HL).

2022-01-20

  • drug allergy: alimta (pemetrexed) moderate skin rash recorded in database as from 2021-12-20.
  • HER2 test might be tried to opt-in Trastuzumab as a backup candidate.

700223701

230614

[past history]

  • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
  • Hypertension    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-05-12 Sonography for peripheral vessel
    • Peripheral Vascular Test: Vein, lower limbs
    • Conclusion:
      • No evidence of deep vein thrombosis at bilateral common femoral, femoral and popliteal veins (by color flow filling, direct compression, and distal augmentation response)
      • Left thigh swelling and inguinal lymphadenopathy, consider more proximal vein problem or external compression
  • 2023-05-09 CT - abdomen
    • With and without contrast enhancement CT of abdomen - whole:
      • Wall thickening at rectum and anus, regression.
      • Left adrenal tumor, 1cm. Stationary.
      • Liver cyst, 0.5cm in S4.
      • Regression of left inguinal lymph nodes.
    • Impression:
      • Rectal malignancy and left inguinal lymph nodes with regression.
      • Left adrenal tumor, stationary.
      • Liver cyst.
  • 2023-05-04 Knee Bilat
    • Both knee AP/Lat view: Swelling of left lower extremity.
  • 2023-03-13 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-10 CXR
    • Cardiomegaly is noted.
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
  • 2023-02-03 CXR
    • Borderline cardiomegaly
    • Increased lung markings on left lower lung are noted. Please correlate with clinical condition.
  • 2023-01-31 24hr portable ECG
    • Baseline was sinus rhythm
    • Frequent isolated VPCs / VPC couplets (burden 2%)
    • 1 episode VPC salvo / idioventricular rhythm (3 beats, 81 bpm)
    • Rare isolated APCs / APC couplet
    • No long pause
  • 2023-01-31 Ankle-Brachial Index
    • both lower limbs normal
  • 2023-01-31 Neurosonology
    • Minimal atherosclerosis in right subclavian artery.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
  • 2023-01-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 37) / 105 = 64.76%
      • M-mode (Teichholz) = 64
  • 2023-01-24 MRA - brain
    • Right MCA occlusion at M2 segment with right MCA territory infarct.
  • 2023-01-24 CT - brain
    • Low attenuations in right parietal and temporal regions suspected infarcts.
  • 2023-01-24 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
    • T wave abnormality, consider anterior ischemia
  • 2023-01-17 Patho - soft tissue biopsy/simple excision (non lipoma)
    • Labeled as “left neck mass”, SONO guided biopsy — poorly differentiated.
    • IHC stains: CK20 (+), TTF-1 (-).
    • Section shows lymph node with poorly differentiated carcinoma.
  • 2023-01-09 Whole body PET scan
    • There was increased FDG uptake in the anorectal region (SUVmax early: 17.21, delay: 21.74), in bilateral lower pelvis lymph nodes (SUVmax early: 8.94, delay: 12.81), bilateral inguinal lymph nodes (SUVmax early: 11.70, delay: 15.82), bilateral para-aortic lymph nodes (SUVmax early: 8.61, delay: 13.92), gastrohepatic lymph nodes (SUVmax early: 5.44, delay: 6.64), and left mediastinal lymph nodes (SUVmax early: 5.29, delay: 8.80). In addition, increased FDG uptake was also noted in the left adrenal region (SUVmax early: 8.77, delay: 14.81), left lobe of the thyroid gland (SUVmax early: 9.57, delay: 11.41), and left several level V cervical lymph nodes (SUVmax early: 6.06, delay: 8.71).
    • IMPRESSION:
      • Glucose hypermetabolism in the anorectal region, compatible with the primary anorectal cancer.
      • Glucose hypermetabolism in bilateral lower pelvis lymph nodes, bilateral inguinal lymph nodes, bilateral para-aortic lymph nodes, and gastrohepatic lymph nodes, highly suspected anorectal cancer with regional and distant lymph nodes metastases.
      • Glucose hypermetabolism in the left mediastinal lymph nodes, the nature is to be determined (reactive or metastatic nodes, or other nature ?), suggesting follow-up with PET scan for investigation.
      • Increased FDG uptake in the left adrenal region, probably a functioning tumor in the left adrenal gland, suggesting further investigation.
      • Increased FDG uptake in the left lobe of the thyroid gland and left several level V cervical lymph nodes, highly suspected another primary thyroid cancer with regional lymph nodes metastases, suggesting biopsy for investigation.
      • Anorectal cancer with regional and distant lymph nodes metastases, cTxN2bM1b, stage IVB (AJCC 8th ed.); highly suspected left thyroid cancer with left cervical lymph nodes metastases, by this F-18 FDG PET scan.
  • 2023-01-03 Patho - colon biopsy
    • Colorectum, rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-01-02 CT - abdomen
    • History and indication: Anorectal cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of anus and rectum with adjacent fat stranding and regional LAP.
      • Enlarged LNs at left neck, retroperitoneum and left inguinal region.
      • Enlargement of left adnexa (3.0cm) with calcification.
      • Enlargement of left adrenal gland.
      • Left liver cysts (up to 7mm).
  • 2022-12-30 Anoscopy
    • Impression:
      • Buttock & perianal region: No discharge, no abscess or fistula
      • DRE/Anoscopy: normal anal tonicity; mixed hemorrhoids with congestion, tumor mass like lesion at low rectum!
  • 2022-12-30 Sigmoidoscopy
    • Suspected anorectal cancer with impending obstruction

[MedRec]

  • 2023-06-08 MultiTeam
    • Multi-team Recommendations
      • Medical Team Discussion
        • Dr. He Jingliang: Briefly described the patient’s condition and current treatment direction. Currently, the pain control is mainly morphine, and oral chemotherapy drugs are used to control metastatic skin tumors.
        • Dr. Chang Youkang: Attempted to do radiotherapy positioning on Tuesday, but it failed due to severe lower back pain. Maybe we can try using oral chemotherapy for a week. If the effect is limited, we can move towards palliative care.
        • Psychologist: The patient has actively asked about palliative care and actively expressed a desire to be as comfortable as possible at the end of life.
        • Palliative Care Nurse: Discussed with the family about the advance medical directive and palliative care.
        • Discharge Preparation Center: Recommended hospice care.
        • Social Worker: Will continue to care about the economic situation and contact available resources.
        • Disability Handbook: The functional recovery after the stroke does not meet the rules for issuing the handbook.
        • Patient’s Sister: Respect the patient’s wish to be comfortable and hope that the social worker can help find available financial resources.
        • Patient’s Son: Asked about dyspnea, bowel movement, and left lower limb edema issues.
          • The current shortness of breath is not a lung problem (5/31 CHEST CT: no lung meta.) It might be caused by pain.
          • Bowel movement problem: The lower frequency of bowel movements is due to the lower food intake, but medication can assist treatment.
          • Left lower limb edema: Due to lymph node metastasis and after radiotherapy, causing lymphatic damage and blockage, currently can only symptomatic treatment, cannot fully recover.
    • Conclusion
      • Try a week of oral chemotherapy drugs and then palliative care.
      • Refer to the family medicine department to discuss subsequent advance medical directives and palliative care.
  • 2023-02-10 SOAP Hemato-Oncology
    • Objective
      • Multi-disciplinary Oncology Team Meeting Conclusion, Meeting Date: 2023-01-10
        • Arrange for a neck tumor biopsy first to plan for thyroid cancer.
  • 2023-02-10 SOAP Neurology
    • Impression
      • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, r/o cancer related hypercoagulability (TOAST:5. Undetermined etiology - conflict date)
      • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema
      • Malignant neoplasm of rectum
      • Unspecified viral hepatitis B without hepatic coma
      • Modified ranking scale 2
      • Hyperlipidemia, unspecified
      • Essential (primary) hypertension
      • Contusion of unspecified part of head, initial encounter
      • Laceration without foreign body of left eyelid and periocular area, initial encounter
    • Plan
      • Keep Bokey, Crestor, Diovan
    • Prescription
      • Diovan (valsartan 160mg) 1# QD
      • Bokey (aspirin 100mg) 1# QD
      • Crestor (rosuvastatin) 1# QD

[consultation]

  • 2023-01-30 Rehabilitation
    • Q
      • We sincerely need your help for arrange rehab. program.
    • A
      • Rehabilitation programs: GYM PT, OT rehabilitation programs
      • Goal: Ambulation with/without device ID, BADL ID
  • 2023-01-27 Hemato-Oncology
    • Q
      • This is a 57-year-old woman with history of
        • Hypertension
        • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy,
        • Thyroid papillary carcinoma.
      • The patient was arrnged to accept chemotherapy and radiotherapy for her Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa as schedule. But unfortunately, she had acute ischemic stroke with right MCA infarction. Now the patient was in our ward for stroke therapy.
      • Acue ischemic stroke for right MCA infarction
      • Assessment
        • MRA showed acute infarct in
          • Right temporo-parietal area,
          • Right MCA posterior M2 occlusion
          • subacute small infarct in left parietal lobe.
        • CT showed low attenuations in right parietal and temporal regions suspected infarcts.
        • NE showed
          • Left side central type fascial palsy
          • MP: Upper limbs-> Rt:5, Lt:4+ , Lower limbs-> Rt:5, Lt:4
          • Rombers test : unstable, Tanden gait : unstable
      • Plan
        • Antiplatelet therapy: Bokey 1# QD
        • Hypolipidemic agents: Crestor 1# QD
        • Anti-dizziness drugs: Diphenidol 1# BID
        • Stress ulcer prevention: ULSTOP 1# BID
      • We hope your visit to evaluate her adenocarcinoma of anorectum radiotherapy and chemotherapy condition.
    • A
      • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB. She was admiited to neuro ward due to acute ischemia stroke (Right MCA occlusion at M2 segment with right MCA territory infarct). For cancer treatment, we are consulted.
      • CCRT for down staging is suggested at tumor board. Please send All-RAS (sample number S2023-00082) for further cancer work up.
      • However, due to the patient’s stroke condition (right MCA infarction) and it sequela that might be, chemotherapy may not change much. If the family still consider aggressive treatment,
      • After stroke condition stable, we may take over this case in the next week if you agree.
  • 2023-01-24 Neurology
    • A
      • S
        • This is a 57-year-old woman with history of hypertension and adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, s/p neoadjuvant chemotherapy and radiotherapy, and thyroid papillary carcinoma. She still could walk and speak without any difficulty before the noon on 2023/01/23. She presented with slower speech and slurred speech at night. Her family found she had a laceration wound in the left forehead and left upper eyelid in the midnight (00:30) on 2023/01/24. Thus, she was sent to our ED.
        • Non-contrast brain CT showed hypodensity in right MCA territory.
      • O
        • NE Consciousness: E4V5M6, alert
        • EOM: full and free, preferential gaze to left side
        • left side hemianopia
        • pupil 3/3, light reflex +/+
        • left central facial palsy
        • mild intelligible dysarthria
        • MP: right upper 5, right lower 5
        • left upper 4+, left lower 4+
        • FNF and HKS: no dysmetria
        • Sensation: anesthesia in the left limbs
        • NIHSS: 8 (000 111 1010 02010)
      • Assessment
        • Acute ischemic stroke in right MCA territory, onset on 2023/01/23, suspected cancer related hypercoagulability
        • HTN
        • Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa
      • Suggestion
        • Please arrange brain MRA with/without contrast to clarify large vessel occlusion and to exclude brain metastasis
        • Keep Aspirin 100mg QD.
        • Keep adequate hydration with normal saline at 40 ml/hr.
        • keep BP < 220/120 mmHg.
        • Arrange admission to NEURO ward. Thanks. (Stroke survey in the NEURO ward: check D-dimer, lipid profile, HbA1C, carotid duplex+TCD, cardiac echo, Holter EKG)
  • 2023-01-16 Radiation Oncology
    • A
      • Diagnosis: Adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction, left inguinal, pelvis, paraaortic LAP metastasis and lympoedema of left lower limb; ECOG =1.
      • Plan: CCRT to anorectal tumor, pelvic and paraaortic LAPs for 5040cGy/28 fx is suggested for locoregional control. CT simulation was arranged on 2023/01/17, 08:30am. Treatment will be started on 2023/01/27.
  • 2023-01-16 Hemato-Oncology
    • Q
      • This is a 57 years old female with hypertension and asthma suffers from constipation, distended pain of low abdomen for 1-2 month. Progressive swelling of the left lower extremity for one month.
      • 2022-12-30 sigmoidoscopy: R/O Anorectal cancer with impending obstruction
      • 2023-01-02 CT showed wall thickening of anus and rectum with adjacent fat stranding and regional LAP, enlarged LNs at left neck, retroperitoneum and left inguinal region.
      • CEA:149
      • Colorectum, rectum, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Under impression of adenocarcinoma of anorectum, cT4aN1bM1a, stage IVa, with impending obstruction and left inguinal LNs enlargement and left lower limb edema, she was admitted for port-A, biopsy of neck mass and further survey
      • We would like to consult for your expertise, thank you.
    • A
      • This 57 year old woman is a case of Anorectal cancer with regional and distant lymph nodes metastases, cT4N2bM1b, stage IVB and highly suspected left thyroid cancer with left cervical lymph nodes metastases.
      • CCRT for down staging is suggested at tumor board. Pending neck biopsy result. In addition, please send All-RAS (S2023-00082) for further work up. We may take over this case if you agree.

[chemotherapy]

  • 2023-02-03 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 2hr + fluorouracil 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-06-14

  • Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. - Lab data indicate a deterioration in renal function, accompanied by rising levels of CRP and WBC. Please keep a close eye on the patient for any indicators of an escalating infection.
    • 2023-06-05 Creatinine 0.60 mg/dL
    • 2023-06-12 BUN 37 mg/dL
    • 2023-06-05 BUN 16 mg/dL
    • 2023-06-12 CRP 11.7 mg/dL
    • 2023-06-05 CRP 6.2 mg/dL
    • 2023-06-12 WBC 23.30 x10^3/uL
    • 2023-06-05 WBC 10.59 x10^3/uL
  • Valsartan, an ARB, can indeed be associated with increases in serum Cre levels and/or AKI, particularly in patients who have renal artery stenosis or who are volume depleted. Typically, the increase in serum Cre levels due to ARBs is expected to stabilize within a range of 20% to 30% above baseline levels. However, in this patient’s case, Diovan (valsartan 160mg) has been prescribed by our neurologist since 2023-02-10 and has been used for several months. This long-term use makes it less likely that valsartan is the cause of the recent worsening in renal function.

2023-05-24

  • The D-dimer levels in this patient have remained elevated for nearly one month. Elevated plasma D-dimer levels indicate that coagulation has been activated, fibrin clot has formed, and clot degradation by plasmin has occurred. A long-lasting high D-dimer level could be a sign of an ongoing or chronic medical condition that is associated with increased blood clotting or fibrinolysis (breakdown of blood clots).
    • 2023-02-21 D-dimer 7638.09 ng/mL(FEU)
    • 2023-01-30 D-dimer 7283.81 ng/mL(FEU)
    • 2023-01-25 D-dimer 8056.38 ng/mL(FEU)

2023-02-22

  • The patient was admitted to the hospital yesterday (2023-02-21), and the admission note indicates that she just experienced abdominal distension and watery diarrhea up to 10 times per day according to the review of systems. Nevertheless, the patient has been prescribed sennoside and lactulose, and she is currently taking these medications. Please verify the patient’s current bowel movement status.
  • If the patient’s heavy diarrhea is related to chemotherapy, it might be beneficial to consider omitting the 400mg/m2 5-FU bolus and adjusting the 5-FU infusion dose to 2800mg/m2 from 2400mg/m2 to keep the dose unchanged in the FOLFOX regimen.

700514981

230614

[exam findings]

  • 2023-03-29 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the lateral aspect of the left rib cage, and increased activity in the maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the left rib cage, maxilla, some T- and L-spine, sacrum, bilateral shoulders, hips, and knees.
  • 2023-03-28, -02-13 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2023-01-02 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Tumor, L’t breast, frozen + partial mastectomy — Invasive carcinoma of no special type
      • Resection margins, frozen — Tumor involved at above tumor, others are free
        • Margin, above tumor recut, frozen — Free of tumor invasion
      • L’t axillary sentinel lymph nodes, frozen — Tumor metastasis (2/5) without extracapsular extension (0/2)
        • L’t axillary non-sentinel lymph nodes, ditto — Free of tumor metastasis (0/4)
      • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IIA
  • 2022-12-30 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
    • IMPRESSION: Probably a sentinel lymph node at the left axillary region.
  • 2022-12-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81 - 23) / 81 = 71.60%
      • M-mode (Teichholz) = 70
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild MR, mild TR and trivial PR
      • Preserved RV systolic function
  • 2022-12-28 CT - chest
    • Indication: Left breast cancer
    • Findings
      • Lungs: mild fibrosis at both apical lung regions.
        • normal appearance of both lower lobes and RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • well opacification of proximal segments of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Chest wall and visible lower neck: a small enhancing nodule in Lt breast (15cm) and enlarged LNs in left axilla
      • Visible abdominal contents:
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.no enlarged lymph node. no ascites..
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • Lt breast cancer with axillary LAP
  • 2022-12-20 Patho - breast biopsy
    • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains: ER (-, 0%), PR(-), Her2/neu: positive (score=3+), Ki-67(30 %), E-cadherin (+).
  • 2017-11-15 Thyroid Ultrasound
    • Autoimmune thyroid disease

[surgical operation]

  • 2022-12-30
    • Surgery
      • Left partial mastectomy and Left axillary lymph node dissection
      • Right subclavian vein port-a implantation
    • Finding
      • Left breast invasive ductal carcinoma at 3/3cm, size: [su2.15x2.00cm, invasive ductal carcinoma, cT2N1M0, ER(-), PR(-), HER-2(3+). (1/8)

[immunochemotherapy]

  • 2023-06-12 - trastuzumab 600mg SC 5min (Herceptin)

  • 2023-05-17 - cyclophosphamide 300mg/m2 457mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 53mg D5W 250mL 2hr (AC(lipo) Endoxan 50%)

    •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-25 - cyclophosphamide 600mg/m2 970mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 57mg D5W 250mL 2hr (AC(lipo))

    • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2023-03-28 - cyclophosphamide 600mg/m2 996mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

    • lenograstim 250ug SC + betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO
  • 2023-02-13 - cyclophosphamide 600mg/m2 992mg NS 500mL 1hr + liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr (AC(lipo))

    •                    betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL + aprepitant 125mg PO

==========

2023-06-14

  • On 2023-01-02, breast mastectomy with regional lymph node pathology revealed the disease to be pT1cN1a; if cM0, stage IIA. Adjuvant chemotherapy with trastuzumab is indicated for this disease.

  • The dose-dense AC regimen (cyclophosphamide 600mg/m2, original doxorubicin 60mg/m2 replaced by liposomal doxorubicin 35mg/m2) was administered on 2023-02-13, 2023-03-28, 2023-04-25, 2023-05-17, with cyclophosphamide at 50% of the planned dose on the last administration.

  • The timeline of the patient’s WBC level is organized in the following table, with asterisks indicating instances where the WBC count was less than 2K/uL. The lowest WBC values occurred 2 to 4 weeks after administration of the adjusted AC regimen, suggesting a prolonged nadir or slow recovery of the white blood cells given the dosage and frequency at that time, even G-CSF was administered.

    • 2023-06-12 WBC 1.74 x10^3/uL * trastuzumab 06-12
    • 2023-06-05 WBC 1.07 x10^3/uL *
    • 2023-05-22 WBC 2.28 x10^3/uL
    • 2023-05-17 WBC 2.73 x10^3/uL CT 05-17
    • 2023-05-03 WBC 1.25 x10^3/uL * CT 04-25
    • 2023-04-24 WBC 2.35 x10^3/uL
    • 2023-04-17 WBC 1.33 x10^3/uL *
    • 2023-04-03 WBC 2.81 x10^3/uL CT 03-28
    • 2023-03-27 WBC 2.70 x10^3/uL
    • 2023-03-13 WBC 3.29 x10^3/uL
    • 2023-03-06 WBC 1.74 x10^3/uL *
    • 2023-02-13 WBC 4.35 x10^3/uL CT 02-13
    • 2022-12-28 WBC 3.81 x10^3/uL
    • 2018-11-14 WBC 4.65 x10^3/uL
  • According to Taiwan’s NHI reimbursement rules, the use of G-CSF is permitted for patients with non-hematological malignancies who have a WBC count of less than 1000/uL or an ANC of less than 500/uL post-chemotherapy. In this patient’s case, the criteria are not met, so G-CSF is not covered by the NHI.

  • Granocyte (lenograstim) was administered concurrently with the adjusted AC regimen on 2023-03-28, 2023-04-25, and 2023-05-17. It’s recommended for primary and secondary prophylaxis that G-CSF administration typically starts 24 to 72 hours after the end of chemotherapy treatment (https://www.uptodate.com/contents/use-of-granulocyte-colony-stimulating-factors-in-adult-patients-with-chemotherapy-induced-neutropenia-and-conditions-other-than-acute-leukemia-myelodysplastic-syndrome-and-hematopoietic-cell-transplantation). ref(1): Delayed Granulocyte Colony-Stimulating Factor (G-CSF) Administration after Chemotherapy Reduces Total G-CSF Doses without Affecting Neutrophil Recovery in a Randomized Clinical Study in Children with Solid Tumors. Pediatr Hematol Oncol. 2020;37(8):665-675. ref(2): Efficacy of delayed administration of post-chemotherapy granulocyte colony-stimulating factor: evidence from murine studies of bone marrow cell kinetics. Exp Hematol. 2008;36(1):9-16.

700928067

230614

[diagnosis]

  • Rectal cancer, adenocarcinoma, 10 cm from anal verge, cT4aN2M0, stage IIIC.

[exam findings]

  • 2023-06-17 Nasopharyngoscopy
    • right buccal leukoplakia, smooth NPx, OPx, HPx
  • 2023-04-28 CT - abdomen
    • History and indication:
      • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV
      • 20230103 CT: rectal cancer, invades the visceral peritoneum, cT4aN0M0, stage IIB
    • Findings:
      • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
        • Please correlate with colonoscopy.
      • S/P resection of S5, S6, and S7 of the liver.
      • Gallbladder stone (3mm).
      • Prior CT identified several nodular soft tissue lesions in the pre-sacral space are noted again, stationary. Benign process is suspected.
    • Impression:
      • Prior CT identified mild focal wall thickening at right lateral aspect of the rectum is not noted again.
      • Please correlate with colonoscopy.
  • 2023-01-13 MRI - pelvis
    • CC: Bloody stool passage
      • Rectal cancer, 10cm from AV Dx at TSGH, CCRT was arranged
      • 20230103 colonoscopy: Rectal cancer at right lateral wall, 8 cm from AV.
      • 20230103 CT:Rectal cancer, cT4aN0M0, cSTAGE:IIB
    • Findings - Comparison: prior CT dated 2020/12/04 and 2021/06/18.
      • There is a soft tissue mass measuring 2 x 1.5 cm in right lateral wall of the rectum that is c/w adenocarcinoma.
        • In addition, There are few engorged vascular structure at the right lateral perirectal tumor space that may be extramural vascular invasion (EMVI) (T4a).
      • There are five enlarged nodes in right perirectal space and right superior rectal space (N2a).
      • S/P near total right hepatectomy and S/P cholecystectomy. (E1)
      • Prior CT identified several nodular lesions in pre-sacral space are noted again, stable in size and feature.
        • All lesions show enhancement in portal venous phase images.
        • Benign vascular lesions are highly suspected.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2023-01-03 Patho - colorectal polyp
    • Colorectum, proximal transverse colon, suspect previous polypectomy site, Biopsy, Specimen: A — chronic inflammation.
      • Section shows piece(s) of benign colon mucosa with chronic inflammation. Cryptitis or crypt abscess is not present.
    • Colorectum, D-colon, 40 cm & 25cm , suspect previous polypectomy sites, biopsy was done at 40cm sites, Specimen: B — ulcer with acute and chronic inflammation.
      • Section shows piece(s) of benign colon mucosa with ulcer, acute and chronic inflammation. Cryptitis or crypt abscess is not present.
    • Colorectum, rectum, right lateral wall, 8 cm from AV, Biopsy Specimen: C — Adenocarcinoma.
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-01-03 CT - abdomen
    • History and indication: Rectal cancer, 10cm from AV
    • Findings
      • Focal wall thickening of rectum with adjacent fat stranding.
      • S/P liver operation.
      • Gallbladder stone (3mm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N0(N_value) M:M0(M_value) STAGE:IIB(Stage_value)
  • 2022-09-17 L-spine AP + Lat. (including sacrum):
    • Disc space narrowing at L2-3 level.
    • Lumbar spondylosis.
  • 2021-06-18 CT - abdomen
    • History and indication: Diffuse abdominal pain. suspect peritionitis
    • Findings
      • S/P liver operation.
      • A patchy density (1.9cm) at RLL.
      • Distention of gallbladder. Mild dilatation of IHD.
      • Atherosclerosis of aorta, iliac, coronary and visceral arteries.
    • IMP:
      • S/P liver operation.
      • A patchy density (1.9cm) at RLL.
      • Distention of gallbladder. Mild dilatation of IHD.
  • 2021-06-03 KUB
    • S/P operation with retention of surgical clips.
    • Degeneration and spondylosis of L-S spine.
    • Stool retention in the bowel.
  • 2020-12-04 CT - abdomen
    • History and indication: RUQ tender, suspected cholecystitis
    • IMP: Distention of gallbladder. R/O distal CBD stone (6mm).
  • 2020-01-20 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Fish bone misswallowing s/p endoscopic foreign body extraction.
      • Reflux esophagitis LA Classification grade A
      • Gastric erosion, antrum.
    • Suggestion
      • PPI and Sucralfate use.

[radiotherapy]

  • 2022-01-13 ~ undergoing - 5040cGy/28 fx, preoperative CCRT

[chemotherapy]

  • 2023-07-03 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-06-13

  • 2023-05-23

  • 2023-04-28

  • 2023-04-06

  • 2023-03-24

  • 2023-03-14

  • 2023-03-23

  • 2023-02-06 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-13 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 10min + fluorouracil 2400mg/m2 4200mg NS 500mL 46hr (FOLFOX Q2W)

    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-07-04

The medications Janumet (sitagliptin, metformin), Kentamin (B1, B6, B12), Diovan (valsartan), and Livalo (pitavastatin) were prescribed at Tri-Service General Hospital on 2023-06-10 and recently refilled on 2023-06-30. However, none of these drugs are currently included in the active medication list. Please verify whether these medications are still required for the patient’s current condition.

2023-06-14

  • This patient recently visited Tri-Service General Hospital for his primary diagnosis of malignant neoplasm of the rectum. The medications prescribed during this visit were sitagliptin, thiamine, valsartan, pitavastatin, ambroxol, and glycyrrhiza extract. These medications, or their equivalent therapeutic classes, are already included in the current active prescription. No issues with medication reconciliation were identified.

700325303

230613

[lab data]

2023-05-10 Blood gas (Vein) 2023-05-10 PH 7.499
2023-05-10 PCO2 39.6 mmHg
2023-05-10 PO2 82.5 mmHg
2023-05-10 HCO3 30.1 mmol/L
2023-05-10 ctCO2 31.3 mmol/L
2023-05-10 Base Excess 7.1 mmol/L
2023-05-10 BEecf 6.9 mmol/L
2023-05-10 SBC 29.7 mmol/L
2023-05-10 O2 Saturation 97.2 %

2023-05-10 Blood Osmolality 291 mOsm/Kg

2023-05-08 Blood gas (Vein) 2023-05-08 PH 7.488
2023-05-08 PCO2 47.6 mmHg
2023-05-08 PO2 47.9 mmHg
2023-05-08 HCO3 35.3 mmol/L
2023-05-08 ctCO2 36.7 mmol/L
2023-05-08 Base Excess 10.6 mmol/L
2023-05-08 BEecf 11.9 mmol/L
2023-05-08 SBC 33.0 mmol/L
2023-05-08 O2 Saturation 87.9 %

2023-05-08 Free Light Chain κ/λ (blood) ratio 2023-05-08 FKLC 8.6 mg/L
2023-05-08 FLLC 10900.0 mg/L
2023-05-08 FK/FL ratio <0.01 ratio

2023-05-02 Protein EP 2023-05-02 Protein, total 6.1 g/dL
2023-05-02 Albumin 59.6 %
2023-05-02 Alpha-1 3.2 %
2023-05-02 Alpha-2 16.6 %
2023-05-02 Beta 11.1 %
2023-05-02 Gamma 9.5 %
2023-05-02 M-peak Negative
2023-05-02 A/G Ratio 1.50

2023-04-29 B2-Microglobulin 13021 ng/mL
2023-04-28 IgG (blood) 687 mg/dL
2023-04-27 Ca (Calcium) 2.89 mmol/L
2023-04-27 LDH 706 U/L

2023-03-17 CD45+Total leukocyte 149733 /uL
2023-03-17 %CD34+ 0.56 %
2023-03-17 CD34+ Count 846 /uL

2023-03-17 HPC Ratio 0.15 %
2023-03-17 HPC# 0.029 10^3/ul

2023-03-16 CD45+Total leukocyte 127292 /uL
2023-03-16 %CD34+ 0.67 %
2023-03-16 CD34+ Count 848 /uL

2023-03-16 HPC Ratio 0.25 %
2023-03-16 HPC# 0.036 10^3/ul

2023-03-15 CD45+Total leukocyte 117620 /uL
2023-03-15 %CD34+ 0.78 %
2023-03-15 CD34+ Count 915 /uL
2023-03-15 HPC Ratio 0.47 %
2023-03-15 HPC# 0.038 10^3/ul

2023-03-15 Ca (Calcium) 2.21 mmol/L
2023-03-15 Alkaline phosphatase 74 U/L
2023-03-15 LDH 235 U/L

2023-03-10 Ca (Calcium) 2.18 mmol/L
2023-03-10 Alkaline phosphatase 69 U/L
2023-03-10 LDH 183 U/L

2023-03-05 Alkaline phosphatase 74 U/L
2023-03-05 LDH 197 U/L

2023-03-05 Total protein 6.3 g/dL

2023-03-05 PT 10.4 sec
2023-03-05 INR 1.01
2023-03-05 APTT 26.7 sec

2023-02-20 Free Light Chain κ/λ (blood) ratio
2023-02-20 FKLC 13.3 mg/L
2023-02-20 FLLC 101 mg/L
2023-02-20 FK/FL ratio 0.13 ratio

2023-02-17 Protein EP 2023-02-17 Protein, total 5.4 g/dL
2023-02-17 Albumin 58.3 %
2023-02-17 Alpha-1 3.1 %
2023-02-17 Alpha-2 11.8 %
2023-02-17 Beta 13.1 %
2023-02-17 Gamma 13.7 %
2023-02-17 M-peak Negative
2023-02-17 A/G Ratio 1.40

2023-02-16 B2-Microglobulin 2245 ng/mL
2023-02-15 IgG (blood) 588 mg/dL

2023-02-15 HBsAg Nonreactive
2023-02-15 HBsAg (Value) 0.29 S/CO

2023-02-15 Anti-HBc Nonreactive
2023-02-15 Anti-HBc-Value 0.09 S/CO

2023-02-15 Anti-HCV Nonreactive
2023-02-15 Anti-HCV Value 0.06 S/CO

2023-02-15 Total protein 5.7 g/dL
2023-02-15 Ca (Calcium) 2.22 mmol/L
2023-02-15 LDH 206 U/L

  • 2022-12-12 (at Cardinal Tien Hospital)
    • IgG: 5288mg/dl
    • IgA: 34mg/dl
    • IgM: 29mg/dl
    • IgD: <46.7IU/ml
    • B2-Microglobulin: 3241ng/ml

[exam findings]

  • 2023-05-08 ECG
    • Sinus rhythm with 1st degree A-V block
    • Left atrial enlargement
  • 2023-05-08 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Dilation of central pulmonary arteries pulmonary trunk
    • Moderate enlarged cardiac silhoutte
    • Clean lung fields based on plain image
    • Normal appearance of both hila
  • 2023-05-02 Patho - bone marrow biopsy
    • Bone marrow, ilium, biopsy — Plasma cell myeloma
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study, flow cytometery and clinical findings is recommended.
    • Microscopically, it shows hypercellularity (>90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<=2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities.
    • Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse+), CD138 (diffuse+), MPO(focal +, <=2%), CD71(<1%).
  • 2023-04-28 CT - abdomen
    • Indication: Multiple myeloma not having achieved remission
    • Findings:
      • Both kidneys show several ill-defined wedge-shaped poor-enhancing areas that may be acute pyelonephritis.
        • The differential diagnosis includes infiltrative lesions.
        • Please correlate with urine routine.
      • A hepatic cyst 2 cm in S7 is noted.
      • There is an ill-defined poor enhancing lesion 6 mm in the spleen. Follow up is indicated.
    • Impression:
      • Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Please correlate with urine routine.
  • 2022-07-20 Patho - bone marrow biopsy (at Cardinal Tien Hospital)
    • C/W Plasma cell myeloma, IgG/Lambda type
    • Immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++.
  • 2022-07 MRI - right femur (at Cardinal Tien Hospital)
    • suspect multiple bone metastasis.
  • 2022-03 CT - chest (at Cardinal Tien Hospital)
    • hepatic cyst in segment 7 of right lobe liver.

[consultation]

  • 2023-05-09 Oral and Maxillofacial Surgery
    • Q
      • Today, she was admitted for short of breathing, hyperkalemia on 2023/05/09, and plan to receive Xgeva treatment, so we need your help for oral health assessment, thanks a lot!!
    • A
      • After intraoral dental examination, no dental decay or mobile teeth was noticed.
      • Xgeva could be used safely.

[MedRec]

  • 2023-05-04 SOAP Nephrology
    • S
      • Hypokalemia was detected during admission
      • Hypercalcemia was also detected
      • Urine K 22.4
      • DM (+) for 10 years.
      • Actos 1# qd, metformin 1# bid, Diamicron 1# qd
    • O
      • BP: 145/66; HR: 87;
      • leg edema (-)
      • CVA knocking pain (-)
      • 2023-05-02 Creatinine 1.21 mg/dL
      • 2023-04-27 Creatinine 1.60 mg/dL
      • 2023-03-15 Creatinine 0.44 mg/dL
      • 2023-02-15 Creatinine 0.64 mg/dL
    • A
      • Suspected poor oral intake with hypercalcemia (diuresis) related hypokalemia.
  • 2023-04-07 ~ 2023-05-04 POMR Hemato-Oncology
    • Course of Inpatient Treatment
      • After admission, owing to blood test showd Balst: 5%, R/O multiple myeloma change to AML. We check total protine, Alb, IgG, B2-Microglobulin, AML+ALL/Myeloid, Protein EP, Free Light Chain κ/λ on 4/27 23 and report showed B2-Microglobulin: 13021 ng/mL, IgG: 687mg/dl, total protine: 6.5g/dl, Alb: 3.8g/dl, protine EP: total protine: 6.1, Alpha-1: 3.2, Alpha-2: 3.2. Beta: 11.1, Gamma: 9.5, M-peak: negative, A/G Ratio: 1.50.
      • Bone marrow on 5/2 23 for further diagnosis and pathology (5/5 23) proved Plasma cell myeloma, hypercellularity (> 90%) and marked proliferation of plasm cells. Blast-like cells highlighted by CD117 is seen (<= 2%). Megakaryocytes are present in normal in numbers (1 per HPF) and demonstate no significant morphologic abnormalities. Immunohisotchemical stain reveals CD34(-), Kappa ligh chain(-), Lambda light chain (diffuse +), CD138 (diffuse +), MPO(focal +, <= 2%), CD71(< 1%).
      • LYRICA 75mg 1# po hs, Deflam-K 25mg 1# po bidprn was added for neuropathic pain due to herpes zoter related.
      • Intervenous KCL 500ml qd, MgSo4 1amp in N/S 100ml IVF 1hr qd, Miacalcic 100 unit q12h were given for hypokalemia, hypomagnesemia and hypercalcemia.
      • The abdominal CT (4/28 23) shwoed Acute pyelonephritis of both kidney is highly suspected. The differential diagnosis includes infiltrative lesions. Septic work-up was performed and antibiotic with Seforce 400mg ivd q12h since 4/28 23. She felt bilateral flanks pain much better.
    • Prescription
      • Const-K (potassium chloride 750mg/10mEq) 1# QD
      • MgO 250mg 1# TID
      • Cinolone (ciprofloxacin 250mg) 2# BIDAC
  • 2023-03-31 SOAP Hemato-Oncology
    • O: 2023/03/17 CD45+ Total leukocyte = 149733/uL
  • 2023-03-05 ~ 2023-03-17 POMR Hemato-Oncology
    • Discharge diagnosis
      • Multiple myeloma not having achieved remission, Bone marrow biopsy (2022/7/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138+++, Kappa light chain -, LAmbda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA:34mg/dl, IgM:29mg/dl, IgD:<46.7IU/ml, B2-Microglobulin :3241ng/ml on 2022-12-12. C1 chemotherapy with Endoxan on 3/6, 3/15, 3/16, 3/17 collect PBSC
      • Endometrium cancer stage I S/P operation on 2013-04
      • Diabetes mellitus due to underlying condition without complications
      • Anemia due to antineoplastic chemotherapy
    • Present Illness
      • This 64-yeasr-old woman, a patient of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response at Cardinal Tien Hospital, suffered from right thight pain when walking June 2022 then visited to Cardinal Tien Hospital for survey and treatment.
      • Image study with right femur MRI (2022/07) showed suspect multiple bone metastasis. Chest CT (2022/07) shwoed negative and abdominal CT (2022/03) revealed hepatic cyst in segment 7 of right lobe liver.
      • Bone marrow biopsy (2022/07/20) proved C/W Plasma cell myeloma, IgG/Lambda type, immunostatins: CD138 +++, Kappa light chain -, Lambda light chain ++, CD34 Focally +, CD71 ++. The laboratory showed IgG: 5288mg/dl, IgA: 34mg/dl, IgM: 29mg/dl, IgD: <46.7IU/ml, B2-Microglobulin: 3241ng/ml on 2022-12-12.
      • She received chemotherapy with VRD (VELCADE / Revlimid / Dexamethasone 20mg) Q3W x 6 since 2022/08/17 to 2022/12/29 finished.
    • CC: for C1 chemotherapy with Cycolphosphamide/Mesna & collect stem cells
    • Course of Inpatient Treatment
      • After admission, chemotherapy with Cyclophosphamide/Mesna was given on 3/6 23 & Mesna 0.6g/m2 from Endox for 4hrs start/from Endox for 8hrs start/from Endox for 12hrs start on 3/6 23, smoothly without obvious side effect.
      • Lenograstim 500mcg & G-CSF 150mcg total 650mcg sc qd was administered post C/T 24hrs given on 3/7 to 3/17 23. right neck double Lumen Catheter was inserted and collect stem cells on 3/15, 3/16, 3/17 23 was done and Vitacal was added for symptom relief of hypocalcemia. Mild bone pain was told due to Lenograstim related and NSAID was given for pain control. Blood transfusion with LPRBC 2U was given on 3/16 23.
  • 2023-02-15 SOAP Hemato-Oncology
    • Plan
      • recheck the disease status
      • prepare for chemotherapy at 2023-03-06, and collection of the stem cell at 2023-03-15.
  • 2023-01-04 SOAP Hemato-Oncology
    • S: She was referred on account of multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
      • Review the referring sheet and system review.
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history:
      • Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: NKA.
      • Travel history: No traveling history within one month.
      • Occupation: Salesperson
    • Assessment: multiple myeloma, IgG, ISS stage II, S/P VRD therapy X 6 with very good partial response, for discussion about auto_HSCT
    • Plan: discussion about auto-HSCT
    • Diagnosis: Multiple myeloma not having achieved remission C90.00

[chemotherapy]

  • 2023-06-13 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 900mg NS 500mL 6hr D1
    • dexamethasone 20mg PO + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL
  • 2023-05-23 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
  • 2023-05-15 - bortezomib 1.3mg/m2 2.3mg SC 0.5min D1
    • dexamethasone 20mg PO D1-2
  • 2023-05-12 - bortezomib 1.3mg/m2 2.0mg SC 0.5min D1 + daratumumab 16mg/kg 1000mg NS 1000mL 6hr D1
    • dexamethasone 20mg PO D1-2
  • 2023-03-06 - cyclophosphamide 2000mg/m2 3400mg NS 500mL 60min + mesna 0.6mg/m2 1000mg NS 500mL 60min (Y-sited Endoxan) and 3 times (each 30min at 4, 8, 12hr after Endoxan)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + NS 250mL
  • 2022-08-17 ~ 2022-12-29 - VRd

Bortezomib (Velcade), lenalidomide (Revlimid), and “low dose” dexamethasone (VRd) for multiple myeloma 2023-05-10 https://www.uptodate.com/contents/image?imageKey=ONC%2F91054&topicKey=HEME%2F6647

  • Cycle length: 21 days.

  • Regimen

    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, and 15
    • Lenalidomide
      • 25 mg by mouth
      • Administer with water. Swallow capsule whole; do not break, open, or chew.
      • Daily, on days 1 through 14
    • Dexamethasone
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, and 15
  • Pretreatment considerations:

    • Emesis risk
      • MINIMAL TO LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction (not including local reactions) occurs with bortezomib or lenalidomide, then neither drug should be readministered.
    • Antithrombotic prophylaxis
      • Routine antithrombotic prophylaxis is warranted. Thromboembolism was reported in 2 to 6% of patients in clinical trials receiving VRd despite antithrombotic prophylaxis.
      • The risk of thromboembolism was over 10% with another lenalidomide and high-dose dexamethasone (RD) regimen.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia.
      • Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VRd.
      • Some clinicians also administer prophylactic trimethoprim-sulfamethoxazole (eg, one double-strength tablet once daily on Mondays, Wednesdays, and Fridays) during treatment.
      • Primary prophylaxis with G-CSF is not indicated.
    • Vesicant/irritant properties
      • Bortezomib is an irritant.
    • Dose adjustment for baseline liver or renal dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to renal insufficiency is necessary.[6] For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the ULN) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Lenalidomide: Patients with renal insufficiency experience more neutropenia with lenalidomide.[7] Dose adjustment is recommended for patients with CrCl <60 mL/min.[8] At this time, studies have not been conducted in patients with hepatic impairment.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, renal function, and liver function prior to starting each cycle. A CBC should also be performed prior to the day 8 and 15 doses of bortezomib during induction therapy.
    • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
    • Monitor for hypotension during bortezomib therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • A cycle of VRd should not be started unless the ANC is >=1000/microL and the platelet count is >=70,000/microL. If platelets are <50,000/microL or the ANC is <1000/microL on day 15, hold day 15 bortezomib dose. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2 or from 1.3 mg/m2 to 1 mg/m2 or from 1 mg/m2 to 0.7 mg/m2) and decrease the daily dose of lenalidomide by 5 mg. Growth factor support can be given on day 8 of the second and subsequent cycles for ANC <500/m2 lasting >7 days or for an episode of febrile neutropenia.
    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
        • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
        • Grade 1 (with pain) or Grade 2 (interfering with function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
        • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
        • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
      • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, renal failure, and/or neurologic findings.[6] If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, hold lenalidomide and bortezomib. Once symptoms have resolved to grade 1 or baseline, reinitiate therapy with lower doses. Reduce dexamethasone dose for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion, or mood alterations.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

DVd (Daratumumab + Velcade (bortezomib) + dexamethasone) is a Chemotherapy Regimen for Multiple Myeloma (MM) 2023-05-10 https://www.chemoexperts.com/dvd-daratumumab-velcade-bortezomib-dexamethasone.html

  • How does DVd work?
    • Each of the medications in the DVd (Daratumumab, Velcade, dexamethasone) regimen is designed to kill or slow the growth of myeloma cells.
  • Regimen
    • D - Daratumumab (Darzalex)
    • V - Velcade (bortezomib)
    • d - dexamethasone (dex)
  • Goals of therapy:
    • DVd is not given to cure multiple myeloma, but rather to slow the progression of the disease and to decrease symptoms.
  • Schedule
    • Drugs
      • Daratumumab intravenous (I.V.) infusion or subcutaneous (SubQ) injection (Darzalex Faspro) on Days 1, 8, and 15 of Cycles 1, 2, and 3; then Day 1 only of Cycles 4, 5, 6, 7, and 8, then once monthly (every 28 days) thereafter. The time of infusion varies depending upon the tolerability and number of previous infusions.
      • Bortezomib subcutaneous (S.Q.) injection on Days 1, 4, 8 and 11 of Cycles 1, 2, 3, 4, 5, 6, 7, and 8
      • Dexamethasone 20 mg (five 4 mg tablets) by mouth on Days 1, 2, then Days 4, 5, then Days 8, 9, then Days 11, 12 of Cycles 1 through 8.
    • Cycles 1 through 8 are repeated every 21 days.
  • Estimated total infusion time for this treatment:
    • For daratumumab, Cycle 1 Day 1 may take up to 8 hours because of the possibility of experiencing infusion reactions. If you do not experience any with the first infusion, Cycle 1 Day 8 may be reduced to 6 hours. If you do not experience any infusion reactions during the first two daratumumab doses, it may only take up to 4 hours after that. There is also a 90-minute rapid infusion option if it is well tolerated.
    • If daratumumab is given by subcutaneous injection (Darzalex Faspro), there may be an observation time of up to 6 hours after the first dose to observe for reactions. If no reactions are seen, the observation times for future doses may be much shorter or not needed at all.
    • On days that only bortezomib and dexamethasone are given, infusion time may be as little as 1 hour
    • Infusion times are based on clinical studies, but may vary depending on doctor preference or patient tolerability. Pre-medications and intravenous (I.V.) fluids, such as hydration, may add more time.
    • DVd is usually given in an outpatient infusion center, allowing the person to go home afterwards. It is repeated every 21 days. This is known as one Cycle. Each cycle may be repeated up to eight times and then ONLY daratumumab is given (no Velcade or dexamethasone) until daratumumab no longer works or until unacceptable side effects occur.
  • Side Effects
    • In clinical studies, the most commonly reported DVd (daratumumab + Velcade + dexamethasone) side effects are shown here:
      • Increased bleeding risk [low platelet count; thrombocytopenia] (59%)
      • Pins-and-needles feeling in fingers and toes (47%)
      • Diarrhea (32%)
      • Anemia [low red blood cell count] (26%)
      • Sinus infection (25%)
      • Cough (24%)
      • Fatigue (21%)
      • Constipation (20%)
      • Shortness of breath (19%)
      • Low white blood cells (18%)
      • Trouble sleeping (17%)
      • Fluid retention (17%)
      • Fever (16%)
      • Pneumonia (12%)
      • Weakness (9%)
      • High blood pressure (9%)
  • Monitoring
    • How often is monitoring needed?
      • Labs (blood tests) may be checked before treatment and periodically during treatment. Labs often include: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), serum protein electrophoresis (SPEP), urine protein electrophoresis (UPEP), serum free light chains (FLC), quantitative immunoglobulins, plus any others your doctor may order.
    • How often is imaging needed?
      • Imaging may be checked during treatment. Imaging may include: bone scans, computerized tomography (CT) scans, or magnetic resonance imaging (MRI).
    • How might blood test results/imaging affect treatment?
      • Depending upon the results, your doctor may advise to continue DVd as planned, reduce the dose of future treatments, delay the next dose until the side effect goes away, or switch to an alternative therapy.

NHS - Chemotherapy Protocol - Myeloma - DVd (Weekly) Bortezomib-Daratumumab-Dexamethasone (cycles 1 to 8) https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/Myeloma/DVd-Weekly-Daratumumab-Bortezomib-Dexamethasone-Cycles-1-to-8.pdf

==========

2023-06-21

2023-06-13

The DVd regimen (Daratumumab + Velcade (bortezomib) + dexamethasone) was initiated on 2023-05-12. Pancytopenia was observed, but it’s important to note that bicytopenia (anemia and thrombocytopenia) was already present even before the regimen started. Furthermore, the fluctuations in HGB and PLT levels are smaller than those in the WBC count. This can be attributed to the fact that the patient has received multiple blood transfusions at our hospital (on 2023-03-16, 2023-04-28, 2023-05-09, 2023-05-15, 2023-05-19, 2023-05-26, 2023-05-31, 2023-06-08, 2023-06-13), which have helped replenish red blood cells and platelets.

  • 2023-06-13 PLT 45 x10^3/uL

  • 2023-06-11 PLT 10 x10^3/uL

  • 2023-06-08 PLT 51 x10^3/uL

  • 2023-06-05 PLT 24 x10^3/uL

  • 2023-06-02 PLT 34 x10^3/uL

  • 2023-05-31 PLT 14 x10^3/uL

  • 2023-05-29 PLT 54 x10^3/uL

  • 2023-05-28 PLT 89 x10^3/uL

  • 2023-05-26 PLT 8 x10^3/uL

  • 2023-05-24 PLT 33 x10^3/uL

  • 2023-05-23 PLT 57 x10^3/uL

  • 2023-05-22 PLT 19 x10^3/uL

  • 2023-05-19 PLT 78 x10^3/uL

  • 2023-05-17 PLT 25 x10^3/uL

  • 2023-05-15 PLT 58 x10^3/uL

  • 2023-05-12 PLT 15 x10^3/uL

  • 2023-05-10 PLT 49 x10^3/uL

  • 2023-05-08 PLT 23 x10^3/uL

  • 2023-06-13 HGB 7.7 g/dL

  • 2023-06-11 HGB 7.5 g/dL

  • 2023-06-08 HGB 6.7 g/dL

  • 2023-06-05 HGB 7.4 g/dL

  • 2023-06-02 HGB 8.7 g/dL

  • 2023-05-31 HGB 7.5 g/dL

  • 2023-05-29 HGB 8.5 g/dL

  • 2023-05-28 HGB 8.1 g/dL

  • 2023-05-26 HGB 8.9 g/dL

  • 2023-05-24 HGB 9.4 g/dL

  • 2023-05-23 HGB 8.5 g/dL

  • 2023-05-22 HGB 7.6 g/dL

  • 2023-05-19 HGB 8.4 g/dL

  • 2023-05-17 HGB 9.0 g/dL

  • 2023-05-15 HGB 6.8 g/dL

  • 2023-05-12 HGB 8.8 g/dL

  • 2023-05-10 HGB 8.2 g/dL

  • 2023-05-08 HGB 8.0 g/dL

Since the VRd (bortezomib, lenalidomide, dexamethasone) regimen has already been utilized from 2022-08-17 to 2022-12-29, and the DVd regimen is preferred in patients who are refractory to full doses of lenalidomide or a lenalidomide-containing triplet, the choice of DVd regimen is reasonable in this case. The major toxicities of the DVd regimen include peripheral neuropathy, transient cytopenias, acute or delayed hypersensitivity reaction, fatigue, and nausea. At present, the WBC count has exceeded the upper limit of normal, reversing the previous leukopenia and presenting as a problem of leukocytosis.

  • 2023-06-13 WBC 16.35 x10^3/uL
  • 2023-06-11 WBC 11.96 x10^3/uL
  • 2023-06-08 WBC 8.48 x10^3/uL
  • 2023-06-05 WBC 5.33 x10^3/uL
  • 2023-06-02 WBC 2.48 x10^3/uL
  • 2023-05-31 WBC 1.32 x10^3/uL
  • 2023-05-29 WBC 0.90 x10^3/uL
  • 2023-05-28 WBC 0.73 x10^3/uL
  • 2023-05-26 WBC 0.68 x10^3/uL
  • 2023-05-24 WBC 0.41 x10^3/uL
  • 2023-05-23 WBC 0.39 x10^3/uL
  • 2023-05-22 WBC 0.36 x10^3/uL
  • 2023-05-19 WBC 0.42 x10^3/uL
  • 2023-05-17 WBC 0.64 x10^3/uL
  • 2023-05-15 WBC 2.06 x10^3/uL
  • 2023-05-12 WBC 21.19 x10^3/uL
  • 2023-05-10 WBC 28.72 x10^3/uL
  • 2023-05-08 WBC 34.88 x10^3/uL

[DVd regimen renal dosing checked]

The recent lab data indicates that the patient’s renal function has stopped deteriorating and shows signs of slight recovery.

  • 2023-06-13 Creatinine 1.86 mg/dL
  • 2023-06-11 Creatinine 1.92 mg/dL
  • 2023-06-08 Creatinine 1.99 mg/dL
  • 2023-06-05 Creatinine 1.86 mg/dL
  • 2023-06-02 Creatinine 1.60 mg/dL
  • 2023-05-31 Creatinine 1.45 mg/dL
  • 2023-05-29 Creatinine 1.51 mg/dL
  • 2023-05-28 Creatinine 1.56 mg/dL
  • 2023-05-26 Creatinine 1.45 mg/dL
  • 2023-05-24 Creatinine 1.25 mg/dL
  • 2023-05-23 Creatinine 1.11 mg/dL
  • 2023-06-13 BUN 31 mg/dL
  • 2023-06-11 BUN 38 mg/dL
  • 2023-06-08 BUN 41 mg/dL
  • 2023-06-02 BUN 21 mg/dL
  • 2023-05-31 BUN 18 mg/dL
  • 2023-05-29 BUN 16 mg/dL
  • 2023-05-28 BUN 18 mg/dL
  • 2023-05-26 BUN 22 mg/dL
  • 2023-05-24 BUN 16 mg/dL
  • 2023-05-23 BUN 16 mg/dL

For patients with CrCl between 15 to 89 mL/minute, there are no dosage adjustments provided in the daratumumab manufacturer’s labeling. Studies show that this range of renal function does not significantly affect the pharmacokinetics of daratumumab. Additionally, no dosage adjustment is necessary for bortezomib in patients with renal insufficiency. For the current treatment regimen of multiple myeloma, there is no need for dosage adjustment.

2023-05-15

[tube feeding]

  • As of 2023-05-15, the patient’s serum potassium level has been measured at 3.7 mmol/L, which falls within the normal range. Therefore, it may be less necessary to continue potassium supplementation, unless there’s clear evidence of ongoing potassium loss.
    • 2023-05-15 K(Potassium) 3.7 mmol/L
    • 2023-05-12 K(Potassium) 3.3 mmol/L
    • 2023-05-11 K(Potassium) 3.0 mmol/L
    • 2023-05-10 K(Potassium) 2.6 mmol/L
  • Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into particles small enough to pass through the feeding tube and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-05-10

  • Based on the PharmaCloud database, the patient has been diagnosed with “Other postherpetic nervous system involvement - B02.29”. The patient has an active, refillable prescription, including medications diclofenac, chlorzoxazone, and pregabalin. At present, the corresponding symptoms are being managed with these medications, or with others that have similar pharmacological effects. Therefore, no issues with medication reconciliation have been identified at this time.
  • The patient’s MM was previously treated with the VRd regimen (Velcade (bortezomib), Revlimid (lenalidomide) and dexamethasone) from mid-Aug to late Dec 2022 at Cardinal Tien Hospital. The DVd regimen (Darzalex (daratumumab), Velcade (bortezomib) and dexamethasone) is being considered as a new therapeutic strategy in the face of disease relapse.
  • If the DVd regimen is ultimately chosen, the first dose of daratumumab on Cycle 1 Day 1 may take up to 8 hours due to the potential infusion reactions. If the patient does not experience any reactions with the first infusion, the infusion time on Cycle 1 Day 8 can be reduced to 6 hours. If no infusion reactions occur during the first two doses of daratumumab, subsequent infusions may be shortened to around 4 hours.
  • By the way, daratumumab is no longer in stock at this time (and isatuximab remains unavailable).

701254669

230612

[diagnosis] - 2023-04-01 admission note

  • Epilepsy, unspecified, not intractable, without status epilepticus
  • Malignant neoplasm of unspecified site of left female breast
  • Constipation, unspecified
  • Pleural effusion in other conditions classified elsewhere
  • Chronic viral hepatitis B without delta-agent
  • Cachexia

[past history]

  • Breast ca with brain meta, lung meta with bilateral pleural effusion
  • HBV

[allergy]

  • NKDA

[family history]

  • Deny any family history

[exam findings]

  • 2023-06-10 CXR
    • Bilateral pleural effusion.
    • Compression fracture of T12. R/O bone lesions at right clavicle and right 5th rib.
  • 2023-05-09 KUB
    • Bilateral pleural effusion.
    • Compression fracture of T12-L1.
  • 2023-04-12 SONO - chest
    • Pleural effusion, moderate, bilateral, left>right, organizing
    • Atelectasis, LLL, RLL
    • Pleural thickening, irregular, bilateral
  • 2023-05-24, -05-05, -04-17, -04-11, -04-07, -03-29, -03-15, …, -01 CXR
    • Bilateral Pleura effusion
    • S/P port-A implantation.
    • S/P partial left Mastectomy?
    • Compression fracture of T12 and L1 vertebral body.
    • Old fracture of right clavicle?
  • 2023-04-07 KUB
    • Fecal material store in the colon.
    • Compression fracture of T12 and L1 vertebral body.
  • 2023-04-01 KUB
    • Stool retention in the bowel.
  • 2023-04-01 CXR
    • R/O bony metastases at right clavicle and right ribs.
    • Bilateral pleural effusion.
  • 2023-04-01 CT - brain
    • Findings
      • Minimal SAH at right frontal region.
      • No midline shift.
      • No abnormal low attenuation lesion in the brain parenchyma.
      • Widening of cortical sulci and dilatation of ventricles.
      • Degeneration and spondylosis of C-spine. Compression fracture of 4-6.
    • IMP:
      • Minimal SAH at right frontal region.
      • Brain atrophy.
  • 2023-01-17 Cell block
    • 50 cc yellow turbid pleural effusion — Atypia
    • The smears show lymphocytes, reactive mesothelial cells and scant atypical cell clusters show hyperchromasia and degenerative quality.
  • 2023-01-17 SONO - chest
    • Bilateral large amount pleural effusion s/p insertion of right side, 14 Fr. pig-tail catheter and fixed at 18cm.
  • 2023-01-16 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Borderline ECG
  • 2022-12-22 SONO - chest
    • pleural effusion
    • Chest echography was performed first. The suitable intercostal space was selected and located.
    • Catheter was inserted with negative pressure smoothly.
    • Right/Left side pleural effusion was drawn smoothly.
    • Watch out BP after tapping.
    • Send left side pleural effusion for examination about cytology (cell block),
    • biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
  • 2022-12-12 MRA - brain
    • Findings
      • Extradural dura-based lobulated tumors (15 mm and 38 mm) with diffusion restriction and vivid enhancement at right frontal convexity, associating with white matter edema beneath the larger one. Meningiomas are first considered. Pachymeningeal metasatses are less likely.
    • IMP: -Right frontal extra-axial tumors (15 mm and 38 mm). Meningiomas are first considered. D/D: metastases.
  • 2022-12-12 CT - brain
    • Indication:
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • A hyperdense right frontal dural based tumor (meningioma)? with white matter edema, up to 35 mm, infarct seems less likely.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
      • Sella and pituitary are normal, parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
    • Imp:
      • suspected a right frontal dural based tumor (meningioma) with white matter edema, infarct seems less likely.
  • 2022-12-12, -11-26 ECG
    • Sinus tachycardia
    • Low voltage QRS
  • 2022-09-19 CT - chest
    • Comparison was made with previous CT dated on 2022/05/31
      • moderate to massiave bilateral pleural effusions, increase in volume and parietal pleural thickening.
      • lungs: mild dependent atelectasis of LLL and RLL.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: normal caliber of thoracic aorta and central pulmonary arteries
      • Heart: normal in size of cardiac chambers.
      • Chest wall and visible lower neck: irregular soft tissue tumor with stippled calcifications and surrouding nodules at left breast, aasociated diffuse thickening over the overlying skin. small LNs at left axilla
      • Visible abdominal contents: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
      • Visualized bones: lytic or blastic change in bony structures still visible.
    • Impression:
      • advanced Lt breast cancer with skin involvement, bony metastasis, stationary, and increase in volume of pleural effusion, as compared with CT on 2022/05/31
  • 2022-09-13 SONO - chest
    • Right thorax: moderate amount pleural effusion s/p drainage of 700cc, yellowish pleural effusion.
    • Left thorax: small amount pleural effusion.
  • 2022-08-01 SONO - chest
    • Bilateral pleural effusion (Left: small and Right: small to moderate), post bilateral therapeutic thoracentesis.
  • 2022-05-31 CT - chest
    • Comparison was made with previous CT dated on 2022/03/03
      • moderate bilateral pleural effusions, stationary.
      • lungs: mild dependent atelectasis of LLL and RLL.
      • Chest wall and visible lower neck: irregular soft tissue tumor (at least 43 mm in longest dimesion with surrouding nodules at left breast, aasociated diffuse thickening over overlying skin. small LNs at left axilla
      • Visualized bones: lytic or blastic change in bony structures still visible.
    • Impression:
      • advanced Lt breast cancer with skin involvement, bony metastasis, and moderate pleural effusion, seem stationary.
  • 2022-03-03 CT - chest
    • Findings
      • Soft tissue lesion at left breast up to 2.26cm in largest dimension. The lesion decreased minimally as compared with previous CT on 2021-11-25.
      • There is bilateral pleural effusion. r/o pleural meta. sdtationary.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Left breast cancer with bone meta and pleural meta. The primary tumor regressed minimally.
  • 2021-11-26 Tc-99m MDP bone scan with SPECT
    • In comparison with the previous study on 2020/12/24, some of the previous bone lesions are a little more evident, suggesting multiple bone metastases in a little more progression.
  • 2021-11-25 CT - chest
    • Indication: left breast cancer with pleural & bone mets
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Loculated, modereate right pleural effusion is found.
        • s/p pigtail placement at left hemithorax. Minimal left pleural effusion is found.
        • Soft tissue mass at left breast up to 2.67cm in largest dimension. In comparison with CT dated on 2021-05-06, mild progression is found.
        • Tiny nodular lesion at left lower lobe is found. Lung meta is considered.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • The GB is well distended without soft tissue lesion
        • There is no evidence of paraarotic LAPs.
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Left breast cancer with left lung and bone meta. Bilateral pleural effsuion. The main mass increased in size slightly
  • 2021-11-22 Cell block
    • 50 cc yellow turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
  • 2021-11-22 SONO - chest
    • Bilateral pleural effusion (Left: massive and Right: moderate), s/p left diagnostic thoracentesis plus pig-tail insertion and right therapeutic thoracentesis.
  • 2021-05-06 CT - chest
    • Indication: breast ca for further staging
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue nodule at left breast up to 2.34*1.79cm in largest dimension. Breast cancer is favored. In comparison with CT dated on 2020-10-01, the lesion regressed.
        • There is moderate bilateral pleural effusion.
        • The lung fields are clear.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Visible brain
        • Marked prominent sulci, fissue and dilated ventricles indicate brain atrophy.
        • No evidence of space occupying lesion in the brain parenchyma is found.
    • Imp:
      • Left breast cancer, in regression.
      • Bilateral pleural effusion.
      • Spine meta. Please correlate with bone scan for treatment respoonse.
  • 2020-12-24 Tc-99m MDP bone scan with SPECT
    • In comparison with the previous study on 2020/10/05, some new bone lesions are noted and some of the previous bone lesions are more evident, suggesting multiple bone metastases in progression.
  • 2020-10-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 32) / 93 = 65.59%
      • M-mode (Teichholz) = 65
    • Conclusion:
      • Adequate LV,RV systolic function with normal wall motion
      • Thick LVPW, Impaired LV relaxation
      • Poor echo window
  • 2020-10-07 SONO - chest
    • Pleural effusion, massive, left
    • No pleural effusion, right
  • 2020-10-06 Patho - breast biopsy
    • Unspecified site, Labeled as “Left breast tumor with bone metastasis”, biopsy — carcinoma.
    • Section shows pieece of fibroadipose tissue with carcinoma highlighted by IHC stain of CK (+).
  • 2020-10-05 Tc-99m MDP bone scan
    • The scintigraphy suggests skeletal metastasis in skull, spine, rib cages, sternum, scapulae, clavicles, bilateral pelvic bones, and left femur.
  • 2020-10-03 MRI - brain
    • No brain nodule found.
    • Right skull metastases was highly suspected.
  • 2020-10-02 Cell block
    • 50 cc red turbid pleural effusion — Positive for malignancy
    • The smears and cell block show lymphocytes, reactive mesothelial cells and many atypical epithelial cell clusters.
    • Immunocytochemistry shows TTF-1(-), GATA-3(+), ER(1+, 50-60%), PR(3+, 10-20%) and Her2/neu(-, Dako score 1+) for tumor cells. According to clinical information and cytomorphologic findings, it is compatible with metastatic carcinoma of breast origin.
  • 2020-10-01 CT - chest
    • History and indication: PLEURAL EFFUSION, BILATERAL
    • Non-contrast CT of chest revealed:
      • A soft tissue tumor (4.3cm) at left breast with adjacent skin thickening and bil. neck and axillary LAP.
      • Osteolytic lesions at L1 and L4.
      • Bil. pleural effusion with adjacent lung collapse.
      • Some LNs at mediastinum.
      • A tumor (3.9cm) at uterus r/o myoma.
    • IMP:
      • In favor of left breast cancer with multiple LNs and spine metastases.
      • Bil. pleural effusion with adjacent lung collapse.
  • 2020-10-01 CXR
    • Bilateral pleural effusion.

[MedRec]

  • 2023-03-15 SOAP Hemato-Oncology
    • Xgeva 120mg
  • 2023-02-15 SOAP Hemato-Oncology
    • Xgeva 120mg
  • 2023-01-06 SOAP Radiation Oncology
    • 2022/12/27~ - RT to the whole brain: 18 Gy/ 6 fx. The metastatic brain tumor: 27 Gy/ 9 fx.
  • 2022-12-30 SOAP Radiation Oncology
    • Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx.

[consultation]

  • 2023-02-02 Family Medicine
    • Q
      • for share care or hospice care
      • Owing to disease progression noted and we explained her poor condition to her family and DNR was consented. We need expertise to evaluate her condition thanks!
    • A
      • S: 56-year-old female, left breast cancer with bones metastasis & possible pleural metastasis with massive pleural effusion and brain metastasis, stage IV.
      • O:
        • Now under bilateral pig-tail drainage
        • Consciousness alert, ECOG 2
        • Patient herself prefer continuation of chemotherapy
        • We will arrange hospice combine care and follow her condition
        • Indication: Left breast cancer
      • Plan
        • Combined Hospice Care
  • 2023-01-24 Infectious Disease
    • Q
      • Suspect hopital acquired pneumonia
      • Will de-escalate when culture results are available
    • A
      • Consultation for IV Zyvox antibiotic
      • 56-year-old breast cancer female patient, who has both-lung effusion with pigtail drainage, has newly developed pneumonia of both lower lobes.
      • Besides Brosym and Cravit, iv Zyvox is added for coverage of possible MRSA infection.
      • Since patient can take oral medications, oral Zyvox is preferred in this case.
      • Please cancel iv Zyvox and add oral Zyvox for 3 days first.
      • Check blood and sputum culture report for further antibiotic adjustment.
  • 2022-12-14 Radiation Oncology
    • A
      • This 56 y/o female was diagnosed left breast cancer with pleura and bone meta. Bilateral pleura effusion was noted.
      • This time, she sufferred from seziure attack. She came to our ER for help. Brain CT and MRA showed suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema.
      • Palliative radiothearpy is indicated. CT-simulation will be arranged on 2022/12/20. Plan to deliver 18 Gy/ 6 fx to the whole brain. Then boost the Rt convexity metastases to 36 Gy/ 12 fx. RT will start around 2022/12/21 or 22. Thank you very much.
  • 2022-12-12 Neurosurgery
    • Q
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • A
      • O
        • at present,
          • E4V5M6
          • pupil: 3+/3+
          • MP R L
          • UE 5 4+
          • LE 5 5
        • ct/MRI: suspect right convexity metastasis with leptomeningeal seeding, tumor perifocal edema
      • Plan:
        • please admit to my service
        • give AED and dexan iv
  • 2022-12-12 Neurology
    • Q
      • 05:30 Wake up
      • 07:00 Dizziness started, no weakness.
      • Dizziness and left face twitchness.
      • PHx: breast ca with pleural effusion and bone metastasis
      • NKDA
    • A
      • S: This 56 y/o patient with terminal breast CA presented with left face twiching for 8 mins
      • O
        • GCS: E4V5M6
        • MP: RU:4 RL:4 LU:4 LL:4
        • Brain MRA with contrast: Right frontal extra-axial tumors, suspected meningioma
      • Imp:
        • Focal onset aware seizures, might due to right frontal extra-axial tumors
      • Suggestion:
        • Keppra 1000mg ST and 500mg #1 BID
        • Consult NS for right frontal extra-axial tumors
  • 2020-11-12 Dermatology
    • Q
      • for left leg skin rash & icthing for half year ago
      • This 54-year-old woman, a patient of left breast cancer with bone mets S/P C/T. She was admitted for chemotherapy. She complained of left leg skin rash & icthing for half year ago. We need expertise to evaluate her condition thanks!
    • A
      • Skin finding: annular erythematous patches with scalings on left lower leg
      • Imp: tinea corporis
      • Plan: exelderm cream BID topical used

[radiotherapy]

[chemotherapy]

  • 2023-06-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-27 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-02-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-11-08 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-25 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-26 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-12 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-08-29 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-08-15 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-07-04 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-30 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-23 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-09 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-05-02 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-04-18 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-04-11 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-14 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-03-01 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-02-21 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-02-07 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-24 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-10 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-01-03 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-12-20 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-12-13 - eribulin 1.4mg/m2 2mg NS 50mL 10min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-04-23 - docetaxel 75mg/m2 110mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-04-01 - docetaxel 75mg/m2 110mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-03-11 - docetaxel 75mg/m2 117mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-02-18 - docetaxel 60mg/m2 90mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2021-01-14 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-12-24 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2020-10-22 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 250mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Xgeva (denosumab 120mg) CXGEV01

  • 2023-05-05 OPD
  • 2023-03-15 OPD
  • 2023-02-15 OPD
  • 2022-10-25 OPD
  • 2022-09-26 OPD
  • 2022-06-20 OPD
  • 2022-05-09 OPD
  • 2022-04-11 OPD
  • 2022-03-01 OPD
  • 2022-01-10 OPD
  • 2021-11-09 IPD
  • 2021-05-04 OPD
  • 2021-04-01 IPD
  • 2021-01-26 OPD
  • 2020-12-24 IPD
  • 2020-11-12 IPD
  • 2020-10-01 IPD

==========

2023-06-12

  • According to the PharmaCloud database, this patient has been exclusively seeking medical services from our hospital, specifically from the hemato-oncology department and the emergency room, for the past three months. No issues related to medication reconciliation have been identified.
  • The patient’s CRP level was recorded as 11mg/dL on 2023-06-10 and bilateral pleural effusion was observed in a chest X-ray. As a response, Brosym (cefoperazone + sulbactam) 4000mg was administered Q12H starting from 2023-06-11. Following the treatment, the patient’s body temperature, which was previously elevated, decreased to under 37°C from 2023-06-11 and has consistently remained below that level since then.
  • The medication Keppra (levetiracetam) is generally prescribed for the management of focal (partial) onset seizures and generalized onset seizures. The usual immediate release oral dosage starts at 500 mg twice daily and can be increased every two weeks by 500 mg per dose, based on the patient’s response and the medication’s tolerability. The maximum recommended dose is 1.5 g twice daily. Considering the patient’s liver and kidney functions are within normal limits, if the current dose of Keppra (500mg daily) appears to be ineffective, there might be a scope to increase the dosage.
  • Xgeva (denosumab 120mg) is typically used to prevent skeletal-related events in patients with bone metastases from solid tumors, and it is usually administered Q4W. Given that the patient’s last administration of this medication was on 2023-05-05 in an outpatient setting, it appears that more than a month has passed. Therefore, it may be appropriate to administer another dose. Denosumab is covered by National Health Insurance for patients with multiple myeloma and patients with breast cancer, prostate cancer, and lung cancer with osteolytic bone metastases.

700857239

230609

[exam findings]

  • 2023-06-08 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • There is no evidence of destructive bone lesion.
    • Pleural effusion over left side is found.
  • 2023-02-21 SONO - nephrology
    • Chronic renal parenchymal disease
  • 2022-05-25 Neurosonology
    • Minimal atherosclerosis in left distal CCA and bilateral proximal ICAs.
    • Normal extracranial carotid, vertebral, and intracranial vertebral, basilar arterial flows.
    • Poor bilateral temporal windows for transcranial insonation.
  • 2022-05-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 34) / 95 = 64.21%
      • LVEF (%) = 64
      • M-mode (Teichholz) = 64
    • Conclusion:
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated ascending aorta; LV diastolic dysfunction Gr 1.
      • Normal RV systolic function.
      • Trivial AR; mild to moderate MR; mild TR; mild PR.
      • Mininmal pericardial effusion.
  • 2022-05-23 MRA - brain
    • Indication
      • Triage level: 3, Stroke symptoms (sudden dysarthria/unilateral limb sensory abnormalities/sudden visual abnormalities) > Symptoms onset time > 4.5 hours or already alleviated. Refer to Neurology OPD. The symptoms of right limb weakness began on 2022-05-21.
      • PH: THROMBOCYTOPENIA, SLE
      • NKDA
      • COVID 19 VACCINATION: NONE
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without IV Gd-DTPA administration shows:
      • Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • The MRA study shows mild arteriosclerosis of the neck and intracranial vessels with irregular outline but without focal severe stenosis or complete occlusion.
    • Imp: Acute left cerebellum, left corona radiata, bilateral thalamus infarcts. Old bilateral basal ganglia, left corona radiata, left cerebellar lacunar brain infarcts also were noted.
  • 2022-05-23 CXR
    • s/p bilateral shoulder arthroplasty
    • mild enlarged cardiac silhoutte
  • 2022-05-23 CT - brain
    • Brain atrophy with multiple old bilateral basal ganglia, corona radiata, left thalamus, left cerebellar lacunar brain infarcts.
  • 2021-03-23 Patho - lymphnode biopsy
    • Lymph node, left axillary, core needle biopsy — lymphoid hyperplasia
    • Section shows cores of reactive lymphoid tissue without malignancy.
    • The immunohistochemical stain of CK is negative. The immunohistochemical stains of CD3 and CD20 show relatively preserved lymphoid architecture. Please correlate with the clinical presentation.
  • 2020-06-18 Patho - synovium
    • Labeled as “right knee OA, SLE synovitis”, “open” — Synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
    • Section shows 1 piece(s) of synovial tissue with acute and chronic inflammtion, calcification, as well as panniculitis.
  • 2020-05-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 19) / 89 = 78.65%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Trivial MR; trivial TR; mild PR

==========

2023-06-09

  • The two medications, Plaquenil (hydroxychloroquine) and dipyridamole, which were prescribed by our Rheumatology and Immunology OPD on 2023-05-15, are correctly listed on the active medication list. No issues with medication reconciliation were identified.

  • Given that hematemesis was just added to the patient’s medical problem list on 2023-06-08, the inclusion of tranexamic acid could be beneficial in reducing gastrointestinal bleeding.

701471389

230609

==========

2023-06-09

[IVIG usage]

According to UpToDate, immune globulin can be used for acute disseminated encephalomyelitis, IV: 400 mg/kg once daily for 5 days.

Based on the patient’s body weight of 80kg and Privigen at 5gm per vial, a dosage schedule of 7-7-6-6-6 vials over 5 days appears to fulfill the recommended dosage.

While the package insert doesn’t specify a need for dilution, if dilution is preferred, D5W can be used as the solvent.

Infusions should ideally begin at a rate of 0.5 to 1 mL/kg/hour for the first 15 to 30 minutes. If no adverse reactions occur, the rate can be incrementally increased every 15 to 30 minutes to a maximum of 3 to 6 mL/kg/hour. This information is referenced from https://www.ncbi.nlm.nih.gov/books/NBK554446/. An alternative infusion rate reference can be found at https://www.gov.nl.ca/hcs/files/bloodservices-resources-pdf-adult-invig-inf-table.pdf.

701453808

230607

[diagnosis] - 2023-03-27 admission note

  • Acute interstitial pneumonitis
  • Malignant neoplasm of hypopharynx, unspecified

[past history]

  • squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)at Cathay Hospital        

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer, hypertension

[lab data]

  • 2022-10-06 HBsAg Negative
  • 2022-10-06 HBsAg Value 0.412
  • 2022-10-06 Anti-HCV Negative
  • 2022-10-06 Anti-HCV Value 0.0392
  • 2022-10-06 Anti-HBc Positive
  • 2022-10-06 Anti-HBc Value 0.00682
  • 2022-10-06 Anti-HBs Negative
  • 2022-10-06 Anti-HBs value 5.16

[exam findings]

  • 2023-04-14 Electromyography, EMG
    • Findings
      • No pick-up on right facial stimulation.
      • Abcense of right R1, R2 and right R2’ latencies on blink reflex study.
    • Conclusion
      • The above finding may suggest right facial nerve neuropathy. Advice clinical correlation
  • 2023-04-07 Nasopharyngoscopy
    • Findings: tube in place
    • Conclusion: right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0 stage IVB post CCRT
  • 2023-03-28 CT - neck
    • Findings:
      • Lobulated mass lesion over laryngeal space and hypopharyngeal space with involvement of A-E folds, vocal cords and right thyroid cartilage. Favor malignancy.
      • One huge lobulated necrotic lesion (8.0cm in size) over right parotid space and level II, favor a malignant node.
      • S/P tracheostomy.
  • 2023-03-24, -03-03 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-03-13 Nasopharyngoscopy
    • Findings
      • several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
    • Conclusion
      • mucosal injury of trachea
  • 2023-02-20 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Bronchiectatic change over left lower lobe is found.
    • Senile fibrotic change is noted at lung fields.
    • Osteopenia of the bony structure is noted.
  • 2023-02-06 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Faint aveolar opacity over left lower lobe is found.
    • S/p tracheal tube placement with its tip in place.
  • 2023-01-31, -01-16, -01-09, -01-04, 2022-12-05, -11-29 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-12-10 MRA - brain
    • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)left leg weakness
    • With- and without-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial FLAIR images and axial DWI; using 4 mm thickness for sagittal section and 5 mm thickness for the others) revealed
      • mild dilated intraventricular and extraventricular CSF spaces
      • punctate white matter gliosis in the supratentorial brain; atrophic change in the right frontal lobe.
      • unremarkable change in the skull base
      • multiple foci with low SI change on T1WI in the skull bones.
      • a heterogeneous enhancing lesion, about 69mm, in the right parotid gland and right posterior cervical space.
    • IMP:
      • no evidence of brain metastasis
      • multiple low SI lesions on T1WI in the skull bones
      • a large mass lesion in the right parotid gland and right posterior cervical space
  • 2022-12-07 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Findings
      • prolonged motor DLs on left peroneal n. with lower CMAP ampltidues and normal NCVs.
      • prolonged sensory DLs on bil. median and ulnar n. with lower SNAP amplitudes on right median n. and slowed NCVs.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal
      • the H-reflex study of bil. tibial n. were normal.
    • Conclusion:
      • bil. median and ulnar sensory neuropathies at distal region.
  • 2022-11-29 CT - chest
    • Indication: squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB post TPF (2022/08/25) and Pembrolizumab(2022/08/31)suspect insterstitial lung disease
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the neck, chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • large necrotic tumor (metsatatic lymphadenopathy, 64x82mm axial dimensions) at Rt neck and infiltrative mass at Rt hypopharyngeal region.
      • lungs: extensive centrilobular emphysema with extensive inhomogeneous opacities at both upper lobes (Rt greater than Lt), lingula, and RML.
        • there is subpleural reticulation and ground-glass opacity, with areas of consolidation at both lower lobes
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels: moderate calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LV; old myocardial infarction at cardiac apex and anterior interventricular septum (with calcification and low attenuated appearance).
      • Pleura: no effusion
      • Visible abdominal-pelvic contents: normal appearance of gall bladder.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node.
        • mild atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • interstirial lung disease (NSIP), drug toxicity?
      • emphysema with area or infection or edema at upper lobes?
      • moderate 2V-CAD and old AMI in LAD teritrory.
      • Rt hypopharygeal cancer with Rt neck LNs metastasis
  • 2022-11-22 Nasopharyngoscopy
    • Findings
      • right hypopharynx bulging with larynx airway compression (vocal cord not clearly seen, left false cord normal), left pyriform sinus visible and smooth mucosa; trachea ok
    • Diagnosis/conclusion
      • hypopharyngeal cancer under chemotherapy
  • 2022-10-24, -10-14 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-10-11 Neck soft tissue
    • S/P tracheostomy in place.
    • S/P Port-A infusion catheter insertion.
    • Thickening of retropharyngeal tissue.
  • 2022-08-30 CT (Cathay Hospital)
    • A large right laryngea tumor or cancer with superior extension through right supraglottis to vallecula and direct invasion through the right thyroid cartilage.
    • A large regional enlarged lymph node (50mm) with extrapsular invasion at right cervical levels II and III.
    • Multifocal centrilobular emphysema in bilateral upper lobes of lungs and pulmonary fibrotic change in both lungs.
    • Bilateral pleural effusions and partial atelectasis at RLL of lungs.
    • Cardiomegaly and atherosclerosis of aorta and coronary arteries.
    • Several small hepatic cysts.
    • Suspicious annular wall thickening at the ascending colon.
    • Mild scoliosis and marked osteoarthritis of the visible thoracolumbar spine.
  • 2022-08-19 Pathology (Cathay Hospital)
    • Hypopharynx, right, direct laryngoscopic biopsy, — squamous cell carcinoma
    • The specimen submitted consists of two tissue fragments measuring up to 0.9 x 0.6 x 0.3 cm in size, fixed in formalin. Grossly, they are gray to tan and firm. All for section.
    • Tumor type: Squamous cell carcinoma
    • Histological grade: Moderately differentiated (grade 2)
    • Histological pattern: Neoplastic squamous epithelial cells growing in confluent solid sheets
    • Nuclear pleomorphism: Moderate
    • Keratin pearl formation: Focally present
    • Tumor necrosis: Present
    • Subepithelial stroma: Included, with desmoplastic change
    • Lymphocytic response: Absent
  • 2022-08-15 CT (Cathay Hospital)
    • A 7.6cm tumor at right piriform sinus, right aryepiglotic fold, bilateral posterior wall of hypopharynx, extending superiorly right posterior wall oropharynx and laterally the right thyroid cartilage and adjacent right strap muscle (T4a).
    • A 8.3x7.0cm abnormal enlarged necrotic LN with extracapsular extention at right level II/III, probably invasion adjacent right SCM muscle, encasement/occlusion of adjacent right IJV, and compression on adjacent right ICA.(N3b)
    • Suspect a small round LAP at right III area.

[consultation]

  • 2023-03-13 Ear Nose Throat
    • Q
      • Bloody sputum and bloody clot was noted after replacement of tracheostomy on 2023/03/12, we need your expertise for further management
    • A
      • Scope: several mucosal injuries within trachea, beyond tracheostomy level. smooth nasopharynx. much saliva accumulated in oropharynx and hypopharynx, poor visualization.
      • Impression: mucosal injury of trachea, probably due to suction.
      • Plan: May provide inhalation for mucolysis.
  • 2023-03-11 Ear Nose Throat
    • Q
      • This time,he was admitted for scheduled chemotherapy.
      • Now, his Tr. tube slip off , so we need tour help for re on Tr. tube, thanks a lot!!
    • A
      • S
        • tracheostomy dislodge
        • fair breathing pattern and saturation (SaPO2: 97-98% when visiting)
      • O
        • Potable scope: visible tracheal ring and carina after tracheostomy replacement
      • A
        • tracheostomy dislodge, s/p replacement
      • P
        • replacement of tracheostomy smoothly
  • 2023-03-07 Infectious Disease
    • A
      • This is a case of A squamous cell carcinoma from right hypopharynx cancer with right LN mass metastasis status post tracheostomy, cT4N3bM0) stage IVB under chemotherapy and immunotherapy.
      • blood culture yielded Staphylococcus caprae.
      • Agree with the use of Zyvox (linezolid).
      • Please adjust antibiotic according to culture results and clinical conditions.
  • 2023-03-01 Ear Nose Throat
    • Q
      • We need your expertise for changing tracheostomy (11fr.), thanks
    • A
      • New Teflon #11 inserted smoothly
      • Scope: smooth NPx,
      • swelling epiglottis, larynx and hypopharynx can’t be clearly seen
      • saliva pooling
  • 2023-01-09 Infectious Disease
    • Q
      • This time, he had suffered from fever for one day and was brought to our ER. Laboratory test revealed leukopenia, impaired liver and renal function.
      • Chest film disclosed no specific penumonia patch. Empiric antibiotics with Tapimycin was adminiustered. Under the impression of fever, cause unknown. He was admitted for further management
      • After admissoin, empiric antibiotics with Tapimycin was administered on 2022/12/27~2023/01/09, blood culture yielded negative. selfpaid of weekly Taxotere was administered on 2022/12/30.
      • Radiotherapy was complete on 2023/01/02. keep Baktar 2tab QD for prevent pjp infection. Ganciclovir 250mg q12h was administered from 2023/01/03 due to Cytomegaloviral reactivation.
      • However, spiking fever was noted this morning and laboratory test revealed elevated CRP and PCT level. Empiric antibiotics with Targocid and Culin were administered.
      • We need your expertise for further management, thanks
    • A
      • Assessment
        • Persistent fever is noted in the past few days and lab data showed higher CRP and PCT levels.
        • Bacterial infection is considered first.
        • Serial CXR films showed no definite newly-developed pneumonia and urinalysis showed no UTI picture.
        • Previous Cravit is replaced by Culin and Targocid today.
        • There was detectable CMV viral load on 2022-12-28, that patient has received 6-day Cymevene till now, since 2023-01-03.
        • Further work up is necessary, including repeated blood culture, check Port-A site, fungus and TB studies.
      • Suggestion
        • Check blood Aspergillus antigen again and cryptococcal antigen, send sputum for TB-PCR.
        • Continue the present antibiotic regimen.
        • Check blood culture report.
  • 2022-12-16 ENT
    • Q
      • We need your expertise for changing tracheostomy (11fr.), thanks
    • A
      • The tracheostomy tube was replaced smoothly.
      • In addition, mucosal erosion with whitish exudative coating was noted in oropharynx.
      • If not contraindicated, please give Nystatin for oral gargling and swallowing, along with pain killer.
  • 2022-12-05 Neurology
    • Q
      • He complained of left leg weakness in recent days. We need your expertise for further management, thanks
    • A
      • S: left arm weakness followed by left leg weakness in recent days
      • NE: aware, fluent speech, normal cranial nerves, no visual field defect
        • decreased dexterity on left hand as well as left leg, and equivocal Babinski signs
      • Impression:
        • Suspected tumor encasing on right carotid artery
        • Suspected polyneuropathies
      • Suggest:
        • brain MRA with contrast might be considered if tolerable
        • nerve conduction study (motor + sensory NCS, upper and lower limbs) might be arranged
  • 2022-12-01 Chest Medicine
    • Q
      • This time, he had suffered from dyspnea with stinky sputum for one week then came to our OPD for help. Laboratory test revealed anemia and hypoalbuminemia.
      • Chest film disclosed suspect instertitial lung pneumonitis. Under the impression of acute instertitial pneumonitis, suspect immunotherapy related. He was admitted for further management
      • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
      • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
    • A
      • Diagnosis
        • Acute interstitial pneumonitis; suspect immunotherapy related
        • Malignant neoplasm of hypopharynx, unspecified
      • Suggestion
        • Keep Dexamethasone 4mg Q12H for 1 week and shifted to oral form
        • Empiric antibiotics with Cravit
        • Keep adequate oxygenation
  • 2022-11-30 Infectious Disease
    • Q
      • After admission, CT revealed interstirial lung disease (NSIP), drug toxicity? emphysema with area or infection or edema at upper lobes? moderate 2V-CAD and old AMI in LAD teritrory. Rt hypopharygeal cancer with Rt neck LNs metastasis.
      • Dexamethasone and empiric Cravit, Baktar were administered. We need your expertise for further management, thanks
    • A
      • Assessment
        • 62-year-old stage 4 hypopharyngel cancer male patient, who contracted recent Covid-19 infection on 2022-11-03, has interstitial lung with right lung secondary infection now.
        • No fever, but tachypnea and desaturation noted.
        • There was Stenotrophomonas isolate from sputum culture on 2022-11-04, which should be selected by previous broad spectrum antibiotic use since the mid-October, including Tienam (imipenem + cilastatin).
        • Secondary bacterial infection is still the first considration, Aspergillus possibility exists, but CMV or PJP not very likely.
        • Patient is receiving Cravit and Baktar now, that change of antibiotic regimen seems not necessary.
        • Further work up necessary.
      • Suggestion:
        • Continue Cravit and Baktar
        • Send sputum for PJP-PCR, TB-PCR
        • Check serum Aspergillus antigen, CMV viral load too.
  • 2022-10-27 Oral & Maxillofacial surgery
    • Q
      • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
    • A
      • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
      • Dental findigns:
        • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
        • Retained root 21,22
        • Extraction wound of tooth of 34 and 35 with stitches
        • Extra-oral
          • A large neck mass more than 6 cm with skin color change and peeling was noticed.
      • Problem:
        • Retained root 21, 22 with poor prognosis
      • Plan:
        • Explain the findings to the patient and her caregiver
        • Complicated extraction of tooth 21 and 22 under local anesthesia
        • Removal stitches of extraction wound tooth of 34 and 35
        • Suggest follow up for the wound condition next week
        • Antibiotic for infection control.
  • 2022-10-17 Oral & Maxillofacial surgery
    • Q
      • RT was consulted for further radiotherapy. We need your expertise for dental examination before RT simulation, thanks
    • A
      • Dear doctor, we are consulted for dental evaluation prior the radiotherapy for squamous cell carcinoma from right hypopharynx cancer
      • Dental findigns:
        • Dental panoramic film showed multiple retained root and full mouth tooth attrition caused by betul nut chewing
        • Retained root 21,22,34,35,44
        • Extra-oral
          • A large neck mass more than 6 cm with skin color change and peeling was noticed.
      • Problem:
        • Retained root 21, 22, 34, 35, 44 with poor prognosis
      • Plan:
        • Explain the findings to the patient and her caregiver
        • Suggest extraction of tooth 21, 22, 34, 35, 44 prior to radiotherapy (Fractured teeth may cause local cellulitis. To avoid possible osteonecrosis of the jaw after future radiation therapy, it is important to prevent tooth extraction.)
  • 2022-10-14 Radiation Oncology
    • A
      • A: Squamous cel carcinoma of the hypopharynx, stage cT4aN3bM0 (stage IVB), s/p induction chemotherapy (TPF regimen) and pembrolizumab.
      • P: Radiotherapy is indicated for this patient with the following indicators: stage cT4aN3bM0 (stage IVB)
        • Goal: pallaition
        • Treatment target and volume: hypopharyngeal tumor, peripheral, to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the hypopharyngeal tumor, peripheral, to bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient. He understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1430, 2022-10-19.
        • Please consult Dental department for pre-RT dental evaluation and management.
  • 2022-10-13 Dermatology
    • Q
      • This 62-year-old male was diagnosed of hypopharynx cancer with right LN mass metastasis (cT4N3bM0) stage IVB post TPF and C1 Pembrolizumab on 2022/08/31 at Cathay hospital.
      • He has psoriasis for several years and skin rash over whole body was noted after the immunotherapy. We need your expertise for further management, thanks
    • A
      • The patient had sufferred from hypopharynx cancer undr PD-L1 therapy and post-herpestic neurogenia with residual wound.
      • Under the impression of replasing psoriasis.
      • The following sugeetion:
        • Belolin onit. (clobetasol) 4 tube topcial QD use and Xamiol gel (calcipotriol hydrate + betamethasone dipropionate) 1 tube topical QN use over psoriatic lesions.
        • Sinphraderm 2 tube topical QN use after body wash for enhance mositurization.

[radiotherapy]

  • 2022-11-14 ~ undergoing - at 5000cGy/25 fractions(6MV photon) of the hypopharyngeal tumor, peripheral, to bilateral neck, and 5800cGy/29 fractions of the hypopharyngeal tumor and right neck involved nodal lesions.

[chemoimmunotherapy]

  • 2023-04-29 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-28 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-14 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-30 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-01 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-30 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-16 - pembrolizumab 100mg NS 100mL 30min + docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-18 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-02 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-26 - docetaxel 35mg/m2 60mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-21 - pembrolizumab 100mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-06-07

[tube feeding]

According to the package insert of Valcyte (valganciclovir), once ingested, it rapidly converts to ganciclovir, which has been shown in animal studies to be mutagenic, teratogenic, and carcinogenic. This morning I called the drug supplier (YuLi Co., Ltd.), who advised against direct contact with the drug substance on the mucous membranes to avoid exposure, so they don’t recommend crushing or splitting the pill by hand. However, they suggested that the pill could be broken into smaller pieces without the operator’s hands directly touching it, dissolved in an appropriate amount of drinking water, and then administered with food via tube feeding.

2023-05-02

  • It appeared that the SCC readings were dropping slowly. However, the 2023-03-28 neck CT findings indicated the presence of two malignant lesions. The first is a lobulated mass in the laryngeal and hypopharyngeal space, involving the aryepiglottic folds, vocal cords, and right thyroid cartilage. The second is a large (8.0 cm) lobulated necrotic lesion in the right parotid space and level II, likely representing a malignant lymph node.
    • 2023-04-24 SCC, Squamous cell carcinoma antigen (nuclear medicine) 41.60 ng/mL
    • 2023-04-19 SCC, Squamous cell carcinoma antigen (nuclear medicine) 43.40 ng/mL
    • 2023-04-07 SCC, Squamous cell carcinoma antigen (nuclear medicine) 54.90 ng/mL
    • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
  • No medication reconciliation issues were identified during this hospitalization.

2023-03-28

  • Lab data from early Feb 2023 showed a short trough. However, recent results indicate that the SCC antigen has doubled compared to late Dec 2022.

    • 2023-03-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 48.20 ng/mL
    • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.10 ng/mL
  • The patient is currently being treated with Valcyte (valganciclovir), Morcasin (sulfamethoxazole/trimethoprim), and Mycostatin (nystatin) for suspected respiratory infections.

  • During this hospital stay, no issues with medication reconciliation were identified, and the drugs recently prescribed and listed in the NHI PharmaCloud System were properly prescribed as self-carried items to address the patient’s underlying conditions.

2023-03-01

  • 2023-02-27 lab results indicated that the CMV viral load was not detected, which is a positive indication. Additionally, the reading for squamous cell carcinoma antigen (SCC) has shown a trend of decreasing levels.
    • 2023-02-09 SCC, Squamous cell carcinoma antigen (nuclear medicine) 9.02 ng/mL
    • 2022-12-27 SCC, Squamous cell carcinoma antigen (nuclear medicine) 20.1 ng/mL
  • Morcasin (sulfamethoxazole, trimethoprim) is appropriately prescribed to treat Pneumocystis pneumonia since 2023-02-07. Typically, treatment for Pneumocystis jirovecii pneumonia lasts for 14 to 21 days. It is suggested to monitor symptoms and response to determine if a longer course of treatment is necessary.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[Zavicefta 2g/0.5g powder for concentrate for solution for infusion - Usage and Precautions ] for the patient’s primary nurse

  • Compatibilities (ref: MicroMedex)
    • D5W (Dextrose 5% in water)
    • NS (Normal saline (Sodium chloride 0.9%))
    • Lactated Ringer’s Injection
    • Dextrose 2.5% in sodium chloride 0.45%

2022-10-12

  • It has been reported that fungitech (terbinafine) itself may cause the following dermatologic adverse reactions: pruritus (3%), rash (6%), and urticaria (1%).

700173157

230606

[exam findings]

  • 2023-06-05 CXR
    • Bilateral pleural effusion.
    • Multiple nodules at bil. lungs.
  • 2023-06-05 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Cannot rule out Inferior infarct, age undetermined

[consultation]

  • 2023-06-05 Family Medicine
    • Q
      • Chief Complaints: SOB for a long time, more severe recently
      • no fever, no URI s/s
      • Past History: malignant tumor of right submandibular gland? with pleural metastases, pleural effusion and pericardial effusion
      • Drug allergy: NKDA
      • 2023/04/21 NTU Cancer Center - Neck + Lung CT: Right suprahyoid neck lymphadenopathy; Progressive bilateral lung and left pleural metastases; Right pleural effusion and pericardial effusion; Indeterminate hepatic lesions at left medial segment;
    • A
      • 52 y/o lady Malignant tumor of right submandibular gland? with pleural metastases, Dyspnea
      • CXR Bilateral pleural effusion. Multiple nodules at bil. lungs.
      • BEd full
      • Our share care would follow up.

==========

2023-06-06

  • This patient has recently been visiting the NTU Cancer Center and Cheng Hsin Hospital for her malignant neoplasm of the pleura (at least since April). The medications prescribed during these visits are already included in her current active prescription list, with no discrepancies identified during the medication reconciliation process.

700790807

230606

{gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type) s/p total gastrectomy with D2 LN dissection & CCRT}

  • past history
    • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV, (poorly cohesive carcinoma, signet-ring cell type),
      • s/p total gastrectomy with D2 LN dissection IP C/T wt Mitomycin-C on 20211004,
      • s/p port-A implantation on 20211020,
      • under post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12 (since 20211026)
    • open cholecystectomy
    • operation for left kidney staghorn stone
  • exam findings
    • 2022-09-26 CXR
      • Patchy consolidation projecting at right middle lung show near complete resolving.
    • 2022-09-22 CXR
      • Patchy consolidation projecting at right middle lung is noted. Please correlate with clinical condition and CT to rule out Bronchopneumonia.
    • 2022-08-17 CT - abdomen
      • Findings
        • S/P total gastrectomy.
        • Mild ascites is highly suspected. Please correlate with sonography.
        • Prior CT identified two tiny nodule at RUL are noted again, stationary. Prior CT identified small amount left pleural effusion and Small amount pericardial effusion are noted again, stationary.
        • Prior CT identified few ground-glass opacity at bil. basal lungs are not noted again.
        • Prior CT identified A vesical stone (1.8cm) shows stationary.
        • There are few poor enhancing lesions in the spleen at portal venous phase images and homogeneous enhancement in delayed phase images that may be hemangiomas. Please correlate with sonography.
      • Impression
        • S/P total gastrectomy.
        • Mild ascites is highly suspected. Please correlate with sonography.
    • 2022-05-17 CT - abdomen
      • History and indication:
        • gastric cancer with peritoneal seeding, pT4aN2M1, stage IV
      • Findings
        • S/P gastric operation. Moderate amount ascites.
        • A tiny nodule at RUL. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
        • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
        • General subcutaneous edema.
      • IMP:
        • S/P gastric operation. Moderate amount ascites.
        • A tiny nodule at RUL r/o metastases. Some patchy densities at bil. basal lungs. Bil. pleural effusion. Small amount pericardial effusion.
        • Left renal stone (up to 4mm). A stone (1.8cm) in urinary bladder.
    • 2021-10-08 Upper GI series
      • Indication:
        • gastric cancer s/p total gastrectomy on 2021/10/04
      • Impression
        • There is no leakage of the contrast medium from esophagus into small intestines.
        • The peristasis of the esophagus and small intestines are intact.
    • 2021-10-05 Patho - Stomach
      • Stomach, total gastrectomy - Poorly cohesive carcinoma, signet-ring cell type
      • Margins, total gastrectomy - Radial margin is involved by tumor
      • Lymph nodes, D2 LN dissection - Metastatic carcinoma (3/55)
      • AJCC Pathologic staging - pT4aN2M1, stage IV
    • 2021-09-27 Patho - Stomach, low body, biopsy
      • Adenocarcinoma, poorly differentiated
      • IHC: CK(+), CDX2(+), and Her-2/neu(Ab): Negative(0).
  • surgical operation
    • 2021-10-04
      • Surgery
        • total gastrectomy with LN 1-9,11,12,14v dissection
        • cholecystectomy
        • IPCT with normotemperature with Mitomycin C 15mg/m2 (30mg) fo 90 mins
      • Finding
        • distal gastric tumor with complete gastric outlet obstruction cT4aN3M1
        • Frozen section: lesser curvature stomach serosa 3 cm below EG junction. positive tumor seeding(+)
  • radiotherapy
    • 2021-11-05 ~ 2021-12-09 - 4500cGy/25 fractions (15MV photon) of the gastric tumor bed, peripheral, and regional lymphatic area.
  • chemotherapy
    • 2022-10-06 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-09-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4720mg 46hr
    • 2022-07-27 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • 2022-07-07 - oxaliplatin 75mg/m2 120mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
    • 2022-06-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2800mg/m2 4600mg 46hr
    • 2022-05-16 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4750mg 46hr
    • 2022-04-26 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4780mg 46hr
    • 2022-03-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2022-03-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4990mg 46hr
    • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-01-24 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-01-13 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2021-11-29 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
    • 2021-11-22 - fluorouracil 200mg/m2 380mg 24hr D1-5 (CCRT)
    • 2021-11-18 - fluorouracil 200mg/m2 380mg 24hr D1-2 (CCRT)
    • 2021-10-06 - fluorouracil 750mg 1hr IP D1-5 + gentamicin 40mg IP D1-5 + sodium bicarbonate 2800mg IP D1-5
    • 2021-10-04 - mitomycin-c 15mg/m2 30mg 90min IP + gentamycin 40mg IP + sodium bicarbonate 4200mg IP

==========

2023-06-06

[compatibility]

There is no compatibility information available in Micromedex for concurrent administration of Nako No.5 and Oliclinomel N4-550E.

Nako No.5 injection contains: - sodium chloride - sodium acetate anhydrous - potassium acetate - magnesium chloride 6H2O - potassium phosphate monobasic - dextrose monohydrate

Oliclinomel N4-550E Emulsion for Infusion contains: - sodium acetate 3H2O - sodium glycerophosphate 5H20 - potassium chloride - magnesium chloride 6H2O - glucose monohydrate - calcium chloride 2H2O

The electrolyte components in both Nako No.5 and Oliclinomel N4-550E share a high degree of similarity, which suggests that they are unlikely to be incompatible when administered concurrently through a Y-line immediately prior to administration.

2022-10-07

  • A HGB level of 6.6g/dL (CTCAE v5 grade 3 anemia) was detected on 2022-10-06, as well as dizziness and mild fatigue. The myelosuppressive chemotherapy might be put on hold for a while if no other consideration.

2022-03-23

  • According to lab data reported on 2022-03-22, serum potassium, magnesium and HGB were low (2.6 mmol/L, 1.4 mg/dL, 6.7 g/dL respectively).
  • KCl (IV), potassium gluconate (PO), MgSO4 (IV), MgO (PO) are prescribed and blood products are ordered.

2022-02-08

  • HER2 tested negative, trastuzumab might not be indicated.
  • PD-L1, microsatellite testing outcome not found, not sure nivolumab should be applicable.
  • Over 95% of gastric cancers are adenocarcinomas, which are typically classified based on anatomic location (cardia/proximal or noncardia/distal) and histologic type (diffuse or intestinal). The diffuse type, which is characterized by poorly differentiated and discohesive tumor cells with a signet-ring or non-signet-ring morphology diffusely infiltrating the gastric wall in a desmoplastic stroma, is more prevalent in low-risk areas and is mostly associated with heritable genetic abnormalities.
    • according the patient’s pedigree chart, he has 3 direct descendants alive, who should be aware of suspected higher risk of gastric cancer.
  • no drug allergy recorded in database, no issue found in active medication.

700051397

230605

{SCC of esophagus, lower third, with mediastinal & SCF LAPs and multiple brain metastases, stage IV}

[diagnosis] - 20230110 admisstion note

  • Malignant neoplasm of lower third of esophagus
  • Squamous cell carcinoma of lower third esophagea with multiple brain metastases, ypT3N1M1, ypStage IVB, mediastinal lymph node and aorta invasion s/p immunity therapy with Nivolumab/chemotherapy with FOLFOX6 from 2022/12/01
  • Hypothyroidism, unspecified
  • Ulcer of esophagus without bleeding
  • Secondary malignant neoplasm of mediastinum
  • Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck
  • Secondary malignant neoplasm of brain
  • Hypokalemia

[past history]

  • Esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021/07/08 ~ -07/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/07/26 ~ 09/01, with FOLFOX from 2021/07 ~ 2021/11, s/p VATS esophagectomy and gastric tube reconstruction on 2022/07/04

[family history]

  • Mother has colon cancer
  • Denied DM, H/T, HCVD or CAD history in his family

[exam findings]

  • 2023-04-11 CXR
    • Atherosclerosis of the aorta.
    • Ground glass opacities in bil. lungs.
    • Bilateral pleural effusion.
  • 2023-04-11 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2023-04-03 SONO - chest
    • Left
      • LEft side trivial pleural effusion, risk of tapping -> suggest closely follow up
        • if progression of pleurale ffusion -> arrange Chest echo again
    • Right
      • Right side trivial pleural effusion, RLL consolidation
  • 2023-03-29 CXR
    • Lt pleural effusion with loculation and nodular metastasis
    • Rt pleural effusion and partial atelectasis of RLL
    • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum, lower tracheal level to lower mediastinum due to large tumor
    • s/p EVAR in Descending thoracic aorta (EVAR: endovascular aneurysm repair)
    • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
  • 2023-03-13, -03-09, -03-06 CXR
    • Left pleura effusion.
    • S/P metalic stent implantation at the descending thoracic aorta.
    • Few nodular opacities on both lungs are noted that are c/w metastases after correlate with CT.
    • Patchy consolidation of the left middle and lower lung is noted. Please correlate with clinical condition to rule out inflammatory process.
  • 2023-02-16 CT - chest
    • Indication: Malignant neoplasm of lower third of esophagusdyspnea RULING OUT BRONCHIAL OBSTRUCTION, PARTIAL
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Necrotic mass at lower third esophagus with consolidation over right lower lobe is found. In comparison with CT dated on 2022-11-03, the lesion enlarged.
        • s/p gastric tube reconstruction.
        • s/p aortic stent placement.
        • Enlarged mass anterior to right heart border measuring 4.08cm in largest dimension, in progression.
        • One soft tissue mass at left heart border about 2.82cm is found.
        • Left mild pleural effusion is found.
      • Visible abdomen:
        • Low density lesions are found at left lobe liver up to 4.2cm in largest dimension. In enlargement.
        • The GB is well distended without soft tissue lesion
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • Imp:
      • Lower third esophageal cancer with probably tumor rupture, causing right lower lobe conoslidation. The primary tumor enlarged.
      • Mediastinal lymphadenopathy, in progression.
      • Liver meta, in enlargement.
  • 2023-02-10 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Lt pleural effusion with loculation and nodular metastasis
    • Rt pleural effusion and partial atelectasis of RLL
    • Rt-sided convexity of the Rt hilum and Rt upper cardiac border with narrowing of Rt main bronchus and increased density over mediasttinum lower tracheal level to lower mediastinum due to tumor
    • s/p EVAR in Descending thoracic aorta
    • Multiple nodules in both lungs and Rt pleural nodularity due to metastases
  • 2023-02-01, -01-19, -01-10, -01-03 CXR
    • Left pleura effusion.
    • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
    • Few nodular opacities on both lung are noted.
  • 2022-12-22, -12-05, -11-30 CXR
    • Left pleura effusion S/P pigtail catheter implantation.
    • S/P metalic stent implantation at the esophagus or descending thoracic aorta?
    • Enlargement of cardiac silhouette.
  • 2022-11-25, -11-15, -11-05 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-11-18 Chest Decubitus Bilat
    • Pleura effusion of left costal-phrenic angle.
    • Peri-bronchial wall thickening of the RML of the lung is suspected? Please correlate with clinical condition or CT.
  • 2022-11-18 Cell block
    • Negative
  • 2022-11-18 SONO - chest
    • left side small amount of loculated and septated pleural effusion, 60cc serosangious fluid was aspirated for analysis.
  • 2022-11-10 Stroboscopy
    • right vocal cord palsy
    • left vocal fold compensation
  • 2022-11-04 Cell block
    • Negative
  • 2022-11-04 SONO - chest
    • left side small amount of pleural effusion, 550cc serosangious fluid was aspirated for analysis.
  • 2022-11-03 CT - chest
    • Indication: Esopageal cancer s/p OP f/u (LLL pleural effusion)
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at lower third esohpagus about 6.6cm in largest dimension. In comparison with CT dated on 2022-05-19, the lesion enlarged.
        • Consolidation over right lower lobe is found.
        • There is moderate bilateral pleural effusion.
        • s/p gastric tube reconstruction at anterior mediastinum is found.
      • Visible abdomen:
        • Low density lesion at left lobe liver about 1.7cm in largest dimension. Liver meta is favored.
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Esophageal cancer at lower third s/p gastric tube reconstruction. The primary tumor enlarged.
      • New liver meta.
      • Bilateral pleural effusion.
  • 2022-11-02 CXR
    • Lung markings: opacification in the left lower lung field.
    • blurred left hemidiaphram
  • 2022-07-22 Upper GI series
    • UGI series was done partially due to very frequent aspirtion and shows
    • Contrast medium stasis at pyriform sinus with leakage into trachea easily
    • post op. of the esophagus is found.
    • Oral intact is not suggested in the current status.
  • 2022-07-18 MRI - brain
    • Indication: brain meta re-follow up
    • History: The 46-y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF (supraclavicular fossa) LAPs and multiple brain metastases. He has suffered from progressive dysphagia for 2 years. SCC of esophagus, lower third, stage II was diagnosed by other hospital in 2019/10 but only Chinese medicine was done by decision of patient.
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition with and without IV Gd-DTPA administration shows:
      • comparison: 2021/10/08, 2022/01/07 MRI
      • Normal cisterns and sulcal systems.
      • Normal bilateral ventricular size and shapes.
      • Normal appearance of bilateral cochlear and vestibular nerves complexes.
      • No evidence of severe mass effect or midline structural deviation.
      • Small poor enhancing nodules in left frontal and right occipital lobes,stationary.
    • Imp:
      • Small poor enhancing nodules in left frontal and right occipital lobes, regressed and stationary.
      • Regressed size and edema of left occipital nodule, stationary.
  • 2022-07-11, -07-05 CXR, Portable supine chest AP view shows:
    • Port-A catheter inserted into SVC via left subclavian vein.

    • approriately positioned endotracheal tube in place

    • s/p VATS esophagectomy and gastric tube reconstruction with gastric tube inserted

    • Right internal jugular central venous catheter with tip in the SVC

    • s/p right chest tube in place, its tip directed superomedially, projecting over Rt upper hemithorax

    • s/p left chest tube in place, its tip directed superomedially, projecting over 6th rib

    • extensive increased opacity over Rt lung field

    • Lung volume reduction and increased opacity over RLL

    • Subcutaneous emphysema in the right neck and chest wall

    • 2022-07-15 Patho - esophagus subtotal/total resection

      • Diagnosis
        • Esophagus, lower third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
          • Stomach, cardia, partial gastrectomy —- Negative for malignancy
          • Azygous vein, excision —- Negative for malignancy
          • Thoracic duct, excision —- Negative for malignancy
        • Resection margin: Circumferential resection margin: involved
        • Lymph node
          • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/10)
          • Lymph node, right, group 2, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 3, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 4, dissection —- Negative for malignancy (0/1)
          • Lymph node, right, group 7, dissection —- Metastatic squamous cell carcinoma (2/2)
          • Lymph node, upper para-esophageal, dissection —- Negative for malignancy (0/0)
          • Lymph node, middle para-esophageal, dissection —- Negative for malignancy (0/0)
          • Lymph node, lower para-esophageal, dissection —- Negative for malignancy (0/1)
        • AJCC 8 th edition pT N M Pathology stage: ypStage IVB, ypT3N1 (if cM1)
      • Gross Description:
        • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 2 segments, the upper segment measuring 6.7 cm in length, the lower segment measuirng 6.2 cm in length with a portion of gastric tissue measuring 3.2 cm in length.
        • Tumor Site: Distal esophagus (low thoracic esophagus)
        • Relationship of Tumor to Esophagogastric Junction: Tumor midpoint lies in the distal esophagus and tumor involves the esophagogastric junction
        • Tumor Size: annularly involving the lower esophagus and measuring 7.5 cm in length
        • Proximal cut end, azygous vein (2.6 cm in length and 0.4 cm in diameter), thoracic duct (5.5 cm in length and 0.3 cm in diameter), group 2, 3, 4, 7, 10, and upper para-esophageal, middle para-esophageal, and lower para-esophageal lymph nodes are received in the another bottles.
        • Sections are taken and labeled as: A1-2: distal gastric resection margin; A3: stomach, non-tumor; A4: esophagus, non-tumor; A5: middle para-esophageal tissue; A6: tumor, upper segment; A7-12: tumor (A7-9: the same level), lower segment; B: lymph node, group 2; C: lymph node, group 3; D: lymph node, group 4; E: lymph node, group 7; F: lymph node, upper paraesophageal; G: lymph node, middle paraesophageal; H1-3: lymph node, lower paraesophageal; I: azygous vein; J: thoracic duct; K: proximal cut.
      • Microscopic Description:
        • Histologic Type: Squamous cell carcinoma
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades adventitia
        • Margins
          • Margin(s) involved by invasive carcinoma
          • Specify involved margin: circumferential
          • Proximal resection margin: 5.5 cm
          • Distal resection margin: 3.2 cm
        • Treatment Effect: Absent: Extensive residual cancer with no evident tumor regression (poor or no response, score 3)
        • Lymphovascular Invasion: Present
        • Perineural Invasion: Present
        • Regional Lymph Nodes: please see diagnosis
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors: y (posttreatment)
            • Primary Tumor (pT): pT3: Tumor invades adventitia
            • Regional Lymph Nodes (pN): pN1: Metastasis in one or two regional lymph nodes
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1
        • Additional Pathologic Findings: The azygous vein and thoracic duct are free of malignancy.
    • 2022-07-01 Pulmonary Flow Volume Loop

      • Mild restrictive ventilatory impairment, possibly due to small airway obstruction
      • Please consult chest specialist
    • 2022-06-27 CXR

      • Patchy infiltration with air-bronchogram projecting at right infrahilum and right lower medial lung zone is noted.
    • 2022-06-01 Patho - bronchus biopsy

      • Labeled as “right lower lobe”, bronchoscopic biopsy — benign respiratory epithelium lined lung tissue with focal fibrosis and focal mild chronic inflammation.
    • 2022-05-19 CT - chest

      • Indication: Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
      • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/p port-A placement with its tip at Superior vena cava.
          • Soft tissue mass encircling lower third esophagus is found. The tumor causes a fistula connecting right posterolateral esophageal wall to RLL lung. Consolidation over right lower lobe and right middle lobe and left lower lobe is found.
          • Some lymph nodes are found at bilateral paratracheal region.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Right renal stone is found.
      • Imp:
        • Esophageal cancer at lower third esophagus and mediastinal lymph nodes.
        • Tumor invasion causes fistula at the right posterolateral esophageal wall, and resulting in RLL pneumonia.
    • 2022-03-10 Patho - esophageal biopsy

      • Esophagus, 30 cm below the incisor, biopsy - Compatible with squamous cell carcinoma
      • IHC: CK(+); P16(-), P63(+) and P53 (+, focal) for atypical cells.
      • According to histopathologic finding and past history, it is compatible with poorly-differentiated squamous cell carcinoma, although no convincing stromal invasion.
    • 2022-03-01 Esophagography

      • Severe stenosis at middle esophagus
    • 2022-01-17 MRI - brain

      • Small poor enhancing nodules in left frontal and right occipital lobes, regressed. Regressed size and edema of left occipital nodule.
    • 2022-01-14 CT - lung/mediastinum/pleura

      • Compatible with middle third esophageal cancer and mediastinal lymph nodes, in regression.
    • 2021-10-11 CT - lung/mediastinum/pleura

      • Esophageal cancer with mediastinal lymph nodes metastasis, in regression post CCRT, but a suspect new RLL nodular metastasis and inflammation or infection in LLL of lungs, compared with CT on 20210428.
    • 2021-10-08 CT - brain

      • Multiple brain metastases, size slightly smaller as compared to that in previous CT done on 20210705.
    • 2021-04-28 Whole body PET scan

      • A glucose-hypermetabolic lesion in the esophagus, L/3, compatible with the primary esophageal cancer.
      • Glucose-hypermetabolic lesions in bilateral mediastinal lymph nodes, probably cancer with regional lymph nodes involvement.
      • Glucose-hypermetabolic lesions in the right lower lung, probably benign in nature.
      • Increased FDG uptake in the colon, probably physiological uptake of FDG.
      • Esophageal cancer, cTxN3M0, by this F-18 FDG PET scan.
    • 2021-04-28 CT - lung/mediastinum/pleura

      • lower third esophageal cancer T3N3M0 IVA

[consultation]

  • 2023-03-03 Family Medicine
    • Q
      • For further hospice care
      • Follow up in this year showed disease progression despite chemotherapy and immunotherapy. Poor prognosis was told, the patient signed Advance Care Directive (ACD). We need your expertise for hospice care, thank you!
    • A
      • When I visited, the patient sit on the bed and his caregiver stood by him. His consciousness was clear, and his ECOG was 4. After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
      • Indication for hospice combine care: Esophageal cancer
      • Plan: Hospice combined care.
  • 2023-03-03 Radiation Oncology
    • A
      • Objective:
        • General Condition-ECOG: 2.
        • PE, 2023/3/03: No palpable neck LNs.
        • Images:
          • Chest CT, 2022/02/16: Lower third esophageal cancer with probably tumor rupture, causing right lower lobe consolidation s/p bypass surgery with gastric tube. The primary tumor & pleural metastasis enlarged. Mediastinal lymphadenopathy, in progression. Liver meta, in enlargement. Thin body fat, c/w cachexia.
          • CXR, 2023/03/02: new LLL consolidation due to pneumonia & lung metastasis; RLL consolidation due to broncho-esophageal fistula. Small nodular lesions in the bilateral lung fields.
      • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases s/p RT (3600 cGy/12 fx) for brain metastases from 2021/7/8-7/23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021/7/26-9/1, s/p C/T with FOLFOX, PF, s/p VATS esophagectomy and gastric tube reconstruction on 2022/7/4 for esophageal cancer and fistula, s/p TEVAR stent placement on 2022/11/29, Zone III TEVAR (Medtronic VALIANT), s/p immunotherapy with Opdivo & FOLOFX6 with disease progression (pleural, lung and liver metastasis); ECOG = 2.
      • Plan: RT is not suggested due to disease progression, cachexia and active infectious process. If he recovers from pneumonia, immunotherapy with R/T may be considered.
    • 2022-11-28 Anesthesiology
      • Q
        • For aorta invasion -> TEVAR (thoracic endovascular aortic/aneurysm repair) stent placement on 2022/11/29, due to poor condition, we need your anesthesia consultation for evaluation. Thanks a lot!!!
      • A
        • To doctor or nurse practitioner, We were consulted for pre-op anesthesia evaluation.
        • Pt: 47 y/o M
        • Op: TEVAR
        • Past hx:
          • VATS esophagectomy and gastric tube reconstruction on 2022/7/4
        • GCS: 456
        • Vitals: stable
        • EKG: sinus tachy
        • CXR: blunting of left CP angle
        • 2D-echo:
          • EF54%
          • Trivial AR
        • Lab:
          • Hb10.3
        • PLAN
          • ASA II
          • EtGA
          • Post-ICU care if needed
          • We have informed the risks of anesthesia and the possible complications to the patient and the patient’s family.
    • 2022-11-28 Family Medicine
      • Q
        • This 47 y/o man is a case of SqCC of the lower third esophagus diagnosed at FuJen Catholic University Hospital in 2019/10 who went to National Taiwan University Hospital for second opinion in 2019/12. He refused chemotherapy and received only chinese medicine. With progression, his current disease status was esophageal cancer, SqCC, L/3, with mediastinal & SCF LAPs and multiple brain metastases, s/p port-A insertion and feeding jejunostomy on 20210707, neoadjuvant CCRT (3600 cGy/12 fx) for brain metastases from 2021-07-08 ~ -07-23, neoadjuvant CCRT (5040 cGy/28 fx) for primary tumor from 2021-07-26 ~ -09-01, with FOLFOX from 2021-07 ~ 2021-11 (9 cycles). He also received chemotherapy with PF (Cisplatin + 5-Fu) since 2021-12-07 to 2022-04-23 (8cycles). He has received VATS esophagectomy and gastric tube reconstruction on 2022-07-04 for esophageal cancer and fistula. This time, he suffered from progressive dyspnea for at least one month.
        • For Combined Hospice Care, thanks
      • A
        • 47-year-old male, esophageal cancer with mediastinal & SCF lymphadenopathy and multiple brain metastases
          • s/p neoadjuvant CCRT, s/p FOLFOX, s/p VATS esophagectomy and gastric tube reconstruction for esophageal cancer with fistula
          • Suffer from exertional short of breath
          • Consciousness alert, ECOG 2
        • We will arrange hospice combine care and follow his condition
          • Indication: Esophageal cancer
          • Plan: Combined Hospice Care
    • 2022-11-26 Cardiac Surgery
      • Q
        • Chest CT on 20221103 showed new liver metastasis and CXR on 20221115 still showed left pleural effusion.
        • For tumor recurrence with aorta invasion, we need your consultation for evaluation. Thanks a lot!
      • A
        • I have had the pleasure of involving with the patient’s care. In brief, He is a 47 year old male seen in consultation for opinion regarding treatment options for Squamous cell carcinoma of lower third esophagea
        • Prophylatic TEVAR (thoracic endovascular aortic/aneurysm repair) is scheduled on 20221130 yet this time the pt was admitted and c/o (complaint of) SOB, not sure if such was caused by airway compression or large amount of pleural effuion
        • SUGGESTION & PLAN:
          • TEVAR stent placement can be brought forward to tuesday 20221129 ETGA, on call, pigtail/chest tube insertion may be performed as combined procedure to relieve his resp. distress.
    • 2022-05-26 Chest Medicine
      • Q
        • The 45 y/o male he has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he was admitted for fever and cough, the CXR showed pmeumonia over RLL, so we need your help. Thank you.
      • A
        • S: short of breath with exertion
        • O:
          • The chest CT showed RLL consoildation. The CXR showed RLL consolidation in progression.
          • According to the patient’s self-report, the taste of sputum after coughing is the same as that of drinks he has had.
        • A:
          • Suspected tracheo-esophageal fistula [T-E fistula]
          • right lower lung pneumonia
          • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV
        • P:
          • consider gastroscopy if possible for diagnosis of T-E fistula
          • suggest bronchoscopy for diagnosis of T-E fistula, however having undergone a bronchoscopy previously, the patient would be more breathless following the procedure. In order to proceed, the patient desired to wait for his condition to stabilize.
          • if T-E fistula is proved, please consult Thoracic Surgery to evaluate esophageal stent or tracheal stent
          • check sputum culture and adjusted antibiotics for pneumonia
          • check sputum TB x3
          • check serum aspergillus antigen
    • 2022-05-23 Infectious Disease
      • Q
        • The 47 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. This time, he sufferes from cough, SOB and high fever since 20220513. We gave antibiotic as Tapimycin for RLL pneumonia treatment, but condition progress and repeat CXR showed significant patch noted, so we need your help for management. Thanks!
      • A
        • O
          • 20220518 WBC: 4070
          • 20220519 S/C: Group F streptococci and mixed flora
        • A
          • Lobar pneumonia, RLL is impressed.
        • Suggestion:
          • Recheck CBC and CRP level
          • Antibiotics with cravit 750mg iv st and qd is suggested
    • 2022-05-19 Chest Medicine
      • Q
        • The 47 y/o man has esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV. Due to fever, cough with sputum since 20220513. RLL pneumonia noted and CT was done today. We need your help for management.
      • A
        • Lab:
          • WBC:4070, band:11%, Hb:10.8, PLT:171K, BUN:28, Cr:0.66, Na:141, K:3.3, AST:45, ALT:41, PCT:0.27
        • Chest CT:
          • Esophageal cancer at lower third esophagus and mediastinal lymph nodes with stationary considition.
          • Consolidation over right lower lobe , probably due to aspiration pneumonia.
        • Impression:
          • Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastasis, stage IV.
          • Suspected Aspiration pneumonia
        • Suggestion
          • Change to Tapimycin or avelox for covering anaerobic pathogen
          • Tracing all culture
          • F/U CXR
          • Moniter fever and respiratory pattern
    • 2022-01-25 Oral and Maxillofacial Surgery
      • A
        • S
          • This 47 year old male patient had SqCC of the esophagus and mediastinal lymph nodes invasion.
          • He complained swelling discomfort of his right upper jaw for 4 days.
        • O
          • The mouth finding showed chronic periodontitis. Swelling of 21 palate side were noted.
        • Plan:
          • Oral hygiene.
          • Pain control.
          • Add antibiotic agent with Amoxicllin 500mg q8h were prescribed.
          • Explained to patient home care.
    • 2021-07-06 Radiation Oncology
      • Q
        • The 46 y/o man has Esophageal cancer, SqCC, L/3, with medastinal & SCF LAPs and brain metastases, we need your help for brain RT management. Thanks!
      • A
        • Diagnosis: Esophageal cancer, SqCC, L/3, diagnosed in 2019/10 without treatment (Chinese Medicine only) with mediastinal & SCF LAPs and multiple brain metastases; ECOG = 2.
        • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan:
          • Target & Volume: Brain metastasis (and esophageal tumors/LAPs).
          • Technique: IMRT & VMAT by linear accelerator.
          • Dose & Fractionation: 3600cGy/12 fractions to brain metastasis (3600cGy/12 fractions to esophageal tumor if feasible).
        • Plan: Brain RT is suggested for tumor control. Possible radiation effects (malaise, IICP, dermatitis) is told. CT simulation is arranged on July 06 16:10 2021. Treatment will be started 1-2 days later. Dexamethasone and mannitol may be prescribed to control the IICP during brain R/T. RT to esophageal tumors/LAPs may be arranged if his condition is stable.

[surgical operation]

  • 2022-11-29
    • Surgery
      • Zone III TEVAR (Medtronic VALIANT)     
      • Left pleural pigtail insertion     - Finding
      • Pre-OP / Post-op diagnosis: advanced esophageal cancer with DsAo adventitia invasion
      • Operative Indications:
        • The patient is a 47 year old male with history of advanced esophageal cancer with DsAo adventitia invasion; he presented with worsening SOB, CT demonstrated aortic encasement by the tumor at low thoracic DsAO; He desired to proceed with prophylactic TEVAR.   
    • Operative Findings:
      • Medtronic VALIANT VAMF2222C100 & VAMF2626C100 were sequentially deployed. (Via RCFA)
      • Left pleral effusion was subseqeuntly drained by a pigtail.
  • 2022-07-04
    • Surgery
      • VATS McKeown esophagectomy gastric tube reconstruction + decortication
    • Finding
      • previous ruptured malignant esophagus with abscess formation and severe orgainzed adjacent tissue s/p esophagectomy + decortication
      • thick mediastinum pleural, dilated and bulky esophagus, subcarina lymphnode necrosis, and main tumor stiffness with partial necrosis were noted
      • severe adhesion of necrotic main tumor to left main bronchus
      • remove azygus vein and thoracic duct abide with esophagus
      • gastric tube reconstruction via retrosternal route, esophagogastric anastomosis at left neck, hand-sewn
      • chest tube insertion: righ pleural cavity: 28Fr; left: 24 Fr.

[radiotherapy]

  • 2021-07-26 ~ 2021-08-30 - 5040cGy/28 fractions (15 MV photon) to esophageeal tumor and LAPs
  • 2021-07-08 ~ 2021-07-23 - 3600cGy/12 fractions (6 MV photon) to brain metastasis

[chemotherapy]

  • 2023-05-17 - nivolumab 3mg/kg 180mg NS 100mL 30min D1
  • 2023-05-08 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-05-02 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
  • 2023-04-12 - docetaxel 35mg/m2 60mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-03 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + docetaxel 35mg/m2 60mg NS 100mL 1hr D2
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] D2
  • 2023-02-21 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
  • 2023-01-30 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2
  • 2023-01-10 - nivolumab 3mg/kg 180mg NS 100mL 30min D1 + oxaliplatin 85mg/m2 148mg D5W 500mL 2hr D2 + leucovorin 400mg/m2 680mg NS 250mL 2hr D2 + fluorouracil 2800mg/m2 4800mg NS 500mL 44hr D2 (Opdivo/FOLFOX6 Q2W)
    • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2 + NS 250mL D2

    • 2022-12-21 - nivolumab 3mg/kg 200mg 30min D1 + oxaliplatin 85mg/m2 145mg 2hr D2 + leucovorin 400mg/m2 700mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

      • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2
    • 2022-12-01 - nivolumab 3mg/kg 180mg 30min D1 + oxaliplatin 85mg/m2 148mg 2hr D2 + leucovorin 400mg/m2 680mg 2hr D2 + fluorouracil 2800mg/m2 4800mg 44hr D2 (Opdivo/FOLFOX6 Q2W)

      • dexamethasone 4mg D2 + diphenhydramine 30mg D2 + granisetron 2mg D2
    • 2022-04-22 - cisplatin 40mg/m2 77mg 4hr + leucovorin 400mg/m2 775mg 2hr + fluorouracil 2800mg/m2 5430mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-03-29 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-03-14 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-02-15 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-01-24 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-01-11 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-12-22 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-12-07 - cisplatin 40mg/m2 78mg 4hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr

      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2021-11-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-02 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-10-18 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-09-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5435mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-10 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-14 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 780mg 2hr + fluorouracil 2800mg/m2 5500mg 46hr (FOLFOX)

      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-04-12

  • After reviewing PharmaCloud, which showed that the recent patient’s medications were all prescribed at our hospital, no medication reconciliation issue was identified.
  • Combined hospice care was arranged due to progression after trying several chemoimmunotherapy regimens.

2023-02-21

  • During this hospital stay, the drugs recently prescribed and disclosed in the NHI PharmaCloud System have been correctly prescribed as self-carried items currently with no medication reconciliation issues found in the patient.

2023-01-11

  • A combined hospice care arrangement has been made for this patient since 2022-11.
  • Medications (ROMICON-A, Pulmicort Nebulising Susp INHL) already prescribed to relieve respiratory symptoms.
  • Underlying conditions hypothyroidism and hypokalemia are appropriately managed with Eltroxin (levothyroxine) and Radi-K (potassium gluconate), respectively.

2022-03-29

  • Nexium (esomeprazole) must not be ground. Instead, it should be dissolved in adequate drinking water prior to tube feeding.

700507760

230605

[exam findings]

  • 2023-05-23 CXR
    • Enlarged heart shadow with tortuous aorta.
    • Placement of right subclavian port-A catheter.
    • Peribronchial thickening at bilateral lower lung field.
    • Bilateral clear costophrenic angles.
    • Degenerative change of the spine with marginal spur formation.
    • Surgical implant fixation at lumbar spine.
  • 2023-05-23 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (165 - 31) / 165 = 81.21%
      • M-mode (Teichholz) = 81
    • Conclusion:
      • Dilated LA and LV; Adequate LV systolic function with normal resting wall motion
      • Moderate to severe MR, moderate TR, mild AR
      • Impaired LV relexation
      • Preserved RV systolic function
  • 2023-04-11 CXR
    • S/P CVP line insertion from right jugular vein and the tip located at SVC.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • A mass-like opacity projecting in the left lower medial lung shows stationary that is c/w hiatal hernia after correlate with CT.
  • 2023-03-18 CT - chest
    • Rt L4 radiculopathy since 202207. History of melanoma post operation at Cardinal Tien Hospital in Apr 2021 and path revealed Lt femoral LN (20/27) melanoma, metastatic.
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated nodule at left lingula lobe is found.
        • Subcarina lymph node is found. Meta is considered.
        • Hiatus hernia is found.
        • No evidence of bilateral pleural effusion.
        • Senile fibrotic change is noted at lung fields.
      • Visible abdomen:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Scoliotic alignment of the thoracolumbar spine is noted.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • left lingula lobe nodule. 1.5cm.
      • Hiatus hernia
      • Mediastinal lymphadenopathy
      • Bone meta.
  • 2023-02-09 KUB + L-spine Lat
    • s/p PI, PD, and PLF at L2-3-4
    • Disc space narrowing at L1/2 and L4/5
  • 2022-12-28 KUB + L-spine Lat
    • post-OP change from L2 to L4
    • severe decreased disc space in the L4/5 disc.
    • mild anterior spur formation at the L-spine
    • compression fractures at L1 and T12 vertebral bodies.
  • 2022-12-27 Spinal angiography
    • The spinal angiograms were done via right femoral approach and show:
      • Tortuous abdominal aorta.
      • Prominent tumor stain with engored tumor feeding vessels were found in right L3 segmental artery.
  • 2022-12-26 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Septal infarct, age undetermined
  • 2022-12-02 MRI - L-spine
    • Indication: Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least
    • MRI of lumbar spine without/with Gadolinium-based contrast enhancement shows:
      • abnormal bone marrow signal lesion with contrast enhancement at the L3 vertebral body, with a heterogeneously enhancing bone mass protruding laterally to the right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root. Bone metastasis is compatible.
      • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • severe right L5-S1 neuroforaminal narrowing.
      • no evidence of abnormal signal lesion in visible spinal cord.
    • Impression:
      • Bone metastasis at L3 vertebral body, with bone mass protruding laterally to right side, obliterating right L3-4 neuroforamen and compressing or involving right L3 nerve root.
      • Degenerative spinal and disc disease.
      • Severe right L5-S1 neuroforaminal narrowing.
  • 2022-10-24 PET scan
    • Increased FDG uptake at the L3 spine, compatible with the pathological findings of metastatic melanoma.
    • Glucose hypermetabolic lesions in mediastinal lymph nodes and in a nodular lesion in the left upper lung, highly suspected melanoma with distant metastases.
    • Glucose hypermetabolic lesions in the right lobe of the thyroid gland and in the left SCF lymph nodes, the nature is to be determined, suggesting biopsy for further investigation.
    • Increased FDG uptake in bilateral knees, the nature is to be determined also (post-traumatic change, melanoma, or other nature ?), suggesting further investigation.
    • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation process.
    • Increased FDG uptake in the colon, probably physiological uptake of FDG.
    • Melanoma with mediastinal lymph nodes, left upper lung, and L3 spine metastases at least, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-14 Tc-99m MDP bone scan
    • Prominently increased activity in the L3-5 spines. The nature is to be determined (malignancy/metastases? other nature?). Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the middle C-spine and middle T-spines. Degenerative change may show this picture. However, please keep follow up to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, knees and left foot, compatible with benign joint lesions.
  • 2022-10-13 Patho - bone biopsy/curetting
    • Vertebral body, L3, CT-guided biopsy — Melanoma, metastatic
    • The sections show a picture of melanoma, metastatic, composed of sheets of large epitheloid neoplastic cells with pleomorphic nuclei and abundant cytoplasm. Small amount of melanin pigment deposition can be found.
    • IHC: CK(-), S100(+), Melan A(+) and SOX10(+).
  • 2022-10-11 ECG
    • Sinus bradycardia
    • Poor wave progression
  • 2022-09-27 MRI - L-spine
    • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
    • Scoliosis of L-spine.
    • One large lobulated mass lesion (5.1cm) over right-side of the L3 vertebral body with destruction of bone cortex. Suggest check enhanced MRI or tissue proof to rule out malignancy.
    • Narrowing of right L5/S1 neural foramen.
  • 2022-09-08 KUB + L-spine Lat
    • Facet degeneration of lower lumbar spine
    • Disc space narrowing at L2-3-4-5-S1
    • General osteoporosis
    • Concave vertebrae of T-L spine
  • 2022-09-08 Merchant view (patella 45 0) Bil
    • No lateral subluxation or lateral tilting of the patella
    • s/p bilateral total knee replacements
  • 2022-09-08 Knee Bilat. standing AP and Lat views:
    • S/P total knee arthroplasty, Bil
    • Good alignment without prosthesis loosening

[MedRec]

  • 2023-04-09 ~ 2023-04-14 POMR Hemato-Oncology
    • Discharge diagnosis
      • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases, cstage IV, status post L3 posterior decompression + L2-4 posterior instrumentation and fusion on 2022/12/28
      • Atherosclerotic heart disease of native coronary artery without angina pectoris
      • Hypertensive heart disease without heart failure
  • 2022-11-24 ~ 2022-12-02 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant melanoma of left lower limb, including hip
      • Melanoma with mediastinal lymph nodes, left upper lung and L3 spine metastases at least, cstage IV
      • Secondary malignant neoplasm of bone
      • Osteoarthritis of knee, unspecified
      • Other spondylosis, lumbar region
      • Radiculopathy, site unspecified
      • Constipation, unspecified
  • 2022-11-22 SOAP Hemato-Oncology
    • Objective: no V600E mutation (dabrafenib not indicated)
  • 2022-10-28 SOAP Hemato-Oncology
    • Plan to apply Tafinlar (dabrafenib) if V600E mutation is documented
      • Note: as monotherapy, dabrafenib is indicated to treat unresectable or metastatic melanoma with BRAF V600E mutation

[chemotherapy]

  • 2023-05-12 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-20 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-13 - Nab-paclitaxel 150mg/m2 200mg 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

Nanoparticle albumin bound paclitaxel (nab-paclitaxel) 2023-05-24 https://www.uptodate.com/contents/nanoparticle-albumin-bound-paclitaxel-nabpaclitaxel-drug-information

  • Melanoma, metastatic (off-label use):
    • Previously treated patients: IV: 100 mg/m2 on days 1, 8, and 15 of a 28-day cycle; if tolerated, may increase dose by 25 mg/m2 in cycle 2 and beyond; continue until disease progression or unacceptable toxicity.
    • Previously untreated patients: IV: 150 mg/m2 on days 1, 8, and 15 of a 28-day cycle; continue until disease progression or unacceptable toxicity.

==========

2023-06-05

  • The patient was prescribed famotidine, sennosides, clopidogrel, isosorbide dinitrate, nicorandil, bisoprolol, valsartan, rosuvastatin, and alprazolam by WanFang Hospital for the primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris on 2023-04-27. The patient refilled these medications at a local pharmacy on 2023-05-24. Among these, alprazolam and sennosides are not included in the current active medication list. These medications may be excluded if there’s no ongoing indication. All the cardiovascular drugs prescribed are properly integrated into the active medication list without any medication reconciliation issues.
  • It has been noted that the disease does not possess the BRAF V600E mutation; however, the status of the V600K mutation is currently undocumented (not found). If the presence of a V600K mutation is confirmed, the combined therapy of dabrafenib and trametinib might be also considered as a treatment option.

2023-05-24

  • The patient made a visit to WanFang Hospital on 2023-04-27, where several medications were prescribed for a duration of 28 days to manage her atherosclerotic heart disease. It appears that clopidogrel, one of the prescribed medications, is not currently listed on the active medication list. If there are no contraindications or other clinical concerns, it might be beneficial to add clopidogrel back into the patient’s regimen to maintain an accurate and up-to-date medication reconciliation.
  • The patient, who has metastatic melanoma, is currently receiving off-label treatment with nab-paclitaxel at a dose of 150mg/m2 on days 1, 8 and 15 of a 28-day cycle. Targocid (teicoplanin) and tapimycin (piperacillin + tazobactam) are currently used to treat cellulitis with pus formation over the port-a-wound. There is no issue with the active prescription.

701482774

230601

[exam findings]

  • 2023-06-01 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 29 dB HL; LE 26 dB HL.
    • RE normal to moderate SNHL.
    • LE normal to mild SNHL.
  • 2023-06-01 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Suspected fatty infiltration of pancreas
      • Small GB
      • Splenomegaly, mild
      • Suboptimal examination of liver,especially the subcostal view due to poor echo window
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2023-05-30 Nasopharyngoscopy
    • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
    • bulging tongue tumor, airway compromised+
  • 2023-05-25 CT - chest
    • Submental and right submandibular lymphadenopathy
    • COPD. Moderate.
    • Diffuse Swelling of the gastric wall is found. Suggest endoscopy.
  • 2023-05-18 MRI - larynx
    • Oralcavity
      • Impression (Imaging stage) : T:4b N:3b M:0 STAGE:IVB
  • 2023-05-17 CXR
    • Multifocal opacities of left lung. Increased infiltration over both lungs. May be active infection.
  • 2023-05-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79.0 - 23.2) / 79.0 = 70.63%
      • M-mode (Teichholz) = 70.6
      • 2D (M-simpson) = 71.0
    • Conclusion:
      • Normal AV/MV with mild MR
      • Concentric LVH, normal LV wall motion
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size
  • 2023-05-15 Patho - tongue biopsy (Y1)
    • Tongue, right lateral, biopsy— well differentiated squamous cell carcinoma
    • Microscopically, section shows well differentiated squamous cell carcinoma consisting of squamous tumor nests in infiltrative growth pattern and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, nuclear pleomorphism, hyperchromasia, and mitiotic activity.
    • HC stain— p16(-)
  • 2023-05-15 ECG
    • Normal sinus rhythm
    • Increased R/S ratio in V1, consider early transition or posterior infarct
    • Prolonged QT
  • 2023-05-13 Nasopharyngoscopy
    • granular tumor right tongue border, whitish lesion over left hard palate, smooth NPx, protuding of right tongue base with yellowish discharge, sputum pooling over HPx, fair vocal cord movement

[MedRec]

  • 2023-05-24 SOAP Hemato-Oncology
    • Arrange admission for PET-CT, Chest CT (including whole body if possibile), EGD, Abdominla sonography and Port-A implantation
    • Refer to CS for Port-A implantation
  • 2023-05-23 SOAP Ear Nose Throat
    • A: Tongue cancer, stage IVb
    • Treatment plan: induction CT + CCRT, referred to Hema

[consultation]

  • 2023-05-30 Anesthesiology
    • Q
      • Injury Severity Score: 3 Difficulty Swallowing > Acute Central Moderate Pain (4-7) Tongue cancer, tongue bleeding for 1 week, significant bleeding today, the patient expresses desire for DNR (Do Not Resuscitate)
      • 5/18 ENT (Ear, Nose, and Throat) discharge diagnosis
        • Right deep neck infection status post right deep neck incision & drainage on 2023-5-14.
        • Right lateral tongue cancer status post biopsy (squamous cell carcinoma) on 2023-5-14.
        • Localized swelling, mass and lump, neck
        • Hypertension
        • Type II diabetes mellitus
    • A
      • Visited the patient in the emergency department
      • The patient was not using any oxygen assistance at the time
      • If the ENT doctor indicates that the patient may have a risk of airway loss at any time
      • Please have the emergency tracheotomy on standby for intubation in the operating room, or directly proceed with a tracheostomy
      • The patient had previously been treated for difficult airway in the operating room, and a direct tracheostomy should be considered.
  • 2023-05-30 Ear Nose Throat
    • A1
      • S:
        • intermittent oral bleeding for 1 week, progressed today
        • the patient complained dyspnea and can’t lying down
        • Deep neck infection s/p I+D and right lateral tongue biopsy
        • Right tongue cancer. T4bN3BM0, Stage IVB
      • O:
        • Scope:
          • left arytenoid swelling, blood clots over larynx and hypopharynx, penetration and impending aspiration
          • bulging tongue tumor, airway compromised+
      • Plan:
        • Suggest tracheostomy, but the patient strongly refused
        • Well explanation to the patient and his family about the risk of active bleeding and airway obstruction with possible death
        • Well education: if bleeding again, sit up with mouth open and head downward to prevent aspiration
        • ENT OPD f/u
    • A2 2023/05/30 16:50
      • We were informed that the patient agreed to receive tracheostomy
      • We will arrange tracheostomy under ETGA on 2023/6/1
      • OA to oncology, if active bleeding or respiratory failure -> intubation
    • A3 2023-05-30 18:00:58
      • We will arrange tracheostomy operation today for airway protection.
      • Keep NPO and finish preOP survey
    • A4 2023-05-30 22:09:46
      • staus post tracheostomy (shiley 6 #)
      • adequate pain control and antibiotics
      • f/u CXR to check tracheostomy position
      • hemoclot and bosmin gauze prn for oral tumor bleeding
      • suction prn carefully (The tumor is located on the right rear side, do not poke too deep.)
  • 2023-05-14 Cardiology
    • Q
      • This 53-year-old male has histories of HTN, D.M, type II and hyperlipidemia. This time, he was admitted to ENT ward for under impression of deep neck infection on May 13, 2023. He underwent 1. Incision and drainage of right deep neck infection 2. Biopsy of right lateral tongue and left soft palate tumor on May 14, 2023. But, acute respiratory failure at POR, re-intubation with ventialtor support was performed on May 14, 2023, and he was transferred to our SICU for intensive care today. Due to ST depression by 12 leads EKG, and elevated of hs Tropnin I (from 179.4 tp 308.4 pg/mL), We need your expertise for suspect acute coronary syndrome evaluation. Thanks a lot!!
    • A
      • We were consulted for diffuse STD and elevated hs-troponin I
      • The STT change was noted while the routine screening of his cardiac enzyme and ECG. Since this patinet was clear consciousness, he could inform us that he had no subjective symptom.
      • S:
        • patient is clear conscious under ventilator support.
        • Denied of chest pain, chest tightness right now and in the past.
      • O:
        • Clear breathing sounds
        • No pitting edema
        • EKG:
          • 20230513 - Q wave in inferior leads, and T wave invertion at anterolateral leads
          • 20230514 - diffuse STD from V2-V6
        • Labs
          • 20230514 - hsTrop I 180 -> 300
        • Bedside echo: adequate EF and no abnormal wall motion, poor echo window.
      • Impression
        • R/o demand ischemia
        • Deep neck infection
      • Suggestion
        • ST EKG V1-V6 + V7-V9 showing recovery of STD changes (spontaneous recovery)
        • F/u hs-Trop and EKG 2hr later.
        • Might consider plavix 1# QD if no bleeding tendency and secure hemostasis at OP site.
        • F/u electrolytes ( Mg, Ca, Ip, Na/K), CAD risk factors including lipid profile, HbA1c and uric acid.
        • Arrange 2D cardioechography. CV OPD follow up
  • 2023-05-13 Ear Nose Throat
    • Q
      • Chief Complaints:
        • left neck pain for one week
        • dysphagia
      • Past History: Nil
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S
        • Right neck pain for one week
        • Previous R tongue border leukoplakia s/p biopsy = benign in 2023/01.
        • Hx of DM, HTN
      • O
        • Local findings: granular tumor over right tongue border, whitish lesion over left hard palate
        • Scope: smooth NPx, protuding of right tongue base, yellowish discharge pooling over HPx, mild airway compromized
      • A
        • Impression: Highly suspect Oral ca with deep neck infection
      • P
        • OA to ENT, continue IV anti, pain control
        • Arrange I&D on 2023/05/14

==========

2023-06-01

This patient visited a local clinic on 2023-05-11 for his primary hypertension (PharmaCloud only reveals one main diagnosis, there should be also diabetes diagnosed) and be prescribed with amlodipine, losartan and glimepiride. Currently Norvasc (amlodipine), Amepiride (glimepiride) and 與 losartan 同藥理作用的 Olmetec (olmesartan) are shown in the active medication list, no reconciliation issue identified.

2023-05-19 anaerobic culture for deep neck wound/pus showed peptostreptoccus spp. 3+

701267240

230531

[exam findings]

  • 2023-05-22 Laryngoscopy
    • Findings
      • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size stable favor granulation; saliva accumulation at bi hypopharynx and on pharyngeal wall
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-05-08 Laryngoscopy
    • Findings
      • flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), favor granulation
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-04-27 Laryngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge)
      • FEES: soft diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction, under swallowing rehabilitation
  • 2023-04-20 Patho - nasopharyngeal/oropharyngeal biopsy
    • Right nasopharyngeal lesion, biopsy — Necrotic ulcer debris, acute inflammatory exudates, and granulation tissue only.
  • 2023-04-20 Nasopharyngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal movement decreased, glottic closure fair; a nodular lesion at right nasopharynx (flap upper edge), size increase >>> biopsy done
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Right nasopharyngeal lesion, biopsy done
  • 2023-04-06 Laryngoscopy
    • Findings
      • Scope: flap at right oropharynx and hypopharynx, right vocal paresis, glottic closure fair; flap upper edge swelling, granulation, r/o tumor
      • FEES:
        • liquid diet: premature leak +, residual + at vallecula and pyriform sinus, penetration +, aspiration +
        • soft diet: premature leak -, residual + at vallecula and pyriform sinus, penetration +
    • Diagnosis/conclusion
      • Malignant neoplasm of pyriform sinus, tumor recurrence at right oropharynx and right parapharyngeal space, s/p op
      • Swallowing dysfunction
  • 2023-03-24 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana) S2023-3886 G1
      • Tumor type: squamous cell carcinoma
      • Tumor location: Oropharynx
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes,
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC >=1% and <5%
        • Percentage of PD-L1 expressing tumor cells (%TC): 3%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >= 10%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 15%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-24 PD-L1 IHC
    • Tissue blocks/unstained slides received labeled as: S2023-03886 G1
      • Tumor type: Labeled H&N cancer
      • Testing assay: 28-8 pharmDx Assay (Agilent/Dako)
    • RESULT:
      • Tumor cell (TC) staining assessment: TC < 1%
  • 2023-03-24 PD-L1 22C3
    • Unstained slides received labeled as: S2023-03886 G1
      • Tumor type: oral cancer
      • Testing assay: 22C3 pharmDx Assay (Agilent/Dako)
    • RESULTS:
      • Tumor Proportion Score (TPS) assessment: TPS >=1% and <50%
        • Tumor Proportion Score (TPS): 1%
      • Combined Positive Score(CPS) assessment: CPS >=1 and <10
        • Combined Positive Score (CPS): 5
  • 2023-03-06 Patho - oral cancer (wide excision + lymph node)
    • Diagnosis:
      • Oropharynx, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage IVB, pT4bN0(if cM0); The immunohistochemical stain of p16 is negative.
      • Lymph node, right neck, level III, selective neck dissection—- Negative for malignancy (0/9)
      • Lymph node, right neck, level IIb, selective neck dissection —- Negative for malignancy (0/2)
      • Lymph node, right neck, level IIa, selective neck dissection —- Negative for malignancy (0/7)
      • Lymph node, right neck, level I, selective neck dissection —- Negative for malignancy (0/5)
      • Submandibular gland, right, excision —- Negative for malignancy
      • Sublingual gland, right, excision —- Negative for malignancy
      • Parapharyngeal space tissue, right, excision —- Negative for malignancy
      • Lymph node, parapharyngeal space tissue, right, excision —- Negative for malignancy (0/1)
      • Prevertebral fascia and muscle, right, excision —- Negative for malignancy
      • Tissue close to skull base, right, excision —- Squamous cell carcinoma
      • Carotid sheath close to skull base, right, excision —- Squamous cell carcinoma
      • Prevertebral tissue close to carotid artery, right, excision —- Squamous cell carcinoma
      • F2023-00085
        • FsA: Carotid sheath, biopsy — Negative for malignancy
        • FsB: Superior margin, biopsy — Negative for malignancy
        • FsC: Medial margin, biopsy — Negative for malignancy
        • FsD: Inferior margin, biopsy — Negative for malignancy
        • FsE: Deep margin, biopsy — Squamous cell carcinoma
        • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
    • Macroscopic examination
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: oropharynx
        • Other part(s) included: Sublingual gland, Parapharyngeal space tissue, Prevertebral fascia and muscle, Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
        • Lymph node dissection: yes, (specify) III, IIb, IIa, I
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: 3.0 x 2.5 x 2.2 cm
        • Additional dimensions (if more than one part): Sublingual gland: a piece, 2.6 x 2.0 x 1.0 cm; Parapharyngeal space tissue: a piece, 3.3 x 2.6 x 1.4 cm; Prevertebral fascia and muscle: 7 pieces, measuring up to 2.2 x 2.0 x 0.3 cm; Tissue close to skull base: 8 pieces, measuring up to 1.4 x 1.0 x 0.5 cm; Carotid sheath close to skull base: 4 pieces, measuring up to 1.5 x 0.4 x 0.2 cm; Prevertebral tissue close to carotid artery: multiple pieces, measuring up to 1.5 x 0.9 x 0.7 cm
      • Depth of invasion: 6 mm
      • Tumor Site: oropharynx
        • Laterality: right  
      • Tumor Focality: single focus with involving several areas, (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Tumor Size: Greatest dimension: 1.8 x 1.0 cm
        • Additional dimensions (if available): not applicable
      • Mucosal Surface: Intact
      • Gross Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Representative sections are taken and labeled as: A: lymph node, level III; B: lymph node, level IIb; C: lymph node, level IIa; D1: submandibular gland; D2-3: lymph node, level I; E: sublingual gland; F1-2: Parapharyngeal space tissue; G1-2: through section from superior (ink green) to inferior (ink blue); G3: anterior margin; G4: posterior margin; H: Prevertebral fascia and muscle; I: Tissue close to skull base; J: Carotid sheath close to skull base; K: Prevertebral tissue close to carotid artery.
        • F2023-00085
          • A: Specimen submitted in fresh and labeled as “Carotid sheath” consists of 2 pieces of tan, irregular tissue measuring up to 0.5 x 0.4 x 0.3 cm. All for section in one cassette FsA1.
          • B: Specimen submitted in fresh and labeled as “Superior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA1.
          • C: Specimen submitted in fresh and labeled as “Medial margin” consists of a piece of tan, irregular tissue measuring 2.1 x 1.3 x 0.4 cm. All for section and inked purple in one cassette FsA1.
          • D: Specimen submitted in fresh and labeled as “Inferior margin” consists of a piece of tan, irregular tissue measuring 1.4 x 0.5 x 0.3 cm. All for section in one cassette FsA2.
          • E: Specimen submitted in fresh and labeled as “Deep margin” consists of a piece of tan, irregular tissue measuring 1.6 x 0.6 x 0.3 cm. All for section and inked green in one cassette FsA2.
          • F: Specimen submitted in fresh and labeled as “Carotid sheath close to skull base” consists of several pieces of tan, irregular tissue measuring up to 0.4 x 0.2 x 0.2 cm. All for section and inked purple in one cassette FsA2.
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma, The immunohistochemical stain of p16 is negative.
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) Tissue close to skull base, Carotid sheath close to skull base, Prevertebral tissue close to carotid artery
      • Margins (obtained from the main resection specimen):
        • F2023-00085: Deep margin involved by invasive carcinoma
        • S2023-03886: Anterior resection margin: 1.2 cm; Posterior resection margin: 0.2 cm; Superior resection margin: 0.4 cm; Inferior resection margin: 0.2 cm
      • Lymph-Vascular Invasion: present
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: please see diagnosis
        • Ipsilateral: Number examined: 24; Number involved: 0
        • Contralateral (if available): not received
        • Size (greatest dimension) of largest metastatic deposit: not identified
        • Extranodal extension: not identified
      • F2023-00085
        • Sections of specimens A, B, C and D are free of malignnacy. Sections of specimens E and F show invasive squamous cell carcinoma.
  • 2023-03-03 Frozen section
    • Preliminary diagnosis:
      • FsA: Carotid sheath, biopsy — Negative for malignancy
      • FsB: Superior margin, biopsy — Negative for malignancy
      • FsC: Medial margin, biopsy — Negative for malignancy
      • FsD: Inferior margin, biopsy — Negative for malignancy
      • FsE: Deep margin, biopsy — Squamous cell carcinoma
      • FsF: Carotid sheath close to skull base, biopsy — Squamous cell carcinoma
  • 2023-01-16 Patho - larynx biopsy
    • PATHOLOGIC DIAGNOSIS
      • R’t pyriform sinus, anterior wall, LMS — Benign squamous epithelium
      • Tumor, right posterior oropharyngeal wall, excision — Squamous cell carcinoma
    • MICROSCOPIC EXAMINATION
      • R’t pyriform sinus anterior wall: benign squamous epithelium without underlying stromal tissue included
      • Right posterior oropharyngeal wall tumor: squamous cell carcinoma with moderate differentiation characterized by solid tumor nests infiltration with focal keratin formation, perineural invasion, tumor emboli and ulceration. Besides, unlabelled peripheral margin and deep margin are involved by tumor. Follow up
  • 2023-01-11 PET scan
    • The right oropharynx wall lesion shown on the previous larynx MRI reveals glucose hypermetabolism, indicating highly suspected tumor recurrence. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the left lower lung, probably inflammation precess, suggesting follow-up.
    • Glucose hypermetabolism in bilateral pulmonaty hilar lymph nodes, and right mediastinal lymph nodes, probably reactive nodes.
    • Increased FDG uptake at bilateral shoulders, probably benign in nature.
    • Increased FDG accumulation in both kidneys and colon, probably physiological uptake of FDG.
    • Right pyriform sinus cancer s/p treatment with highly suspected tumor recurrence in the lateral wall of the right oropharynx, rcTxN0M0, by this F-18 FDG PET scan.
  • 2023-01-09 MRI - larynx
    • Comparison: 2022/10/04, 2022/06/28, 2021/01/25 Neck CT, 2021/0929 MRI
      • No obvious local recurrent right hypopharynx mass or nodule. -Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space with well post contrast enhancement.
        -No obvious right hypopharynx mass or nodule. -Post OP at right submandiublar gland and LNs. -Small left level I-II LNs. -Dental caries? in left low jaw with signal intensity change of the mandible bone, stationary.
        -A small right maxillary sinus retention cyst or mucocele, stationary.
    • IMP:
      • No obvious local recurrent right hypopharynx mass or nodule.
      • Highly suspected tumor recurrence in right oropharynx wall, and recrurent LAP at right carotid space.
  • 2023-01-07 CT - chest
    • Indication: pyriform sinus cancer s/p OP and CCRT
    • Chest CT with and without IV contrast ehnancement shows:
      • s/p left lower lobe op.
      • Calcified coronary arteries is found.
      • Subpleural nodular lesion at left upper lobe measuring 0.89cm is found. In comparison with CT dated on 2022-07-07, the lesion is stationary. Smaller lesion at left upper lobe measuring 0.4cm is found.
      • Calcified dot at right upper lobe measuring 0.3cm is found.
    • Imp:
      • Left upper lobe nodules. 0.4cm to 0.89cm, stationary.
      • Right upper lobe calcified dot.
      • s/p left lower lobe op.
  • 2022-10-11 CT - chest
    • two LLL solid nodules (up to 9mm) stationary.
    • RUL granuloma 3mm.
  • 2022-10-04 MRI - larynx
    • No obvious right hypopharynx mass or nodule. No evidence of tumor recurrence. No neck LAP.
  • 2022-08-03 Patho - larynx biopsy
    • Labeled as “superior part of lesion, right”, Oral tumor or oropharynx excision — ulcer with benign squamous mucosa.
    • Labeled as “inferior part of lesion, right”, Oral tumor or oropharynx excision — fibrotic necrotic tissue.
  • 2022-07-20 Patho - larynx biopsy (Y1)
    • Labeled as “right pyriform sinus”, excision with frozen section for margins (F2022-336FSA) — squamous cell carcinoma. 1 mm from all margins. IHC stain: p16 (-).
  • 2022-07-07 CT - chest
    • Left upper lobe perifissural nodule. 1.04cm, aolid nodule. 3mm, these two nodules are stationary.
  • 2022-06-28 MRI - larynx
    • The current study was compared to the prior one obtained on 2022/04/01.
    • Known a case of right pyriform sinus cancer S/P CCRT. Still effacement of right pyriform sinus with mild mucosal thickening. Suggest clinical correlation.
  • 2022-04-01 MRI - larynx
    • No obvious recurrent hypopharyngeal tumor in this study.
    • A 1.0cm enhancing lesion at the left mandible, stationary. Dental problem or other etiology? Suggest close follow up.
  • 2022-01-05 CT - chest
    • two solid nodules in LLL (9 mm, 4 mm) and a LUL solid nodule 3 mm, suggest f/u at 6-12 months later.
    • RUL granuloma 3 mm.
  • 2021-12-30 MRI - larynx
    • No obvious right hypopharynx mass or nodule.
    • Post OP at right submandiublar gland and LNs.
  • 2021-10-20 Patho - lung wedge biopsy
    • Lung, left lower lobe, VATS LLL wedge — Lymphoid hyperplasia
    • IHC stain — CK(-)
  • 2021-10-06 CT - chest
    • RUL tiny granuloma. Two LLL solid nodules 9 mm and 4 mm. suggest f/u at 6 months with CT.
  • 2021-09-29 MRI - larynx
    • a heterogeneous enhancing lesion at the left mandibular alveolar region, stationary.
  • 2021-09-03 CT - brain
    • Brain atrophy.
    • Chronic maxillary sinusitis.
  • 2021-09-03 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • T wave abnormality, consider inferior ischemia
    • Abnormal ECG
  • 2021-06-09 MRI - larynx
    • a heterogeneous enhancing lesion at the left mandibular alveolar region.
  • 2021-04-28 Endoscopic radiofrequency ablation
    • Indication: Esophageal high grade dysplasia
    • Anesthesia: Dormicum + alfentanil + propofol titrated given
    • Procedure: Endoscopic radiofrequency ablation with catheter type RFA catheter
    • Course:
      • Radiofrequency Ablation is performed with TTS type 90 RFA catheter. After Lugol soln (1.5%) spraying, leopard spots scattering at the whole esophagus was noted. Three Lugol-voiding lesions needed to be ablated.
      • Three lesions are localized at the 37 cm, 30cm and 25 cm.
      • The procedure is done with ablation -ablation-clean- ablation-ablation mode with energy 12 jouls delivered.
    • Other finding
      • Short mucosal breaks noticed at the lower esophagus.
    • Diagnosis
      • Esophageal carcinoma in situ s/p RFA
      • Reflux esophagitis Gr.A
    • Suggestion
      • PPI & sucrafate use
    • Complication
      • No immediate complication
  • 2021-04-09 Tc-99m MDP bone scan
    • Increased activity in the lower C-spine. Degenerative change may show this picture.
    • Increased activity in the maxilla and left aspect of mandible. The nature is to be determined (dental problem? other nature?). Please correlate with other clinical findings for further evaluation.
    • Some hot and faint hot spots in the skull. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2021-04-06 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 20 dB HL.
    • R’t normal to severe SNHL.
    • L’t normal to moderate SNHL
  • 2021-03-23 MRI - larynx
    • Comparison: 2021/01/25 Neck CT
      • Poor defined right hypopharynx mass or nodule.
      • Post OP at right submandiublar gland and LNs.
      • Small left level I-II LNs.
      • Dental caries? in left low jaw with signal intensity change of the mandible bone.
      • A small left oropharynx wall LN?
      • Suggest clinical correlation.
  • 2021-03-17 Patho - larynx biopsy
    • Labeled as “right AE fold”, biopsy — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p40 (+), p16 (-)
  • 2021-02-26 PET
    • A prominent glucose hypermetabolic lesion in the left aspect of mandible. Either dental problem or malignancy may show this picture. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right aspect of the hypopharynx, right aspect of the soft palate, right tonsil, some bilateral neck level II lymph nodes and a left submandibular lymph node. The nature is to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the right submandibular area, compatible with post-operative inflammation.
    • Increased FDG accumulation in both kidneys and colon. Physiological FDG accumulation is more likely.
  • 2021-02-19 Patho - salivary gland resection
    • Lymph nodes, submandibular gland, right, excision — Squamous cell carcinoma, metastatic; p16(-)
    • The sections show a picture of squamous cell carcinoma, metastatic, composed of nests of moderately differentiated neoplastic squamous cells in lymphoid tissue. Keratin formation, focal tumor necrosis, and extranodal extension are evident. The surgical margin is free of carcinoma.
    • IHC: p16(-).
  • 2021-01-25 CT - neck
    • IMP: An ill-defined tumor mass in middle posterior part of right submandibular gland, at least, up to 3.1 cm.
    • Imaging Report Form for major salivary gland malignancy
    • Impression (Imaging stage): T:T2(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IVA (Stage_value)

[MedRec]

  • 2023-04-13 SOAP Hemato-Oncology
    • Waiting for the result of PD-L1 -> Consider IO-based Tx -> Due to trail started since 2023-07, already suggest patient start PF. But patient would like to get better performance status.
  • 2023-03-23 SOAP Hemato-Oncology
    • Waiting for the result of PD-L1 -> Consider IO-based Tx
  • 2021-03-23 SOAP Hemato-Oncology
    • Conclusions of the Multidisciplinary Cancer Team Meeting, meeting date 20210305
      • It is recommended to arrange an MRI examination.
      • Seek the opinion of the original ENT doctor.
      • Further search for the primary (source of cancer).

[consultation]

  • 2023-03-18 Hemato-Oncology
    • Q
      • for chemotherapy
      • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313. Remove neck suture wound on 20230317. Today, tumor board meeting discussion, which suggest chemotherapy. We need yor help for further evaluation and management. Thank you very much!!
    • A
      • Due to RT treatment history, the dose of RT in the patient is limitation. Systemic therapy is indicated in the patient (Ex: immuno, chemo…). We will also discuss with patient about clinical trial (head and neck cancer with IO naive). Please arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-16 Dermatology
    • Q
      • for right face some rash with itching
      • This 54 y/o man had history of DM and hypopharyngeal cancer s/p op + CCRT in 2021. Under the impression of right oropharyngeal cancer, he was admitted and received tumor excision + right neck disection + tracheostomy + flap reconstruction on 20230303 to 20230304. He was tranfered to SICU for intensive care on 2023/03/04 to 2023/03/06. After wound condition stable, he was transferred to our service on 20230309. Tracheostomy removed on 20230313, and keep neck wound care. Right face some rash with itching was found on 20230315. We need yor help for further evaluation and management. Thank you very much!!
    • A
      • The patient had sufferred from erythematous plaques with fine scales over face and chin
      • Under the impression of seborrheic dermatitis over face.
      • The following sugeetion:
        • Betason-N onit 1 tube topical bid use first on the wound and curst lesions first.
        • Mycomb cream 1tube topical bid use over large erytheamtous papules and plaques area on the face.
        • If still itchy or spreading erythema, consider Rinderon cream 1 tube topical QN use (depends on the situation, only needed on areas with red and scaly skin, strengthen locally).
  • 2021-05-28 Radiation Oncology
    • A: Squamous cell carcinoma of right hypopharynx (pyriform sinus), , p16 (-), stage cT2N2bM0 (IVA), s/p induction chemotherapy.
    • P: Radiotherapy is indicated for this patient with the following indicators: hypopharygeal cancer, stage cT2N2bM0 (IVA)
      • Goal: curative
      • Treatment target and volume: right hypopharyngeal cancer to bilateral neck,
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 5000cGy/25 fractions of the bilateral neck, and 7000cGy/35 fractions of the right hypopharyngeal tumor bed to involved neck nodal lesions.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 10AM, 2021-6-2.

[chemotherapy]

  • 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-05-30 - cisplatin 75mg/m2 120mg NS 500mL 24hr D1 (Y site 5-FU) + [magnesium sulfate 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-27 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-20 - carboplatin AUC 2 150mg D5W 250mL 2hr + NS 1000mL (Y site carboplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-13 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-07-06 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-29 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-22 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-06-15 - cisplatin 40mg/m2 70mg NS 500mL 3hr + NS 1000mL (Y site cisplatin)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-05-27 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-05-03 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2021-04-10 - docetaxel 75mg/m2 130mg NS 250mL 1hr + cisplatin 75mg/m2 130mg NS 500mL 24hr (Y site 5-FU) + fluorouracil 750mg/m2 1300mg NS 500mL 24hr D1-5
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-05-31

Based on the PharmaCloud database, this patient has only sought medical care at our hospital in the past three months. On 2023-05-27, our metabolic physician recently prescribed refillable medications including Uformin (metformin), Trajenta (linagliptin), Lipanthyl (fenofibrate), and Zulitor (pitavastatin). These drugs have been correctly integrated into the current active medication list without any issues in medication reconciliation.

700647993

230530

[exam findings]

  • 2023-05-29 CT - abdomen
    • Clinical information: 1) High grade serous carcinoma of fallopian tube with peritoneal metastasis and pleural effusion with positive cytology, cT3N0M1 stage IV, post debulking surgery + Hyperthermic Intraperitoneal Chemotherapy on 2023/04/24. 2) GERD. 3) HTN
    • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
      • Known a case of fallopain tube cancer with peritoneal carcinomatosis S/P operation and chemotherapy. No presence of recurrent or residual tumor.
      • The both kidneys show normal contrast excretion, size, and contour without evidence of renal stone or tumors.
      • The liver parenchyma reveals no evidence of focal lesion.
      • The gallbladder is normal in size and wall thickness.
      • The pancreas & spleen appears normal in size and contour.
      • There is fecal materials impaction in the sigmoid colon and rectum.
  • 2023-04-26 CXR
    • Bilateral parahilar infiltrates with blunting of left costophrenic angle, r/o lung edema. Progression as compare with CXR on 2023-04-24. suggest clinical correlation.
    • Mild cardiomegaly.
  • 2023-04-25 Patho - uterus (with or without SO) neoplastic
    • Diagnosis:
      • Ovary, bilateral, oophorectomy —- high grade serous carcinoma, metastatic
      • Fallopian tube, right, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa
      • Fallopian tube, left, residual, salpingectomy —- high grade serous carcinoma, metastatic, tumor seeding on serosa, s/p salpingectomy (S2023-01126)
      • Uterus, corpus, total hysterectomy —- negative for malignancy
      • Uterus, cervix, total hysterectomy —- negative for malignancy
      • Lymph node, left external ilaic, dissection —- high grade serous carcinoma, metastatic (1/8)
      • Lymph node, left obturator, dissection —- high grade serous carcinoma, metastatic (1/11)
      • Lymph node, right external ilaic, dissection —- high grade serous carcinoma, metastatic (1/9)
      • Lymph node, right obturator, dissection —- negative for malignancy (0/13)
      • Lymph node, left para-aortic, dissection —- high grade serous carcinoma, metastatic (2/20)
      • Lymph node, right para-aortic, dissection —- high grade serous carcinoma, metastatic (1/7)
      • Soft tissue on intestine, excision —- high grade serous carcinoma, metastatic
      • Omentum, omentectomy —- high grade serous carcinoma, metastatic
      • AJCC 8th edition: ypStage IIIC, ypT3cN1a(if cM0), FIGO Stage IIIAIi or ypStage IVA, ypT3cN1aM1a (pleural effusion with positive cytology), FIGO Stage: IVA; please correlate with the clinical presentation and image study.
    • Gross description:
      • Procedure (select all that apply): Debulking surgery (ATH + BSO + Cytoreduction surgery + bilateral pelvic & paraaortic lymphadectomy + infracolic omentectomy); No appendix is received
    • Microscopic Description:
      • Histologic Type: High-grade serous carcinoma
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors): not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only)
        • Serous tumor implants that were formerly classified as “invasive implants” are now classified as low-grade serous carcinoma of the peritoneum.: Present (specify sites): soft tissue on intestine and omentum
      • Other Tissue/ Organ Involvement (select all that apply): bilateral ovary, bilateral fallopian tube, soft tissue on intestine and Omentum
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Macroscopic (greater than 2 cm) (omentum)
      • Peritoneal/Ascitic Fluid: N2023-01554: Atypical
      • Regional Lymph Nodes: please see diagnosis;
      • Additional Pathologic Findings: endometrial polyp, adenomyoma and leiomyomas are seen.
  • 2023-04-20 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A tumor (3.6cm) at uterur. Some soft tissues in peritoneal cavity. A cystic lesion (3.1x6.1cm) at pelvic cavity.
      • Bil. pleural effusions.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • Peritoneal carcinomatosis.
      • A tumor (3.6cm) at uterus. A cystic lesion (3.1x6.1cm) at pelvic cavity.
      • Bil. pleural effusions.
  • 2023-03-27 CXR
    • Right Pleura effusion.
  • 2023-02-03 CXR
    • Bilateral Pleura effusion.
  • 2023-01-26, -01-23, -01-19 CXR
    • S/P port-A implantation.
    • Bilateral Pleura effusion S/P pigtail catheter implantation at right CP angle.
    • Borderline cardiomegaly
    • Hypoinflation of both lung is noted.
  • 2023-01-20 SONO - breast
    • diagnosis: no mass lesion
    • BI-RADS: 1. negative
  • 2023-01-17 Patho - fallopian tube biopsy
    • Peritoneum, biopsy — high grade serous carcinoma, metastatic, consistent with fallopian tube origin
    • Section shows fibrous tissue with metastatic high grade serous carcinoma.
    • The immunohistochemical stains reveal PAX8(+), WT-1(focal +), p53(aberrant expression present), PR(-), CD56(focal +), p40(-).
    • The results are consistent with metastatic high grade serous carcinoma from fallopian tube. Focal neuroendocrine feature can not be excluded.
  • 2023-01-17 Patho - fallopian tube biopsy
    • Fallopian tube, left, salpingectomy — high grade serous carcinoma
    • Section shows fallopian tube with high grade serous carcinoma arising from fimbriae.
    • The immunohistochemical stains reveal CK(+) and PAX8(focal +).
    • Tumor seedings on serosa are seen.
  • 2023-01-16 Body fluid cytology - ascites
    • cell block cytology: Malignancy
    • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.
  • 2023-01-12 MRI - brain
    • NO evidence of brain metastasis.
  • 2023-01-11 Whole body PET scan
    • Glucose hypermetabolism in the T-colon, the nature is to be determined (benign or malignant neoplasm, s/p colon fibroscopy change or other nature ?), suggesting further investigation.
    • Glucose hypermetabolism in the right lobe of the liver and in some right subphrenic lymph nodes, malignnacy with distant metastases should be considered.
    • Glucose hypermetabolism in the spleen, the nature is to be determined also, suggesting further investigation.
    • Increased FDG uptake in the uterus, malignancy should be considered, suggesting pelvis CT or MRI for further investigation.
    • No prominent abnormal focal FDG uptake is noted elsewhere.
  • 2023-01-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower L-spines, L5-sacrum junction, bilateral shoulders, hips and feet in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower L-spines and L5-sacrum junction. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and feet, compatible with benign joint lesions.
  • 2023-01-10 Patho - stomach biopsy
    • Stomach, body, biopsy — Hyperplastic polyp
  • 2023-01-10 Patho - colon biopsy
    • Colorectum, rectum. Cold snaring polypectomy (A) — Tubular adenoma with low grade dysplasia
    • Colorectum, descending colon. Cold snaring polypectomy (B) — Tubular adenoma with low grade dysplasia
  • 2023-01-09 CT - chest
    • favor peritonei carcinomatosis, cause and origin to determined.
    • no lung nodule or mass.
  • 2023-01-05 Body fluid cytology - ascites
    • The immunohistochemical stains reveal CK(+), CK7(+), CK20(-), TTF-1(-), Napsin A(-), Calretinin(-), GATA3(-), CDX2(-), and PAX8(equivocal). There are no conclusive results. Please correlate with the clinical presentation for tumor origin.
    • Smears and cell block show clusters of pleomorphic tumor cells and focal glandular pattern. Metastatic adenocarcinoma is favored.

[surgical operation]

  • 2023-01-17
    • Surgery
      • Diagnosis: peritoneal cacinomatosis
      • Operation: SILS left salpingectomy     
    • Finding
      • Uterus: AVF, adhesion to uterus, with mural mass on the surface
      • Adnexae: adhesion to pelvix wall, with mural mass on the surface of tube
      • Bil ovary : graossly normal
      • Cul-de-sac: with ascites, about 3000ml
      • peritoneal carcinomatosis noted, multiple tumors between omentum and bowels
      • Estimated blood loss: minimal
      • Blood transfusion: nil
      • Complication: nil  

[chemotherapy]

  • 2023-05-16 - paclitaxel 135mg/m2 260mg NS 300mL 3hr + carboplatin AUC 5 800mg NS 250mL 2hr + [paclitaxel 40mg/m2 77mg + cisplatin 30mg/m2 58mg + gentamicin 40mg + sodium bicarbonate 2800mg NS 800mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + NS 500mL pre-C/T + NS 500mL post-C/T
  • 2023-04-23 - [Liposome doxorubicin 30mg/m2 60mg D5W 250mL 90min + carboplatin AUC 5 700mg NS 250mL] IP (HIPEC)

  • 2023-03-28 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-07 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 345mg NS 300mL 1hr + carboplatin AUC 5 750mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-20 - paclitaxel 175mg/m2 360mg NS 300mL 1hr + carboplatin AUC 5 740mg NS 250mL 2hr

    • dexamethasone 8mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

700762682

230529

[exam findings]

  • 2022-04-13 CT - abdomen, pelvis
    • S/P segmental small intestine resection and side-to-side duodenojejunostomy.
    • There is marked dilatation from the stomach to duodenum.
  • 2021-12-03 Patho - small intestine resection for tumor
    • pathologic diagnosis
      • Jejunum, proximal, segmental resection – Adenocarcinoma, well differentiated
      • Resection margins, segmental resection – Free
      • Lymph nodes, regional and group 12, segmental resection and LN dissection — Negative for malignancy
      • Pathology stage: pT4N0; Stage IIB if cM0
    • microscopic examination
      • Histology: Adenocarcinoma
      • Histology Grade: well differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Present
      • Tumor cell budding: intermediate
      • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
      • Lymph node metastasis, mesenteric (11) and LN 12(1): Negative (0/12)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition) pT4N0, if cM0
      • Type of polyp in which invasive carcinoma arose: Tubular adenoma
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2021-11-25 Patho - small intestine biopsy
    • Tumor, possibly proximal jejunum, biopsy — Villotubular adenoma with high grade dysplasia
  • 2021-11-23 MRI - liver, spleen
    • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
  • 2021-11-17 CT - abdomen, pelvis
    • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
    • Hemangioma in S4 liver is also suspected.
    • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
    • Please correlate with MRI to R/O angiosarcoma.
  • 2021-05-20 CT - abdomen, pelvis
    • Left liver hemangioma (15.3cm).
    • S/P hysterectomy? Bil. ovary cysts (up to 3.2cm).
  • 2021-05-12 Peripheral Vascular Test - Vein, lower limbs
    • Conclusion:
      • No evidene of DVT, bilateral lower legs
      • Both LSV and SSV without reflux
      • Right CFV, LSV and DFV, venous pulstile flow pattern, etiology?
      • Both leg MVO/SVC is related low
    • Suggestion:
      • Because of low MVO/SVC and venous pulstile flow pattern; maybe follow up CT to rule out upstream lesion.

[MedRec]

  • 2023-03-28 SOAP Hemato-Oncology
    • O
      • 2023/03/15 Tc-99m MDP whole body bone scan
        • Hot spots in the L4-5 spines, the nature is to be determined (severe DJD or others?), suggesting follow-up with bone scna in 3-6 months for investigation.
        • Suspected benign lesions in both rib cages, maxilla, some lower T-spine, bilateral shoulders, S-I joints, and hips.
      • 2023/03/10 PATHO - peritoneum biopsy
        • R’t ovary tumor, frozen section + RSO — Metastatic adenocarcinoma
        • Pelvic peritoneum, Exp.Lap. — Metastatic adenocarcinoma
    • P
      • Admission for C/T with DFL
  • 2021-12-25 SOAP Hemato-Oncology
    • small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op on 20211202.
  • 2019-04-20 SOAP Cardiology
    • Diagnosis
      • Other forms of angina pectoris [I20.8]
      • Heart failure, unspecified [I50.9]
      • Other pulmonary embolism and infarction [I26.99]
      • Autoimmune disease not eleswhere classified [D89.89]
    • Prescription
      • Coxine (isosorbide-5-mononitrate 20mg) 0.5# PRNQD
  • 2019-02-20 SOAP Rheumatology
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
    • Prescription
      • Bokey (aspirin 100mg) 1# QD
      • Plaquenil (hydroxychloroquine 200mg) 1# QD
  • 2019-01-22 SOAP Rheumatology
    • S
      • persistent R’t lower leg swelling pain & soreness
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]
      • Arterial embolism and thrombosis of lower extremity [I74.3]
  • 2019-01-15 SOAP Rheumatology
    • S
      • Limb swelling & stiffness sensation, high D-dimer was detected in LMC after mycoplasma infection.
      • Family Hx: SLE (her daughter)
      • Allergy: amoxicillin
    • O
      • maculopapules over bilateral palms
    • Diagnosis
      • Autoimmune disease not eleswhere classified [D89.89]

[consultation]

  • 2023-05-25 Diagnostic Radiology
    • Q: This 50-year-old woman patient is a case of Small bowel adenocarcinoma, pT4N0cM0, Stage IIB, s/p left hepatectomy, segmental small intestine resection and side-to-side duodenojejunostomy reconstruction and cholecystectomy on 2021/12/02, s/p adjuvant chemotherapy with FOLFOX finishing in 2022/07/25 (2022/01/03 to 2022/07/25), pelvic cavity metastasis, s/p cytoreductive surgery HIPEC with oxaliplatin, right salpingo-oophorectomy and bilateral ureteral catheterization on 2023/03/09, pT4N0M1, Stage IV s/p palliative chemotherapy with DFL from 2023/04/21. She was admitted for chemotherapy. This time, for Port-A catheter obstruct. Now, for evaluate Antegrade Venograghy. Thank you.
    • A: According to the clinical condition and imaging findings, venography is indicated.
  • 2023-03-07 Urology
    • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 2023/02/14. Physical examination showed abdomen soft and ovoid, mild tenderness over lower abdominal, no palpable mass. Under impression of pelvic tumor suspect small bowel cancer recurrent, she admitted for surgical intervention. She will receive exploratory laparotomy with pelvic tumor excision +- HIPEC on 2023/03/09. We need your expertise for ureteral catheter insertion. Thanks for your times.
    • A: I will arrange catheter insertion
  • 2023-02-17 Colorectal Surgery
    • Q: Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor evaluation for colonscopy or sigmoidoscopy.
    • A: please arrange colonoscopy (booking time with 3F GI room), thanks a lot!
  • 2023-02-17 Obstetrics and Gynecology
    • Q: On 2022/11/15 following abdomen CT showed soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis. On 11/25 arrange PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity. The nature is to be determined (a metastatic lesion of low FDG uptake? other nature?). However, she suffered from RLQ dull pain since 2023/02/08, nausea since yesterday. She also had tenesmus, denied of appetite change, no body weight loss, no tarry nor bloody stool. Abdomen CT was performed which revealed a large tumor (10.2cm) in pelvic cavity r/o tumor seeding on 02/14. We need your expertise for pelvic tumor for GYN sono evaluation. Thanks for your times.
    • A
      • S
        • This 50 y/o female: 1) Sjogren syndrome; 2) small bowel cancer, pT4N0M0 Stage IIB s/p segmental small intestine resection and side-to-side duodenijejunostomy reconstruction on 2021/12/02 and s/p chemotherapy on 2022/01/03 to 2022/07/05; 3) GYN history of left salpingectomy on 1995, Uterine myoma s/p laparoscopic assisted vaginal hysterectomy on 2017/08/25.
        • She had RLQ pain since 2023/02/08, she denied vaginal bleeding or discharge
        • Pap smear done this year and normal finding was told
      • O
        • 2022/11/15 abdomen CT: soft tissue tumor, 3.9cm in right pelvic cavity, r/o metastasis.
        • 2023/02/14 abdomen CT: A large tumor (10.2cm) in pelvic cavity r/o tumor seeding.
        • 2022/11/25 PET revealed a mild glucose hypermetabolic lesion in the right pelvic cavity
        • Lab:
          • CEA 5ng/mL (2022/11/09)
          • 2023/02/15 WBC 8460, CRP 2.31, Hb 15.6
        • Sono:
          • s/p ATH
          • pelvic mass 113*75mm
          • CDS minimal fluid
      • A
        • Impression: Huge pelvic mass (size 113*75mm), malignancy suspected, tumor seeding cannot be rule out
      • P
        • Suggestion:
          • please f/u tumor marker: CEA, CA199, CA125
          • if operation decided and GYN problem noted, fell free to contact us
  • 2021-12-15 Hemato-Oncology
    • Q
      • For further chemotherapy evaluation
      • This 49 years old female has underlying of (1) autoimmune disease under AIR OPD follow and medication control, (2) liver hamengioma was noted for 3years. According to her statement, body weight loss 20kg within 6 months and anemia (Hb: 12 -> 9g/dL) was noted on Sep 2021. Denied of nausea or vomiting, dysphgia, no diarrhea or constipation, no tarry or bloody stool, no abdomen pain. On 2021/09/28 arrange UGI pendoscopy at a local clinic which showed reflux erosive esophagitis, LA grade A, healing GU s/p biopsy, gastric polyp s/p biopsy, chronic superficial gastritis. The pathology revealed chronic gastritis consistent with healed ulcer and polyp. Colonscopy was done and showed mixed hemorrhoids, rectal polyp, s/p biopsy, patholegy revealed hyperplastic polyp.
      • After UGI scopy examination, she suffered from nausea with vomiting postprandial frequently and easy abdomen fullness. Therefore, she visited to our GI OPD on Nov. Abdomen echo was done which revealed (1) liver hemangioma of left lobe, (2) suspicious GB stone, (3) suspicious SMA syndrome. Abdomen CT was arranged and showed huge hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected. However, pertise of symptoms, she went to our ER for help on 2021/11/22. Admitted for further survey and jejuunum tumor s/p biopsy was done. The pathology revealed Villotubular adenoma with high grade dysplasia. She underwent left hepatectomy, segmental small intestine resection and side-to-side duodenijejunostomy reconstruction and cholecystectomy on 2021/12/02. The final pathology showed adenocarcinoma, well differentiated, lymph node with metastesis, pT4N0; Stage IIB if cM0. We need your expertise for further chemotherapy evaluation. Thanks for your times.
    • A
      • The further Tx for the pt wt small bowel adenocarcinoma, pT4N0 cM0, Stage IIB, s/p Op is to be proposed.
      • PH:
        • autoimmune disease under AIR OPD follow and medication control
        • liver hamengioma was noted for 3years.
      • Lab:
        • Jejunum, proximal, segmental resection (2021/12/02): AdenoCA, WD
        • Resection margins, segmental resection – Free
        • LNs, regional and group 12, seg. Resection & LN dissection: Negative for malignancy
      • Pathology stage: pT4N0; Stage IIB if cM0
        • Histology: Adenocarcinoma
        • Histology Grade: well differentiated
        • Depth of invasion: To serosa
        • Perineural invasion: Present
        • Tumor cell budding: intermediate
        • Circumferential (radial) margin: Uninvolved, 5 mm from the margin
        • LN metastasis, mesenteric (11) and LN 12(1): Negative (0/12) (No. Positive / No. Total)
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4 (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (No regional LN metastasis)
        • Distant Metastasis (pM): Not applicable
        • Type of polyp in which invasive carcinoma arose: Tubular adenoma
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        • Tumor, possibly proximal jejunum, biopsy (11/25 21): Villotubular adenoma with high grade dysplasia
    • Image study:
      • UGI series (11/24 21): Luminal narrowing of proximal jejunum.
      • EGD (11/24 21)
        • Proximal jejunal tumor, with obstruction, s/p biopsy
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis
        • Bile reflux in stomach
      • CXR (12/11 21):
        • S/P operation.
        • Right CVP inserted to SVC in position.
        • S/P NG tube indwelling.
        • Pneumoperitoneum.
        • Normal appearance of trachea and bil. main bronchus.
        • Normal size of heart
      • Abd CT (11/17 21):
        • Huge Hemangioma in S2-3 of the liver with central fibrosis and cystic degeneration is highly suspected.
        • Hemangioma in S4 liver is also suspected.
        • Left lobe portal vein shows small size that may be tumor compression? This feature is relative unusual.
      • Liver MRI (11/23 21):
        • Bil. liver hemangiomas (up to 15.5cm). Inviaible left portal vein.
    • Medical advice:
      • Small bowel adenocarcinoma ( SBA ) is rare cancer that has been treated similarly to colorectal cancer in the advanced setting. Few studies have been published to help guide management of this dz, and resectable and advanced SBA have been primarily treated as an extensin of CRC.
        • Despite SBA being treated as a large intestinal cancer, pt outcomes are inferior.
        • SBA tends to be diagnosed at a later stage compared wt CRC.
          • 33.7% of pt wt SBA ( excluding duodenal ) were diangosed wt stage I-II Dz compared wt 52.3 % of those wt colon cancer.
          • 32.1% of pt wt SBA diagnosed wt distant mets compared wt 15.6% of those wt CRC, from SEER-Medicare database.
        • Molecular biology progress had expanded understanding of SBA.
          • Several hereditary cancer syndromes can predispose individuals to developing SBA. Hereditary nonpolyposis CRC (HNPCC) or Lynch syndrome is an autosomal dominant inheritance of germline mutations in DNA mismatch repair (MMR) genes, including MLH1, MSH2, MSH6, and PMS2, and rarely EPCAM and PMS1.
        • IHC staining of small bowel adenoCA of this pt showed normal MLH1, MSH2, MSH6, and PMS2.
        • The lifetime risk of developing SBA in Lynch-affected individuals remains low at about 1%, according to European registry studies, and therefore no small bowel screening recommendations currently exist.
          • routinely assessing all SBA tumors for deficient MMR (dMMR) gene expression or high microsatellite instability (MSI-H) is indicated and may help predict better therapies, including immune checkpoint therapy, for these patients.
        • Molecular Alterations
          • Recent studies have made major strides in understanding the molecular drivers of SBA and demonstrated SBA to represent a unique molecular entity with distinct differences between both CRC and gastric cancer.
          • APC (26.8% vs 75.9%; P,.001), TP53 (58.4% vs 75%; P,.001), and CDKN2A (14.5% vs 2.6%; P,.001), showed statistically different molecular alterations between SBA and CRC.
      • By NCCN guideline 2021 for small bowel adenocarcinoma, T3, N0,M0 wt high risk features or T4,N0,M0 (MMS or pMMR) , observation or FOLFOX or CAPEOX (3~6 mo) or 5-FU/LV or capecitabine (6 mo) was recommended.
      • The pt is relatively young & pMMR, post-Op adjuvant C/T wt FOLFOX or CAPEOX is recommended.
  • 2021-11-22 General and Gastroenterological Surgery
    • assessment:
      • BW loss since 2021-05, 10kg in 4 months (2021-05 ~ 2021-09)
      • frequent abdominal fullness and vominting since 2021-09, BW loss 13kg in 2 months
      • liver tumor over left lobe, favor hemangioma, size stationary
    • impression:
      • dyspepsia, not related to liver tumor, SMA syndrom related?
      • liver tumor over left lobe, favor hemangioma, less likely hemangiosarcoma
    • suggest:
      • admit for UGI series survey
      • PPN support
      • MRI survey

[surgical operation]

  • 2021-12-02
    • Surgery
      • left hepatectomy
      • segmental small intestine resection and side-to-side duodenijejunostomy reconstruction
      • cholecystectomy
    • Finding
      • huge hemangioma over left lobe of liver
      • suspect small bowel cancer over proximal jejunum, 10cm distal to the Treiz ligament, no significant LAP
      • no peritoneal seeeding
      • one small gallstone
  • 2017-08-25 Laparoscopy hysterectomy
    • Diagnosis
      • adenomyosis
    • Finding
      • Uterus: enlarged, 15x12x5cm, 235gm, adenomyosis-like
      • EM – thickened, endometrial hyperplasia?
      • cervix eroded, dysplasia?
      • bil adnexa: normal-looking
      • CDS: no fluid but pelvic endometriosis and pelvic adhesion were noted between post uterus, bil US ligaments, pelvic walls and bowels s/p laparoscopic fulguration of pelvic endometriosis and lysis

[chemoimmunotherapy]

  • 2023-05-25 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-21 - docetaxel 60mg/m2 100mg NS 250mL 1hr + leucovorin 300mg/m2 520mg NS 250mL 2hr + fluorouracil 300mg/m2 520mg NS 250mL 10min + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-09 - [oxaliplatin 300mg/m2 530mg D5W 3000mL + sodium bicarbonate 4200mg + gentamicin] IP 30min

  • 2022-07-25 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-07-05 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-21 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-06-08 - oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4770mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-05-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4750mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-04-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4790mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-28 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-03-14 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-24 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-02-11 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-01-19 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-01-03 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4600mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-05-29

  • The patient received two cycles of the docetaxel and fluorouracil regimen on 2023-04-21 and 2023-05-25. The lowest WBC count (nadir) was observed on 2023-05-02, 11 days after the first dose.
    • 2023-05-25 WBC 4.57 x10^3/uL
    • 2023-05-09 WBC 5.74 x10^3/uL
    • 2023-05-02 WBC 1.03 x10^3/uL (nadir, Granocyte (lenograstim 250ug) QD 5/2 ~ 5/4)
    • 2023-04-20 WBC 5.36 x10^3/uL
  • Since the second dose was the same as the first, the patient is likely to experience leukopenia again. To prevent severe leukopenia, it is recommended that G-CSF be prepared and administered approximately one week after the second cycle of chemotherapy.

2023-05-26

  • Based on the PharmaCloud data, this patient has exclusively sought medical care at our hospital. The drug Plaquenil (hydroxychloroquine), as prescribed by our attending rheumatologist, has been included in the active medication regimen for the patient. There were no discrepancies or issues identified in the medication reconciliation process for this patient.

2022-05-12

  • This patient has stage IIB small bowel adenocarcinoma s/p segmental small intestine resection on 2021-12-02, and has been receiving Folfox since 2022-01-03.
  • CT images on 2022-04-13 CT showed a marked dilatation from stomach to duodenum, however, it is not symptomatic to be enrolled as an active problem.
  • Lab data on 2022-05-11 indicated generally normal readings.

701393260

230529

[diagnosis] - 2022-12-15 admission note

  • Right breast cancer - invasive carcinoma of no special type, Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-), stage IV, with multiple liver and lymph nodes metastases.
  • Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left vertebral artery.
  • epatomegaly
  • poor liver function
  • hyperbilirubinemia

[exam findings]

  • 2023-05-19 MRI - brain
    • History and indication: Speaking unclearly, there are multiple metastases of breast cancer.
    • With and without-contrast multiplannar and multisequences MRI of brain revealed:
      • Multiple enhancing nodules in brain parenchyma.
  • 2023-04-20, -03, 24, -02-02 CXR
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
  • 2023-02-13 CT - abdomen
    • History and indication:
      • Right breast cancer - invasive carcinoma of no special type, stage IV, with multiple liver and lymph nodes metastases.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Much regression of right breast cancer. Necrosis and regression of liver metastases.
      • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
      • Multiple bony metastases.
    • IMP:
      • Much regression of right breast cancer. Necrosis and regression of liver metastases.
      • Left ovary cyst (4.6cm) with minimal hemorrhage. Minimal ascites.
      • Multiple bony metastases.
  • 2022-12-15, -12-02, -11-23 CXR
    • Borderline cardiomegaly
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-11-25 Gynecologic ultrasonography
    • Ascites
    • EM: 7.7mm
  • 2022-11-14 CT - abdomen
    • Indication
      • Right breast cancer–invasive carcinoma of no special type
      • Secondary malignant neoplasm of liver and intrahepatic bile duct
      • Secondary malignant neoplasm of bone
      • Diffuse bone metastases
    • Findings
      • Massive ascites is found. Several confluent low density lesions are found at both lobes of liver up to 12.4cm at right lobe liver. Liver meta is considered. In comparison with CT dated on 2022-08-03, the lesions become necrotic. Chemotherapy effect is considered.
      • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Mild enhancement of the peritoneum at pelvis is found. Cancerous peritonitis is suspected.
      • No evidence of abnormal soft tissue mass at pelvic cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Soft tissue mass at right lateral breast is found about 2.5cm. In comparison with CT dated on 2022-08-03, the lesion is decreased in size.
      • Right massive pleural effusion is found.
      • Suggest clinical correlation
    • Imp:
      • Right breast cancer with liver meta with primary tumor regression and liver tumors necrosis. Chemotherapy effect is considered.
      • Bone meta, please correlate with bone scan study.
      • Massive ascites and right pleural effsuion. suspected cancerous peritonitis.
  • 2022-11-11 CXR
    • Enlargement of cardiac silhouette.
    • Right Pleura effusion is noted.
    • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2022-11-02, -10-20, -10-17, -10-10, -10-06 CXR
    • Bilateral Pleura effusion with more severe on right side.
    • Few nodular opacity projecting in the left lung are suspected. Follow up is indicated. Otherwise, Please correlate with CT.
  • 2022-10-28 SONO - chest
    • Echo diagnosis:
      • left side trivial amount of pleural effusion
      • right side moderate amount of pleural effusion, 750cc serosangious fluid was aspirated for analysis.
  • 2022-10-20, -09-26 Ascites tapping
    • After echo localization, local anesthesia was performed at RLQ and 2000ml straw-colored ascites was drained out with 18Fr catheter.
    • Moderate clear ascites was noted.
  • 2022-10-17 SONO - chest
    • Echo diagnosis:
      • Bilateral pleural effusion (Left: trivial and Right: small to moderate), post right diagnostic and therapeutic thoracentesis.
      • Abdominal ascites
  • 2022-10-11 SONO - chest
    • Echo diagnosis:
      • Right thorax: large amount pleural effusion s/p drainage of 910cc, yellowish pleural effusion
      • Left thorax: no pleural effusion.
  • 2022-10-04 SONO - chest
    • Echo diagnosis:
      • Left thorax: no pleural effusion.
      • Right thorax: moderate amount pleural effusion s/p drainage of 960 cc, yellowish pleural effusion.
  • 2022-10-03 Ascites tapping
    • The RLQ of the abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. The paracentesis catheter was inserted and advanced with negative pressure until STRAW colored fluid was aspirated
  • 2022-09-26 SONO - chest
    • Echo diagnosis:
      • Right thorax: moderate amount pleural effusion s/p drainage of 600 cc, yellowish pleural effusion.
      • Left thorax: minimal amount pleural effusion
  • 2022-09-21 SONO - chest
    • Echo diagnosis:
      • Pleural effusion, moderate, right
      • Pleural effusion, minimal, left
      • Atelectasis, RLL
  • 2022-08-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (60.8 - 19.1) / 60.8 = 68.59%
      • M-mode (Teichholz) = 68.6
    • Adequate LV,RV systolic function with normal wall motion
    • Thick IVS, Impaired LV relaxation
    • Left pleural effusion
  • 2022-08-18, -08-15, -08-12, -08-09, -08-08 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2022-08-09 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma of no special type
    • The specimen submitted consists of 4 tissue cores measuring up to 1.7x0.1x 0.1 cm in size, in fixed state. Grossly, they are tan and elastic.
    • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in solid to ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic activity.
    • Immunohistochemical study demonstrates ER(-), PR(-), Her2/neu: positve(3+), p53(patchy+, weak to moderate, wild-type), p63(-), Ki-67 inedex: 30%, CK5/6(-).
  • 2022-08-09 Tc-99m MDP whole body bone scan with SPECT
    • The scintigraphic findings suggest multiple bone metastases.
  • 2022-08-09 SONO - chest
    • Echo diagnosis:
      • Bilateral thorax:
        • minimal amount pleural effusion;
        • bilateral lower lung consolidation (+);
        • thoracocentesis was not performed.
  • 2022-08-08 Breast Ultrasound in Operation
    • Diagnosis: Highly suspicious of malignancy, with sonographic negative axillary LNs
    • Treatment: Core-needle biopsy
    • Suggestion and Plan:
      • Arrange core biopsy with 18 guage puncture needle
      • BI-RADS: 5-Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken
  • 2022-08-05 MRI - C-spine
    • Indication: breast tumor with liver and C-spine meta
    • Findings
      • diffuse enhancing bone masses involving C2-C7, T1-T4 spine, compatible with bone metastases. There is pathological compression fracture at C5, C7 vertebral bodies. Exophytic masses at left C1, C2 lateral masses and transverse processes causing encasement of left vertebral artery (VA) is noted.
      • enlarged bilateral cervical lymph nodes, suspect lymphadenopathy.
      • no evidence of abnormal signal lesion and pathological enhancement in visible spinal cord.
    • Impression:
      • Diffuse bone metastases involving C2-C7, T1-T4 spine, with left C1, C2 lateral mass tumors encasing left VA.
  • 2022-08-05 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Metastatic invasive carcinoma, consistent with breast primary
    • The specimen submitted consists of two strips of yellow gray soft tissue, labeled liver, measuring up to 2.0 x 0.1 x 0.1 cm.
    • The sections show metastastic invasive carcinoma of no special type, breast primary, composed of nests and cords of large pleomorphic neoplastic cells in fibrous stroma. Focal ductal differentiation and tumor necrosis are present.
    • IHC shows following features:
      • ER (Ab): Negative
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Positive (score= 3+)
      • Ki-67 index: 30%
      • GATA3: Positive
  • 2022-08-03 MRI - brain
    • a heterogeneous enhancing tumor in the left C1 vertebral body
  • 2022-08-03 CT - abdomen
    • History: epigastric protruding sensation with fullness.
      • abnormal LFT: AST/ALT 62/100 GGT 83 (2022-04-20 at Taichung)
      • HBsAg non-reactive. HBsAb(anti-HBs) reactive
      • 20220801 echo: numerous liver tumors, suspected metastasses
      • AST/ALT 472/167: we’ve strongly suggested admission for supportive care and close observation and exam: but patient refused admission.
    • Findings:
      • There is a well-defined rim-enhancing soft tissue mass in right breast, measuring 3.4 cm. Breast cancer is suspected.
        • Please correlate with sonography and mammography.
      • There are multiple variable-sized poor enhancing tumors on both hepatic lobes that are c/w metastases.
        • In addition, There is hepatomegaly and the greatest cranial-caudal dimension measuring about 21.7 cm in length.
      • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
      • There is mild ascites in the cul-de-sac.
        • Please correlate with sonography.
      • Bilateral ovarian cysts are suspected.
        • Please correlate with GYN. sonography.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Right breast cancer with multiple liver and lymph nodes metastases is highly suspected.
      • Please correlate with breast sonography and mammography.
  • 2022-08-01 SONO - abdomen
    • Diagnosis
      • mild fatty liver
      • liver tumors, favor metastatic tumors
      • pancreas obscured
    • Suggestion
      • 4 phase CT scan

[body fluid]

  • 2022-08-24 pleural effusion 720ml (orange, turbid)
  • 2022-08-26 ascites 75ml (orange)
  • 2022-08-30 pleural effusion 760ml (red, turbid)
  • 2022-09-02 pleural effusion 600ml (orange, turbid)
  • 2022-09-06 pleural effusion 630ml (red, turbid)
  • 2022-09-08 pleural effusion 550ml
  • 2022-09-15 pleural effusion 700ml (yellow, turbid)
  • 2022-09-21 pleural effusion 600ml (yellow, turbid)
  • 2022-09-26 ascites 2000ml
  • 2022-09-27 pleural effusion 600ml (yellow, slight turbid)
  • 2022-10-03 ascites 1750ml
  • 2022-10-04 pleural effusion 960ml (yellowish)
  • 2022-10-11 pleural effusion 910ml
  • 2022-10-17 pleural effusion 860ml (yellowish, cloudy)
  • 2022-10-21 ascites 2000ml

[MedRec]

  • 2023-05-24 SOAP Radiation Oncology
    • A: Invasive carcinoma of no special type of the right breast with multiple including liver and bone metastases.
    • P: Radiotherapy is indicated for this patient with the following indicators: multiple brain metastases
      • Goal: palliation
      • Treatment target and volume: whole brain
      • Technique: 3D
      • Preliminary planning dose: 3000cGy/12 fractions of the whole brain.
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2023-05-30.

[consultation]

  • 2022-08-17 Rehabilitation
    • Q
      • For correct body posture and movement
    • A
      • Assessment
        • right breast tumor with liver, and C-spine metastasis
      • Conclusion
        • The patient refused to transfer or sit-up when I visited due to dyspnea, abominal fullness and severe discomfort. Please contact us if the patient get better and has willing to take rehab training.
  • 2022-08-04 Radiation Oncology
    • Q
      • for C-spine radiotherapy evaluation
      • The 31-year-old female who denied having any past history, the she was getting the COVID-19 on June 25, 22.
      • This time, she suffered from stiff neck since end of April, then the symptoms intensify, so she went to our Chinese Medicine department for help, however, treatment was ineffective. And the liver index too high from health examination and epigastric protruding sensation with fullness, so she went to our GI OPD for help. The abdomen echo: numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis, so we need your help, thanks a lot!!
    • A
      • S:
        • For radiotherapy due to suspicious metastatic lesion over left C1 vertebral body.
        • PI: The patient suffered from stiff neck since end of April, 2022. The symptoms intensify, so she went to our Chinese Medicine department for treatment but was ineffective. The abdomen echo showed numerous liver tumors: suspected metastatic tumors, the abdomen CT showed right side breast lesion with multiple liver metastasis, the brain MRI: C-spine metastasis.
        • Family history: (-)
        • Cancer site specific factors: Alcohol (-); Smoking (-); Betel nut (-).
        • Personal Hx: DM(-); HTN(-)
        • Previous RT Hx: (-)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: pain of the left upper neck.
        • Abd sono (2022-08-01): mild fatty liver; liver tumors, favor metastatic tumors; pancreas obscured.
        • MRI of brain (2022-08-03): a heterogeneous enhancing tumor in the left C1 vertebral body.
        • CT scan of abdomen (2022-08-03): pending.
      • A:
        • Suspicious right breast cancer with multiple including liver and bone metastases.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: metastatic lesions in the left C1 vertebral body.
        • Goal: palliation
        • Treatment target and volume: possible the left C1 vertebral body.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family. Further work-up including tissue proven should be completed. The treatment planning of radiotherapy will be started after positive pathologic report available (please notify me).

[surgical operation]

  • 2022-08-08
    • Surgery
      • Port-A insertion, L’t after L’t cephalic vein exploration        
      • Sonography guided R’t breast tumor core biopsy     
    • Finding
      • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
      • A 5x2.72x1.78 cm hard tumor over R’t (1, 2).   

[chemoimmunotherapy]

  • 2023-05-26 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-04-21 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-03-24 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-02-27 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-02-03 - Herceptin (trastuzumab) 6mg/kg 240mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 95mg 6hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-01-10 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 6hr (<- 3hr)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-15 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-23 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 100mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-03 - Herceptin (trastuzumab) 6mg/kg 250mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 80mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-10-12 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 420mg 1hr + Intaxel (paclitaxel) 80mg/m2 60mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-09-21 - Herceptin (trastuzumab) 6mg/kg 280mg 90min + Perjeta (pertuzumab) 840mg 1hr + Intaxel (paclitaxel) 80mg/m2 20mg 3hr (pertuzumab loading dose)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-09-12 - Intaxel (paclitaxel) 80mg/m2 20mg 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2022-08-29 - Herceptin (trastuzumab) 6mg/kg 440mg 90min (loading)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

PREVIOUSLY UNTREATED PATIENTS - Trastuzumab plus pertuzumab plus a taxane - 2022-11-24 UpToDate - https://www.uptodate.com/contents/systemic-treatment-for-her2-positive-metastatic-breast-cancer

  • Preferred option
    • While there is no ideal strategy for the management of patients with HER2-positive metastatic breast cancer, one reasonable approach stratifies patients by whether or not they were previously treated with trastuzumab in the adjuvant setting. For previously untreated patients, we suggest trastuzumab, pertuzumab, and a taxane (docetaxel or paclitaxel). This regimen improves clinical outcomes compared with trastuzumab plus docetaxel. For most patients receiving treatment with trastuzumab or pertuzumab, we administer the HER2-directed agent along with chemotherapy. However, patients with hormone receptor- and HER2-positive metastatic breast cancer may receive HER2-directed therapy in combination with endocrine therapy, especially if their disease is not rapidly progressive or symptomatic, or is not characterized by significant visceral involvement (ie, multiorgan metastases). For women with hormone receptor-positive, HER2-positive disease, endocrine plus HER2-directed therapy may offer a less toxic approach compared with HER2 treatment combined with chemotherapy.
  • Trastuzumab plus pertuzumab plus a taxane
    • For patients with untreated HER2-positive metastatic breast cancer who did not receive adjuvant therapy at the time of the initial diagnosis, we administer trastuzumab plus pertuzumab in combination with a taxane (docetaxel or paclitaxel). In our practice, we often use weekly paclitaxel rather than docetaxel with this combination as a less toxic and better tolerated taxane. However, other taxanes are appropriate in this setting. Alternatives to this regimen, and particular considerations for those with hormone receptor-positive disease, are discussed below.
    • The evidence to support the three-agent combination of trastuzumab plus pertuzumab and a taxane comes from the phase III CLEOPATRA trial, including 808 women with HER2-positive metastatic breast cancer who were treated with trastuzumab (8 mg/kg loading dose then 6 mg/kg intravenous [IV]) and docetaxel (75 mg/m2 IV) and then randomly assigned to treatment with pertuzumab (840 mg loading dose then 420 mg) or placebo. Treatment was administered every three weeks and continued until disease progression or intolerable side effects. Approximately 10 percent of these patients had previously received trastuzumab in the adjuvant or neoadjuvant setting. At a median follow-up of 19 months, the addition of pertuzumab to docetaxel plus trastuzumab resulted in (see “Treatment protocols for breast cancer”, section on ‘THP (docetaxel, trastuzumab, and pertuzumab)’ https://www.uptodate.com/contents/image?imageKey=ONC%2F96342&topicKey=ONC%2F85677):
      • Improvement in the overall response rate (ORR, 80 versus 69 percent).
      • Improvement in progression-free survival (PFS) compared with placebo (median, 19 versus 12 months; hazard ratio [HR] 0.62, 95% CI 0.51-0.75).
      • At over eight years of follow-up, the addition of pertuzumab resulted in: Improvement in overall survival (OS) compared with placebo (median, 57 versus 41 months without pertuzumab; eight-year survival rates of 37 versus 23 percent without pertuzumab; HR for death 0.69, 95% CI 0.58-0.82).
    • Trastuzumab, pertuzumab, and docetaxel is associated with higher rates of toxicity compared with trastuzumab and docetaxel. These included higher rates of diarrhea (67 versus 46 percent), neutropenia (53 versus 50 percent), rash (34 versus 24 percent), mucosal inflammation (27 versus 20 percent), dry skin (10 versus 4 percent), and serious (grade 3/4) febrile neutropenia (14 versus 8 percent). However, there was no increase in the rate of left ventricular dysfunction, which was very low in both arms (1 versus 2 percent).
    • Although the CLEOPATRA trial described above used docetaxel, we consider other taxanes to be acceptable alternatives to docetaxel in combination with trastuzumab and pertuzumab. In the first reporting from the PERUSE study, among 1436 patients with advanced HER2-positive breast cancer, median PFS was comparable between docetaxel, paclitaxel, and nanoparticle albumin-bound paclitaxel (nabpaclitaxel; 20, 23, and 18 months, respectively). Compared with docetaxel-containing therapy, paclitaxel-containing therapy was associated with more neuropathy (31 versus 16 percent), but less febrile neutropenia (1 versus 11 percent) and mucositis (14 versus 25 percent). A limitation in interpretation of these data, however, is that patients were not randomly assigned to different taxanes.
    • The addition of trastuzumab to chemotherapy has shown OS benefits in the adjuvant setting as well. (See “Adjuvant systemic therapy for HER2-positive breast cancer”, section on ‘Benefits’.)
  • Formulations
    • Subcutaneous forms of trastuzumab as well as trastuzumab and pertuzumab have received approval by the US Food and Drug Administration based on similar pathologic complete response rates as the IV forms of these therapies when used with chemotherapy in the neoadjuvant setting. Either formulation may be used in the metastatic setting.

==========

2023-06-08

[tube feeding]

A grinding substitution method for Tykerb (lapatinib 250mg) tab

  • Please prepare the medications to be given, a cup, chopsticks (for stirring), and room temperature drinking water.
  • Put all the medications in the cup, add 20ml of room temperature drinking water.
  • Let it sit for 5 to 10 minutes.
  • Stir evenly with chopsticks to form a suspension, and then it can be given.
  • Add another 20ml of room temperature drinking water to the cup to rinse the cup and then drink it. For patients with a nasogastric tube, the medication solution should be poured into a feeding syringe, and then add another 20ml of room temperature drinking water to the cup to rinse the cup.
  • Then pour it into the feeding syringe again to flush into the nasogastric tube, which is used to rinse the tube wall.

2023-01-11

  • After over 15 kg of weight loss between late August and early December in 2022, the patient’s weight has remained at approximately 41kg for one month, with no further noticeable decline in her weight.

  • The elevated D-dimer readings are getting closer to the normal limits in a gradual manner. Given that the half-life of the D-dimer is only 15.8 (13.1 - 23.1) hours (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2693750/), could this slow decline be indicative of latent fibrin degradation?

    • 2022-12-23 D-dimer 3391.46 ng/mL(FEU)
    • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)
  • It is advised to assess LVEF immediately prior to pertuzumab/trastuzumab initiation, every 3 months during pertuzumab/trastuzumab therapy, every 3 weeks if pertuzumab/trastuzumab is withheld for significant left ventricular cardiac dysfunction, and every 6 months for at least 2 years following completion of adjuvant pertuzumab/trastuzumab therapy. Pre-pertuzumab/trastuzumab 2D transthoracic echocardiography was performed on 2022-08-11, so it might be in need of updating. (Nov and Dec 2022 CXR showed borderline cardiomegaly and enlargement of cardiac silhouette.)

  • Since bilirubin total was 0.95 mg/dL on 2023-01-11, there is no need to adjust the dose of paclitaxel.

2022-12-16

  • Over 15 kg of body weight have been lost in the past four months (41.2kg 2022-12-15 <- 55.8kg 2022-08-24). It is possible that the serum creatinine level remains below LLN since August 2022 as a result of insufficient dietary intake or muscle mass loss (malnutrition, muscle wasting). It should be necessary to encourage the patient to consume more food and there may be benefits to prescirbe megestrol as an appetite stimulant.

  • The presence of elevated plasma D-dimer concentrations indicates recent or ongoing intravascular coagulation and fibrinolysis. Although the reading remained high, it trended downward, a relatively positive sign. The metastatic liver lesion reduced clearance of fibrin degradation products?

    • 2022-12-15 D-dimer 4269.08 ng/mL(FEU)
    • 2022-12-02 D-dimer 5167.01 ng/mL(FEU)
    • 2022-11-11 D-dimer 6070.93 ng/mL(FEU)
    • 2022-10-28 D-dimer 6632.74 ng/mL(FEU)
    • 2022-09-26 D-dimer 9267.55 ng/mL(FEU)
    • 2022-08-29 D-dimer > 10000.00 ng/mL(FEU)
  • According to the patient’s updated liver function lab results, paclitaxel dosage does not need to be adjusted.

2022-11-24

  • 2022-11-23 AST 79 > 2x ULN(39), ALT 76 > 1.5x ULN(41), Bilirubin T 1.21 > 1x ULN(1.0), Bilirubin D 0.43 > 2x ULN(0.18). The dose of paclitaxel in this chemotherapy (3-hour infusion setting) does not need to be adjusted.

701466853

230529

[chemoimmunotherapy]

  • 2023-05-26 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 420mg NS 250mL 1hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-05-05 - Herceptin (trastuzumab) 600mg SC 5min + Perjeta (pertuzumab) 840mg NS 250mL 2hr + docetaxel 75mg/m2 135mg NS 250mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-04-14 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-24 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1073mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-03-01 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1075mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL
  • 2023-02-07 - liposome doxorubicin 35mg/m2 60mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 1082mg NS 500mL 1hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg PO + NS 250mL

==========

2023-05-29

  • Trastuzumab and Pertuzumab, both monoclonal antibodies utilized in the management of HER2-positive breast cancer, can lead to several dermatologic side effects.

  • With Trastuzumab, patients may experience a skin rash in approximately 4% to 18% of cases.

  • Our dermatologist has prescribed Mycomb (nystatin, neomycin, gramicidin, triamcinolone) TOPI and Exelderm (sulconazole nitrate) EXT for the symptom on 2023-05-15.

  • In case of Grade 3 or higher paronychia - which is inflammation of the skin around the nails - the following approach is generally recommended aiming to manage the paronychia effectively while minimizing the impact on the patient’s overall cancer treatment plan. (ref: Prevention and management of dermatological toxicities related to anticancer agents: ESMO Clinical Practice Guidelines. Ann Oncol. 2021;32(2):157-170)

    • First, it’s crucial to interrupt the causative treatment until the severity of the paronychia has reduced to Grade 0 or 1. This will help to prevent exacerbation of the condition.
    • If there is suspicion of an underlying infection, bacterial, viral, and fungal cultures should be taken. This will help to determine the appropriate antimicrobial therapy, if necessary.
    • The ongoing management of the skin reaction should involve the use of topical treatments such as 2% povidone-iodine, topical beta-blocking agents, and topical antibiotics and corticosteroids. These can all help to reduce inflammation and prevent secondary infection.
    • Oral antibiotics can also be administered, particularly if there is concern about a more widespread infection.
    • After two weeks of this approach, the patient’s condition should be reassessed to evaluate the effectiveness of the intervention and to determine whether it’s safe to resume the original treatment.

700899684

230523

[diagnosis] - 2022-11-01 discharge note

  • Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
  • Hyperlipidemia
  • Type 2 diabetes mellitus
  • Chronic viral hepatitis B without delta-agent
  • Herniated Intervertebral Disc
  • Diarrhea, unspecified

[past history]

  • Type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment and follow up at endocrinology & metabolism clinic.

  • History of operation:

    • Liver abscess at right posterior lobe s/p needle aspiration on 2015/01/21.
    • CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10.
    • T11, 12 compression fracture s/p T11, T12 vertebroplasty on 2018/03/23.

[Current Medication] - 20230220 admission note

  • Kentamin (B1 50mg & B6 50mg & B12 500mcg) 1# PO BID
  • Rivotril 0.5mg/tab (Clonazepam) 1# PO HS
  • Nicametate citrate (saline) 50mg/tab 1# BID (2023/02/03 Hold)
  • Uformin 500mg/tab (metformin) 1# PO BID
  • Zulitor 4mg/tab (pitavastatin) 1# PO QN
  • Kludone MR 60mg/tab (Gliclazide) 1# PO BID
  • Canaglu 100mg/tab (canagliflozin) 1# PO QDAC                            

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-01-20 CT - abdomen
    • S/P segmental resection of the descending colon.
    • There is no evidence of tumor recurrence.
  • 2022-12-27 CXR
    • S/P posterior longitudinal transpedicular screws and rods fixation.
    • Ground glass opacities in bil. lungs.
  • 2022-12-27 ECG
    • Normal sinus rhythm
    • Inferior infarct, age undetermined
    • Anterior infarct, age undetermined
    • Prolonged QT
  • 2022-12-19 Colonoscopy
    • not well prepare of colon
    • no obvious mucosal lesion is seen
  • 2022-12-06 Pelvis & Rt. Hip Lat
    • S/P posterior instrumentation fixation from L4 To L5 and s/p cage implantation within the L4-5 disk space.
    • Atherosclerotic change of superficial femoral artery.
  • 2022-09-27 CXR
    • Atherosclerotic change of aortic arch
  • 2022-08-20 KUB
    • degenerative change of the bony structure with marginal osteophyte formation is identified.
    • s/p posterior fixation of the lumbar spine is found.
    • phlebolith at pelvic cavity is also found.
  • 2022-08-12 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS codon 12 GGT>GTT, p.G12D)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-08-11 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, descending colon, laparoscopic-assisted left hemicolectomy — Moderately differentiated adenocarcinoma
      • Cut-end, proximal and distal, descending colon, laparoscopic-assisted left hemicolectomy — Free of tumor
      • Lymph node, regional, dissection — Metastatic adenocarcinoma (3/13)
      • AJCC 8th edition pathology stage:pT3N1b(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: laparoscopic-assisted left hemicolectomy
      • Tumor Site: Descending colon
      • Tumor Size: 5.4x 4.5 cm
      • Macroscopic Tumor Perforation: Not identified
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 ‘hotspot’ field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 3/13
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition):
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
        • Regional Lymph Nodes (pN):
          • pN1b: Two or three regional lymph nodes are positive
        • Distant Metastasis (pM):
          • N/A
      • Additional Pathologic Findings (select all that apply):
        • None identified
  • 2022-08-09 Patho - colon biopsy
    • Intestine, large, descending colon, biopsy— adenocarcinoma
    • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
  • 2022-08-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (73 - 15) / 73 = 79.45%
      • LVEF (%) = 80
      • M-mode (Teichholz) = 80
    • Normal LV systolic function with normal wall motion.
    • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 1.
    • Normal RV systolic function.
    • Aortic valve scleorsis with no AS and AR; posterior mitral annulus calcification with no MS, mild MR; mild TR; mild PR. - 2022-08-08 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Pulmonary disease pattern
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-08-08 Colonoscopy
    • colon cancer, descending colon, s/p biopsy
  • 2022-08-05 CT - abdomen
    • History: LLQ pain for 1 month
      • Low abdomen pain and fever happened this morning
      • Past Hx of DM, liver abscess
    • Findings:
      • There is segmental wall thickening at the descending colon with irregular contour and lumen narrowing, measuring 1.7 cm in the maximal wall thickness that may be adenocarcinoma (T4a) with near complete obstruction. Please correlate with colonoscopy.
        • In addition, There are five enlarged nodes in the adjacent mesocolon (N2a).
      • S/P cholecystectomy.
        • There is dilatation and pneumobilia on IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
      • A renal cyst measuring 1.8 cm in left upper pole is noted.
    • Imaging Report Form for Colorectal Carcinoma
      • T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC (Stage_value)
  • 2022-07-28 SONO - abdomen
    • Diagnosis
      • Suspected pneumobilia,bil
      • S/p cholecystectomy
      • Suspected left renal cyst
      • Pancreas not shown
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • 2019-12-13 Pure Tone Audiometry
    • Tymp: Bil type A.
    • PTA
      • Reliability: fair
      • Average: R’t 19 dB HL, L’t 20 dB HL.
      • Bil high frequency mild SNHL.
  • 2019-03-20 Echo for liver, gall bladder, pancreas, spleen
    • Postcholecystectomy
    • Fatty liver, moderate
    • Pneumobilia
  • 2018-06-25 Doppler color flow mapping
    • LVEF = (LVEDV - LVESV) / LVEDV = (127 - 38) / 127 = 70.08%
      • M-mode (Teichholz) = 70
    • Mild septal hypertrophy with indeterminate LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • AV sclerosis and prominnet posterior mitral annulus calcification with trivial MR; trivial PR.
    • Mild aortic root calcification.
  • 2018-04-02 Bone densitometry - Hip
    • Hip BMD performed by DXA revealed:
      • Left hip, BMD is 0.607 gms/cm2, about 1.8 SD below the peak bone mass (76%) and 0.5 SD above the mean of age-matched people (108%).
    • IMP: Osteopenia
  • 2017-08-23 Echo for liver, gall bladder, pancreas, spleen
    • Postcholecystectomy
    • Pneumobilia
    • Renal cyst, left
    • Fatty liver, moderate

[MedRec]

  • 2023-05-11 SOAP Neurology
    • S
      • P’t is a case of DM with regular F/U.
      • P’t suffered bilateral feet numbness for 1 year and hand cramping in recent days.
      • 20230216: Condition stationary, for medicine
      • 20230511: stationary, for medicine.
    • Diagnosis
      • DKA, NIDDM Type, adult-onset or unspecified type, not stated as uncontrolled [E11.65]
      • DM with neurological manifestation, NIDDM Type, adult-onset or unspecified type, not stated as [E11.40]
      • Displacement of lumbar intervertebral disc without myelopathy [M51.27]
    • Prescription
      • Rivotril (clonazepam 0.5mg) 1# HS
      • Saline (nicametate citrate 50mg) 1# BID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2023-05-03 SOAP Dermatology
    • S: severe itchy papules and plaques erupition over trunk after medication.
    • O
        1. urticaria/angioedema type
        1. maculopapular type
        1. urticaria-purpura type
    • A
      • hand-foot syndorme. r/o erythema mutiformis.
      • Suspect related medication: chemotherapy.
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • Localized skin eruption due to drugs and medicaments taken internally L27.1
    • Prescription
      • Topsym cream (fluocinonide 0.05%) BID EXT
      • Compesolon (prednisolone 5mg) 2# PRNQD
      • tetracycline BID EXT
      • Sinpharderm cream (urea) QN TOPI
  • 2023-04-25 SOAP Metabolism and Endocrinology
    • S: type 2 DM since 2013, hypertension, irregular Tx before, hyperlipidemia, hyperuricemia, poor control, family Hx of DM: (+)
      • patient refuse insulin injection
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • Obesity, unspecified [E66.9]
    • Prescription
      • Uformin (metformin 500mg) 1# BID
      • Zulitor (pitavastatin 4mg) 1# QN
      • Kludone (gliclazide 60mg) 1# BID
      • Canaglu (canagliflozin 100mg) 1# QDAC

[consultation]

  • 2022-12-06 Rehabiliation
    • A
      • Physical examination
        • Tenderness point: right lateral posterior lower back, near qudratus lumborum
          • Right lower back pain will exagerate when spine flexion and standing.
          • She denied pain over spine, SI joint or hip joint, muscle weakness or numbness.
          • suspected muscle strain or HIVD
        • L spine X ray: pending report
      • Assessment
        • Adenocarcinoma of descending colon with impending obstruction, status post laparoscopic-assisted left hemicolectomy on 2022/08/11, pT3N1bM0(3/13), G2, LVI(+), PNI(-), stage IIIB s/p chemotherapy with FOLFOX from 2022/09/28
        • Hyperlipidemia
        • Type 2 diabetes mellitus
        • Chronic viral hepatitis B without delta-agent
        • Herniated Intervertebral Disc s/p OP
        • Constipation
      • Plan
        • patient education for core-strengthening exercise, but the patient and her family refuse to do them.
        • keep current pain control medication;
          • NSAID or toricam could be considered if no contraindication
        • arrange rehab OPD follow up for further evaluation and treatment.
  • 2022-09-28 Dermatology
    • Q
      • For skin itchy, and skin rash at back, four limbs
      • This 77 years old female patient was a case of type 2 diabetes mellitus, hyperlipidemia, and hypertension for 8 years under medications treatment.
      • She also had surgical history of 1) s/p needle aspiration of liver abscess at right posterior lobe in 2015; 2) CBD stone with cholangitis s/p laparoscopic cholecystectomy on 2015/07/09; and s/p EST and balloon lithotripsy on 2015/08/10; 3) s/p T11, T12 vertebroplasty in 2018.
      • According to patient statement, she suffered from left low abdominal dull pain while defecation was noted for one month; the LLQ pain was got worse with difficult defecation in recenyly days. The colon biopsy showed: adenocarcinoma, stage: pT3N1b(if cM0); AJCC stage IIIB. Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+). This time, she is admitted for chemotherapy with FOLFOX, and she denied having a fever, chillness, abdomen pain, or TOCC history.
      • She complaints skin itchy, and skin rash at back, four limbs since 2022/09/21, so we need your help, thanks a lot!!
    • A
      • The patient had sufferred from diffuse itchy papules over dry xerotic skin over back and upper limbs.
      • Under the impression of xerotic dermatitis over four limbs and eczema over back
      • The following sugeetion:
        • keep Allegra (fexofenadine) 1# bid po use and consider add ketotifen 1# bid po use.
        • consider shift Mycomb (nystatin, neomycin, triamcinolone, gramicidin) to Topysm cream (fluocinonide) 2 tube topical bid use for itchy papules over back/four limbs.
        • add Sinphraderm (urea, hydrocortisone) 1 tube topical QN use after body wash for skin mositurating enhancement, especially on the four limbs.
        • Keep patient’s back from becoming stuffy by avoiding prolonged bed rest.
  • 2022-08-05 Colorectal Surgery
    • Q
      • LLQ pain for 1 month
      • Low abdomen pain and fever happened this morning
      • No vomiting, loose stool noted yesterday
      • Past Hx of DM, liver abscess
    • A
      • Abdomen: soft, mild tenderness at left, no distended
      • CT: Adenocarcinoma of the descending colon with near complete obstruction is highly suspected. Please correlate with colonoscopy.
        • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for colon cancer: T4a N2a M0, stage: IIIC
      • A: Tumor of D-colon, cT4aN2aM0
      • P: admission, nutrition support
        • we’ll arrange sigmoidoscopy next Monday for identification of colon lesion

[surgical operation]

  • 2018-03-23 T11, 12 compression fracture s/p T11, T12 vertebroplasty
  • 2015-08-10 EST and balloon lithotripsy (EST = endoscopic sphincterotomy)
  • 2015-07-09 CBD stone with cholangitis s/p laparoscopic cholecystectomy
  • 2015-01-21 Liver abscess at right posterior lobe s/p needle aspiration

[chemotherapy]

  • 2023-05-22 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + NS 250mL + aprepitant 125mg
  • 2023-04-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-08 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-20 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-03 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Due to ANC 1262, Ox 85 -> 65, DC 5FU bolus)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-18 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-12-15 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-12-05 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-17 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-01 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-18 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-28 - oxaliplatin 85mg/m2 125mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOX Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg

==========

2023-05-23

  • Based on the PharmaCloud database, it appears that the patient has only been seen at our hospital for the past three months. No discrepancies or issues were identified in the medication reconciliation process for the patient upon admission this time.

  • The CT scan performed on 2023-01-20 showed no evidence of tumor recurrence. In addition, on 2023-05-03, both tumor markers, CEA and CA199, fell into the normal range for the first time. This is an encouraging development in the patient’s condition to date.

  • The patient experienced a severe eruption of pruritic papules and plaques over the trunk in early May 2023, probably in response to medication. The dermatologist has prescribed appropriate medications to treat this skin reaction. Please monitor closely for any recurrence of these symptoms.

  • The patient’s serum glucose levels have remained high, exceeding 270 mg/dL for the past two days. All medications prescribed by our endocrinologist have been added to the active formulary, and the patient is unwilling to take insulin injections. This makes appropriate dietary control even more important. It may be beneficial to schedule a consultation with a dietitian during the patient’s hospitalization to provide guidance on dietary changes to manage blood glucose levels.

2023-04-21

  • Blood glucose control becomes less effective, as evidenced by rising HbA1c levels.
    • 2023-04-12 HbA1c 8.0 %
    • 2023-01-11 HbA1c 6.8 %
    • 2022-10-12 HbA1c 6.0 %
    • 2022-07-11 HbA1c 5.8 %
  • Since the patient has been taking at least 3 therapeutic categories of oral antihyperglycemic agents for a long time, it is recommended that injectable insulin be introduced to assist with glycemic control.

2023-03-09

  • The patient has been receiving FOLFOX treatment since late Sep 2022. In early Feb 2023, the patient’s oxaliplatin dose was reduced from 85mg/m2 to 65mg/m2, and her 5FU bolus was skipped. Since then, there have been no further occurrences of severe leukopenia.
    • 2023-03-07 WBC 3.39 x10^3/uL
    • 2023-02-15 WBC 3.04 x10^3/uL
    • 2023-02-01 WBC 2.97 x10^3/uL
    • 2023-01-11 WBC 6.52 x10^3/uL
    • 2022-12-27 WBC 2.63 x10^3/uL
    • 2022-12-15 WBC 4.83 x10^3/uL
    • 2022-12-01 WBC 3.93 x10^3/uL
    • 2022-11-15 WBC 3.30 x10^3/uL
    • 2022-11-01 WBC 4.29 x10^3/uL
    • 2022-10-12 WBC 4.10 x10^3/uL
    • 2022-09-27 WBC 6.83 x10^3/uL
    • 2022-08-20 WBC 9.71 x10^3/uL
  • The patient has poor blood sugar control, which has been observed across multiple recent hospital stays. Despite taking Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide), the patient’s blood sugar levels have been poorly controlled during her hospital stay, increasing from 214 to 339 to 333mg/dL. It might be necessary to consider insulin as an option to help manage her blood sugar levels.

2023-02-21

  • The drugs that were recently prescribed at our Neurology, Metabolism & Endocrinology department and were disclosed in the NHI PharmaCloud System have been appropriately prescribed as self-carried items during this hospital stay. There have been no medication reconciliation issues found in the patient.
  • The results of the finger prick blood glucose tests indicate high readings (304 <- 316 <- 351mg/dL) despite the current use of Uformin (metformin), Canaglu (canagliflozin), and Kludone (gliclazide).
  • In consideration of the patient’s longstanding diabetes and development of neuropathy, retinopathy might need to be checked.
  • Consideration can be given to adding basal insulin if the patient’s fasting plasma glucose levels continue to remain consistently above 300mg/dL.

2023-01-19

  • The patient’s blood sugar level appears to have become less under control over the past half year. The results of finger prick blood glucose tests indicate that the readings are also high. (266 <- 296 <- 354mg/dL)
    • 2023-01-11 HbA1c 6.8 %
    • 2022-10-12 HbA1c 6.0 %
    • 2022-07-11 HbA1c 5.8 %
  • In the absence of iodinated contrast imaging, Uformin (metformin 500mg/tab) 1# BID can be added to help improve blood glucose control as long as the patient’s creatinine level remains low (2023-01-11 0.72mg/dL).

2022-12-16

  • The vital signs are stable and lab results on 2022-12-15 showed no extreme abnormalities. The control of blood sugar levels is better than it was during the last hospitalization.

2022-12-06

  • The lab results (2022-12-01) were generally normal except for a low PLT reading (107 x10^3/uL).
  • Despite treatment with metformin, gliclazide, and canagliflozain, the blood sugar level was still high at 205 mg/dL on 2022-12-06 06:09. An addition of DPP4 inhibitors, such as Trajenta (linagliptin), may be beneficial in lowering blood sugar levels.

2022-11-18

  • The lab results (2022-11-15) were generally normal without extreme readings.
  • There was a slight increase in blood pressure and blood sugar levels compared to normal. Please monitor on a regular basis.
  • There are no issues with the scheduled chemotherapy and the current prescription.

2022-11-02

  • A rise in pulse rate and drop in blood pressure were observed (2022-11-02 08:40 109/59, pulse 102), while SpO2 remained above 95%. Could it be caused by a lack of hydration?
  • Diabetes is managed by oral hypoglycemic agents and ordered human insulin, however, blood glucose levels are volatile and maintained high. Please continue to monitor it on a regular basis.
  • The active prescription is not subject to any issues.

2022-10-19

  • The patient has a history of diabetes. Under self-carried metformin, gliclazide, and canagliflozin medication, fasting blood sugar levels were highly volatile (231mg/dL 2022-10-19 06:17 <- 102mg/dL 2022-10-18 16:39) and should be closely monitored.
  • The most recent data on renal and liver function, serum electrolytes, CBC, WBC DC are dated 2022-10-12 and might be updated prior to chemotherapy.
  • Please keep the patient’s back from becoming stuffy by avoiding prolonged bed rest. (skin itchy, and skin rash at back, four limbs were observed during last hospital stay)

2022-09-28

All-RAS + BRAF + IHC results were like 700811991’s.

  • Using patient-carried antiglycemic agents Uformin (metformin), Kludone (gliclazide), and Canaglu (canagliflozin), the blood sugar level of the patient was acceptable.
  • TPR and BP readings were stable. The results of the lab test on 2022-09-27 were grossly normal.
  • No problems are identified that would make it inappropriate for the patient to receive the chemotherapy he is scheduled to receive.

700516200

230522

  • 2023-05-19 SONO - chest
    • Echo diagnosis:
      • right side small amount of pleural effusion
      • left side moderate amount of pleural effusion, 600cc straw-color fluid was aspirated for analysis.
    • Special Procedure:
      • echo-assisted pleural tapping 18# needle Left side 600ml straw-color
  • 2023-05-18 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Massive bilateral Pleura effusion
  • 2023-05-17 CXR
    • Sinus tachycardia
    • Left axis deviation
    • Low voltage QRS
    • T wave abnormality, consider anterior ischemia
    • Abnormal ECG
  • 2023-05-11 Cell block cytology - pleural effusion, left side
    • 50 ml urbid — positive for malignancy
    • SMEARS and CELLBLOCK: Many red blood cells, lymphocytes, mesothelial cells, and neoplastic cells present.
  • 2023-05-11 KUB
    • Spondylosis with scoliosis of the L-spine with convex to left side.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
    • S/P CVP line insertion from right femoral vein and the tip located at IVC.
  • 2023-05-11 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Massive left Pleura effusion
  • 2023-05-11 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Left side 500 ml straw-color
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Left side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
    • Echo diagnosis:
      • Pleural effusion, left side.
    • Suggestion:
      • check BP for one hour. supine position for taking rest after tapping.
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, cell count, and TB exam. TB PCR.
  • 2023-05-10 Patho - esophageal biopsy
    • Esophagus, lower, biopsy — Esophageal ulcer
    • The sections show a picture of esophageal ulcer, composed of necrotic debris, inflammatory exudate and clusters of degenerative atypical cells.
    • IHC, the degenerative atypical cells reveal: CK(-), WT1(-) and Leukocyte common antigen (focal +). There is no evidence of carcinoma involvement in the sections examined.
  • 2023-05-10 ECG
    • Sinus tachycardia
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2023-05-10 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal survey, due to severe belching during exam
      • Reflux esophagitis LA Classification grade D
      • Esophageal ulcer, 25cm to 40cm below incisors
      • Superficial gastritis
      • Antral deformity
    • Suggestion
      • Suboptimal survey, due to severe belching during exam
      • PPI and sucralfate use
  • 2023-04-06 Patho - stomach biopsy
    • Stomach, upper body, AW, Biopsy — Hyperplastic polyp
  • 2023-04-06 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis, middle and lower esophagus, LA classification, grade D
      • Esophageal ulcer, middle and lower esophagus
      • Edematous change of gastric mucosa, body
      • Gastric polyp, upper body, AW, s/p biopsy
    • Suggestion
      • Please check albumin level
  • 2023-04-03, -02-06 Abdomen - Standing (Diaphragm)
    • Rim gas shadow in the pelvis is noted. please correlate with clinical condition or CT.
    • Non-specific bowel gas pattern in right lower abdomen and pelvis is noted. please correlate with clinical condition. Follow up is indicated.
    • Spondylosis with scoliosis of the L-spine with convex to left side
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • 2023-02-23 CT - abdomen
    • History and indication: ovarian ca
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
      • Atherosclerosis of aorta.
      • Disc space narrowing at L3/4.
    • IMP:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Some fluid collection at left subhepatic region.
  • 2022-11-22 Body fluid cytology - ascites
    • Finding: ovarian cancer with recurrence
    • 46 cc, orange, cloudy — Positive for carcinoma
    • Smears show clusters of carcinomatous cells with nuclear hyperchromasia, irregular contour and pleomorphism.
  • 2022-11-17 CT - abdomen
    • Findings
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
      • Right liver cyst (7mm).
      • Atherosclerosis of aorta.
      • Disc space narrowing at L3/4.
    • IMP:
      • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding. Large amount ascites.
  • 2022-09-03 CT - abdomen
    • s/p hysterectomy and salpingo oophorectomy
    • No evidence of tumor recurrence
    • Some soft tissue at abdominal wall, stationary
  • 2022-05-06, -01-07 CT - abdomen
    • Prior CT mentioned Some soft tissues at abdominal wall are noted again, stationary. Benign process is highly suspected. Follow up is indicated.
  • 2022-01-05 Nerve Conduction Velocity, NCV
    • Findings
      • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
      • prolonged sensory DLs on right median and bil. ulnar n. with slowed NCVs, otherwise normal SNAP amplitudes and NCVs of bil. sural n.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
      • the H-reflex study of bil. tibial n. were normal.
    • Conclusion: left median and bil. ulnar sural sensory neuropathies at distal region
  • 2022-01-04 Cerebral perfusion SPECT
    • There was no prominently abnormal focal radiotracer uptake in bilateral cerebral hemispheres. Please correlate with clinical findings for further evaluation.
  • 2022-01-04 MRI - brain
    • Chronic bil. paranasal sinusitis, chronic left mastoiditis.
    • Brain atrophy. Mild Bilateral subcortical and periventricular white matter change (leukoaraiosis).
  • 2021-12-28 CT - brain
    • No brain parenchymal lesion.
    • Intracranial ICAs and VAs atherosclerosis.
    • Brain atrophy.
    • Chronic left sphenoid-posterior ethmoid sinusitis and left mastoiditis.
  • 2021-09-23 CT - abdomen
    • S/P hysterectomy. Some soft tissues at peritoneal cavity r/o tumor seeding (stable). Stationary condition of anterior abdominal wall.
  • 2021-03-18 CT - abdomen
    • S/P hysterectomy. Increased soft tissues at peritoneal cavity r/o tumor seeding. Small amount ascites.
    • Wall thickening of gallbladder.
  • 2020-12-15 CT - abdomen
    • S/P hysterectomy. Increased soft tissues at right lower peritoneal cavity, r/o tumor seeding. Increased enhancement at anterior abdominal wall.
  • 2020-08-07 CT - abdomen
    • Prior CT identified a cystic lesion at right adenxa 6.2 x 5.2 cm is noted again, mild increasing in size to 6.8 x 6.4 cm. Please correlate with clinical condition.
  • 2020-08-04 Gynecologic ultrasonography
    • ATH + BSO
    • IMP: R/O Pelvis mass: (63mmx59mm), no blood flow
  • 2020-06-09 Patho - peritoneum biopsy
    • Labeled as “pelvic tumor”, clinical history: “ovarian cancer s/p op”, excision biopsy — fibrosis
    • Section shows 1 piece(s) of fibrotic tissue. No maligmancy.
  • 2020-04-27 CT - abdomen
    • S/P hysterectomy. Cystic lesions at bil. pelvic cavity.
  • 2020-02-02 KUB
    • Non-specific bowel gas pattern in left lower abdomen is noted. please correlate with clinical condition or CT. Follow up is indicated.
    • Spondylosis with scoliosis of the L-spine with convex to left side .
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4.
    • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
  • 2020-01-22 MRI - brain
    • no evidence of recent infarction.
  • 2020-01-10 ECG
    • Normal sinus rhythm
    • Prolonged QT
    • Abnormal ECG
  • 2020-01-07 Patho - soft tissue tumor, extensive resection
    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, debulking — Serous adenocarcinoma, high grade.
        • IHC stains: ER (+), PR (-), WT-1 (+), PAX-8 (+): compatible with ovarian origin, vimentin (-): dis-favor endometrial origin.
      • Ovary, left, debulking — Serous adenocarcinoma, high grade
      • Fallopian tube, right, debulking — Serous adenocarcinoma, high grade
      • Fallopian tube, left, debulking — Serous adenocarcinoma, high grade
      • Uterus, corpus, total hysterectomy — Myomas; benign strophic endometrium.
      • Uterus, cervix, total hysterectomy — Free
      • Omentume, omentectomy (S20-289) — Serous adenocarcinoma, high grade
      • Lymph node, bilateral pelvic and para-aortic, dissection — Free
      • Urinary bladder, mass above bladder, excision — Transmural tumor invasion to bladder mucosa.
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma,
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: present
      • Right tube involvement: present (in parenchyma)
      • Left tube involvement: present (in parenchyma)
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: present
      • Left adnexa soft tissue involvement: present
      • Pelvic soft tissue involvement: present
      • Uterine serosa involvement: absent
      • Omentum involvement: present (invasive ) The largest tumor: 8 x 5 x 1.1 cm.
      • Uterine Cervix involvement: not received
      • Endometrium involvement: absent
      • Myometrium involvement: absent
      • Appendix involvement: not received
      • Largest Extrapelvic Peritoneal Focus Macroscopic (greater than 2 cm)
      • Peritoneal/Ascitic Fluid: N2019-05003 - Malignant (positive for malignancy)
      • Regional Lymph Nodes: Free (0/56)
        • left external iliac (0/9);
        • left obturator (0/12);
        • right external iliac (0/6);
        • right obturator (0/12);
        • left para-aortic (0/12);
        • right para-aortic (0/5).
      • Other organs or specimens involvement: N/A.
  • 2020-01-07 Immunohistochemistry, IHC
    • Using block omental tissue S2020-289A1: IHC stains: ER (+), PR (-); WT-1 (+), PAX-8: (+): favor ovarian origin; vimentin (-): dis-favor endometrial origin.

[consultation]

  • 2023-05-11 Family Medicine
    • Q
      • The 74y/o woman has left ovarian serous adenocarcinoma, stage IIIC /p chemo with Avastin + Topotecan on 20230319. She has can’t intake and vomit coffee ground, suspect disease progress, so we need your help for hospice share care. Thanks!
    • A
      • 74-year-old female, left ovarian serous adenocarcinoma, stage IIIC s/p chemotherapy
      • This time suffer from poor intake & coffee ground vomitus
      • Consciousness alert, ECOG 3
      • We will arrange hospice combine care and follow up her condition

[chemotherapy]

  • 2023-03-20 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-14 - topotecan 3mg/m2 3.7mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - bevacizumab 15mg/kg 500mg NS 100mL 1.5hr + topotecan 3mg/m2 3.7mg NS 120mL 0.5hr (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-13 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-06 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-16 - topotecan 3mg/m2 3.8mg NS 120mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-06 - bevacizumab 15mg/kg 600mg NS 100mL 1.5hr + topotecan 4mg/m2 5.1mg NS 150mL 30min (Avastin Q3W + topotecan D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-11-05 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-09-28 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-08-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-07-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-29 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-01 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-11 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-20 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-07 - gemcitabine 1000mg/m2 1200mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-05-26 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-05-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-04-14 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 500mL
  • 2020-03-24 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-03-03 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-02-05 - paclitaxel 175mg/m2 240mg NS 250mL 3hr + carboplatin AUC4 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 3mg + acetaminophen 500mg PO + NS 250mL
  • 2020-01-05 - [liposome doxorubicin 30mg/m2 40mg D5W 100mL + carboplatin AUC 5 450mg NS 100mL] IP 2min

701451122

230522

[diagnosis] - 2023-04-09 admission note

  • Multiple myeloma not having achieved remission

[exam findings]

  • 2023-04-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 43) / 156 = 72.44%
      • M-mode (Teichholz) = 72.6
    • Conclusion
      • Adequate LV,RV systolic function with normal wall motion
      • LV hypertrophy, Impaired LV relaxation
      • Mild MR,TR,AR,PR
      • Calcified aortic valve
  • 2023-04-06 MRI - L-spine
    • Intravenous injection of gadolinium was not given.
    • Findings:
      • The lumbar spine shows spondylosis and disk space degeneration at the L2/3 through L5/S1 levels.
      • Retrolisthesis of L3 on L4, grade I.
      • Spondylolisthesis of L5 on S1, grade I.
      • One low signal intensity nodular lesion within T11 vertebral body. May be secondary to multiple myeloma.
  • 2022-09-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — plasma cell neoplasm (plasmacytoma or multiple myeloma).
    • Section shows piece(s) of bone marrow with 60-70% cellularity and M:E ratio of approximately 1:2. Three cell lineages are present with normal maturation of leukocytes and a predominant plasmacytoid subpopulation. Megakaryocytes are adequate in number.
    • IHC stains: CD138: 70%; Lambda and Kappa light chains: a predominant lambdsa light chain population, MPO: 10 %; CD71: 20% (of the nucleated cells). The findings are a pattern of plasmacytoma or multiple myeloma. Please correlate with image findings.

[MedRec]

  • 2023-05-05 SOAP Neurosurgery
    • S - BMT soon (20230521); walk level > 10 mins; Rt LE soft/weakness told
    • Prescription
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# QD
      • Saline (nicametate citrate 50mg) 1# QD
  • 2023-04-07 SOAP Neurosurgery
    • S - respsone to neurotine; still bil legs soreenss; lying worser;
    • Prescription
      • Neurontin (gabapentin 100mg) #1 PRNBID
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
      • Saline (nicametate citrate 50mg) 1# BID
  • 2023-03-17 SOAP Neurosurgery
    • S - LBP with Rt > Lt LE radiatioanl pain/ numbness to foot for months; Associated with Weakenss; Pitting edema; night pain
    • Prescription
      • Neurontin (gabapentin 100mg) #1 PRNBID
  • 2022-09-29 SOAP Hemato-Oncology
    • O: 2022/09/27 Albumin = 2.8 g/dL
    • P:
      • NHI reimbursement - Bortezomib (such as Velcade) is limited to use in combination with other cancer treatment drugs for patients with multiple myeloma.
        • Maximum of 16 treatment cycles per person; Myzomib has a maximum of 8 treatment cycles per person.
        • Requires prior application before use, applying for 4 treatment cycles at a time.
        • After using 4 treatment cycles, it is necessary to confirm that paraprotein (M protein) has not increased after drug use (indicating response or stable status), or for some non-secretory type MM patients, the treatment effect is based on the ratio of plasma cells in bone marrow examination, only then can the treatment continue.
  • 2022-09-27 SOAP Hemato-Oncology
    • S: He was diagnosed to have multiple myeloma presenting as normocytic anemia
    • O: 2022/09/17 IgA = 6539 mg/dL;
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220926
      • Multiple myeloma IgA Lambda
      • ISS stage 2 at least
      • use VTD followed by autoPBSCT
  • 2022-09-16 SOAP Hemato-Oncology
    • O
      • 2022/09/16 Free Light Chain κ/λ
        • FKLC = 7.44 mg/L;
        • FLLC = 155 mg/L;
      • 2022/09/13 Protein EP
        • M-peak = Positive;
  • 2022-09-09 SOAP Hemato-Oncology
    • S: He was informed to have anemia since March 2022 and he received check up at HuaLien TzuChi Hospital
    • O:
      • 2022/09/09 Reticulocyte count = 6.340 %;
      • 2022/09/09 CBC
        • HGB = 7.2 g/dL;
        • MCV = 97.1 fL;
      • 20220909: BP 126/74; Pulse 74;
    • A:
      • Normocytic anemia requiring transfusion

[chemothereapy]

  • 2023-04-14 - cyclophosphamide 3000mg/m2 5500mg NS 500mL 2hr (Endoxan for PBSC mobilization protocol)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + Uromitexan (mesna) NS 100mL 1hr + NS 250mL
  • 2023-03-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-02-09 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-01-31 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)
  • 2023-01-10 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-12-27 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-12-13 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-29 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-15 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-11-01 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2022-10-18 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1,8 (VTd)
  • 2023-10-11 - Velcade (bortezomib) 1.3mg/m2 2.4mg SC 1min D1 (VTd)

Bortezomib (Velcade), thalidomide (Thalomid), and dexamethasone (VTd) induction therapy for initial treatment of patients with multiple myeloma 2023-05-22 https://www.uptodate.com/contents/image?imageKey=ONC%2F101205&topicKey=HEME%2F6647

  • Cycle length: 28 days.
  • Regimen
    • Bortezomib
      • 1.3 mg/m2 SC
      • Given as a single SC injection.
      • Days 1, 8, 15, and 22
    • Thalidomide
      • 100 mg for first 14 days then 200 mg per day thereafter by mouth
      • Take with water on an empty stomach at least one hour after the evening meal.
      • Daily, days 1 through 21
    • Dexamethasone (“low dose”)
      • 40 mg by mouth
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22

[lab data]

prior to peripheral blood stem cell harvest

2023-04-17 CMV viral load assay Target not detecetedIU/mL
2023-04-17 EBV DNA quantitative amplification test <120 copies/mL
2023-04-13 EB VCA IgG Positive Ratio
2023-04-13 EB VCA IgG Value 5.3 Ratio
2023-04-12 EB VCA IgM Negative Index
2023-04-12 EB VCA IgM Value 0.0 Index
2023-04-10 RPR/VDRL Nonreactive
2023-04-10 CMV IgM Nonreactive
2023-04-10 CMV IgM Value 0.54 Index
2023-04-10 CMV_IgG Reactive
2023-04-10 CMV_IgG Value 834.1 AU/mL
2023-04-10 HIV Ab-EIA Nonreactive
2023-04-10 Anti-HIV Value 0.05 S/CO
2023-04-10 Anti-HBc Nonreactive
2023-04-10 Anti-HBc-Value 0.24 S/CO
2023-04-10 Anti-HCV Nonreactive
2023-04-10 Anti-HCV Value 0.06 S/CO
2023-04-10 HBsAg Nonreactive
2023-04-10 HBsAg (Value) 0.50 S/CO
2023-04-10 Anti HTLV I/II Nonreactive
2023-04-10 Anti HTLV I/II Value 0.05 S/CO

700901572

230518

[lab data]

  • 2023-05-15 CMV_IgG Reactive
  • 2023-05-15 CMV_IgG Value 628.6 AU/mL
  • 2023-05-15 CMV IgM Nonreactive
  • 2023-05-15 CMV IgM Value 0.16 Index

[exam findings]

  • 2023-05-14 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Linear infiltration over right and left lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2023-02-20 Patho - bone marrow biopsy
    • Bone marrow, iliac reast, biopsy— Hypercellularity (near 100%) with presence of blasts (about 10%)
      • NOTE: Differential diagnosis includes chronic myeloid leukemia and myeloproliferative neoplasm. Correlation of CBC data, molecular cytogenetic study, BCR/ABL1 test and bone marrow smear is recommended.
    • Microscopically, it shows hypercellularity (near 100%) with myloid cell proliferation. Blasts highlighted by CD34 and CD117 are seen and about 10%. Megakaryocytes are increased.
    • Immunohistochemical stain reveals MPO(+), CD61(+), CD71( focal+), CD20(-), CD138(-), TdT(-).
  • 2023-02-20 SONO - abdomen
    • Liver cysts
    • bilateral pleural effusion
    • right renal cyst
  • 2023-02-17 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 35.9) / 116 = 69.05%
      • M-mode (Teichholz) = 69.1
    • Conclusion
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild to moderate MR and TR, mild AR
      • Impaired LV relaxation
      • Dilated LA, thick IVS
  • 2020-09-09 MRI - thyroid, parathyroid
    • Indication: L thyroid tumor
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed
      • a cystic lesion, about 24.76mm, in the left thyroid gland. NO obvious enhancement was noted.
      • no neck LAP.
      • unremarkable change in the skull base.
      • unremarkable change in the naspharynx, oropharynx, and hypopharynx
    • IMP:
      • a thyroid cystic lesion in the left thyroid gland.
  • 2020-09-07 Nasopharyngoscopy
    • Findings: Lymphoid tissue noted in posterior pharyngeal wall
    • Conclusion: thyroid cyst, left
  • 2020-06-18 Patho - intradermal nevus
    • Skin, face, excision biopsy — Seborrheic keratosis
    • Section shows piece(s) of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis.

[MedRec]

  • 2023-05-09 SOAP Hemato-Oncology
    • P
      • RTC 1 weeks -> Due to elevated WBC > 400K
      • Visit Dermatologist for skin induration
      • Visit Urologist for urine frequency
  • 2023-03-30 SOAP Hemato-Oncology
    • A: Body weight loss might be related to poor dental condition
  • 2023-03-16 SOAP Hemato-Oncology
    • S: 2022-03 Chromosome: 46~47,XX,+8[cp19]
    • O: 2023/03/09 JAK2 single site gene mutation = Undetectable
  • 2023-03-02 SOAP Hemato-Oncology
    • O:
      • Cancer Multidisciplinary Team Meeting Conclusion, Meeting Date 20230227: waiting for JAK2 data
      • 2023/02/27 BCR/abl = Undetectable
  • 2023-02-16 ~ 2023-02-24 POMR Hemato-Oncology
    • Discharge diagnosis
      • R/O Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission
      • Gout, unspecified
    • CC
      • for higher WBC and PLT level
      • for SOB
    • Present illness
      • This 84 y/o female with dyslipidemia was admitted to our ward via ER due to abnormal leukocytosis during OPD examination.
      • According to the patient’s family, she started to cough and suffered from dyspnea, especially on exertion one week ago. She was brought to LMD for help, and came to our OPD today again for persisted symptoms. At our Family medicine OPD, her lab data showed leukocytosis with WBC level of 84810/uL, and thrombocytosis of 1118K. And the data was significantly different from last data in 2022/02, with WBC level of only 11070/uL. She was then refered to Hema OPD, and follow-up lab data showed even higher WBC count of 88170/uL, and metamyelocyte 19%, myelocyte 31.0 %, promyelocyte 2.0 %, blast 2%, PL 1118000/uL. Therefore, admission for further survey on 2023/02/17.
    • Course of inpatient treatment
      • After admission, she received NS hydration, Hydrea 2# qd (2/17-2/20), Feburic 0.5# qd and Bokey 1# qd for higher WBC and PLT. Critical condition for closely monitor. She will do the bone marrow, abd echo and echocardigraphy for general survey. Empiric antibiotic as Flumarin for low grade fever. Heart echo was done, LVEF 69%. Abd echo showed no splenomegaly. Bone marrow was done and no hematoma, report showed Hypercellularity (near 100%) with presence of blasts (about 10%) on 2023/2/23 and pending BCR-ABL. Norvasc 1# qd for hypertension, but lower limbs mild edema, so we shifted Olmetec and consult CV for assessment. After treatment, her WBC and PLT level decrease, so she can be discharged on 2023/02/24.
    • Prescription
      • Ulstop (famotidine 20mg) 1# QD
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) 1# TID
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Feburic (febuxostat 80mg) 0.5# QD
      • Bokey (aspirin 100mg) 1# QD
  • 2023-02-16 SOAP Hemato-Oncology
    • Diagnosis
      • Chronic myeloid leukemia, BCR/ABL-positive C92.1
      • Dyspnea, unspecified R06.00
    • Prescription
      • Bokey (aspirin 100mg) 1# QD
      • Ulstop (famotidine 20mg) 1# QD
      • Hydrea (hydroxyurea 500mg) 2# QD
  • 2023-02-16 SOAP Family Medicine
    • O
      • 2023/02/16 CBC
        • WBC = 84.81 x10^3/uL;
        • HGB = 11.4 g/dL;
        • PLT = 1118 x10^3/uL;
    • P: refer to hema OPD

[consultation]

  • 2023-02-21 Cardiology
    • Q
      • The 84 y/o woman has hypertension without drug use. We gave Norvasc, but lower limbs pitting edema weak 1+. LVEF not dysfunction. We shift to ARB for control. We need your help for anti-hypertension agent assessment. Thanks!
    • A
      • Currently the patient’s blood BP is relatively stable.
      • Keep SBP 140-150 mmhg during admission with current medication.
      • CV OPD f/u.

==========

2023-05-18

[assessment]

  • Based on the serial trend of WBC counts, it appears that hydroxyurea 1000mg daily might be excessively suppressing WBC levels, while 250mg or 500mg daily might not be sufficient. It might be worthwhile considering a daily dose of 750mg, using a combination of 500mg QD and 500mg QOD to achieve the desired therapeutic effect.
    • 2023-05-18 hydroxyurea 500mg 2# QD
    • 2023-05-17 WBC 57.14 x10^3/uL hydroxyurea 500mg 1# QD 1# ST
    • 2023-05-15 WBC 49.31 x10^3/uL hydroxyurea 500mg 1# QD
    • 2023-05-13 WBC 52.53 x10^3/uL hydroxyurea 500mg 1# QD
    • 2023-05-09 WBC 46.73 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-04-26 WBC 11.91 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-04-13 WBC 8.67 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-30 WBC 12.58 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-23 WBC 26.55 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-16 WBC 59.00 x10^3/uL hydroxyurea 500mg 1# QOD
    • 2023-03-02 WBC 5.00 x10^3/uL
    • 2023-02-24 WBC 3.62 x10^3/uL
    • 2023-02-22 WBC 4.46 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-20 WBC 19.99 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-18 WBC 62.40 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-16 WBC 88.17 x10^3/uL hydroxyurea 500mg 2# QD
    • 2023-02-16 WBC 84.81 x10^3/uL hydroxyurea 500mg 2# QD 2# ST
  • In addition, the PLT count is clearly in a downtrend, which would also be closely watched.
    • 2023-05-17 PLT 285 *10^3/uL
    • 2023-05-15 PLT 281 *10^3/uL
    • 2023-05-13 PLT 324 *10^3/uL
    • 2023-05-09 PLT 414 *10^3/uL
    • 2023-04-26 PLT 456 *10^3/uL
    • 2023-04-13 PLT 419 *10^3/uL
    • 2023-03-30 PLT 399 *10^3/uL
    • 2023-03-23 PLT 536 *10^3/uL
    • 2023-03-16 PLT 664 *10^3/uL
    • 2023-03-02 PLT 637 *10^3/uL
    • 2023-02-24 PLT 702 *10^3/uL
    • 2023-02-22 PLT 678 *10^3/uL
    • 2023-02-20 PLT 928 *10^3/uL
    • 2023-02-18 PLT 1102 *10^3/uL
    • 2023-02-16 PLT 1091 *10^3/uL
    • 2023-02-16 PLT 1118 *10^3/uL

Dacogen (decitabine)

  • The drug candidate for the treatment of this patient, Dacogen (decitabine 50mg/vial), is currently being temporarily purchased by both Hualien General Hospital and Taipei Xindian Branch. The “temporary procurement” process for a drug usually takes about 1 to 2 months.
  • The in-hospital unit prices for Dacogen (decitabine 50mg/vial) are TWD 14,280 for patients covered by NHI and TWD 16,422 for self-pay patients.
  • Current “National Health Insurance Drug Reimbursement” for decitabine (2023-04-24 updated)
    • For patients with high-risk myelodysplastic syndromes: RA with excess blasts, RAEB; RAEB in transformation, RAEB-T; chronic myelomonocytic leukemia, CMMoL.
    • Pre-approval review is required for the initial application of this drug.
    • Continuation of this drug does not require pre-approval review, but the medical record should keep pathology or imaging diagnosis proofs, and clinical data related to the treatment. If the patient’s condition worsens to acute myeloid leukemia, the drug should be stopped.
    • Definition of acute myeloid leukemia: myeloblast count greater than 30%.
    • This drug and azacitidine can only be used alternatively. Except for intolerability, they should not be interchanged. If this drug is ineffective, azacitidine cannot be applied for again.

700561422

230517

[past history]

  • Heart:(-)

  • Chest:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-)

  • Other medical:denied

  • Surgical: s/p Peripheral glioma excision 20+ years ago

  • Menstrual history: G4P2SA2, NSD x2

  • Menarche at the age of 13 years old

  • Menopaused at the age of 56 years old

  • Menstrual cycle:Duration/Interval:4days/28days                 

[allergy]

  • NKDA                 

[family history]

  • Father: prostate cancer
  • Mother: HTN, DM

[exam findings]

  • 2023-04-28 Body fluid cytology - ascites
    • negative
  • 2023-04-26 Body fluid cytology - ascites
    • negative
  • 2023-03-23 Patho - uterus with or without SO non-neoplastic/prolapse
    • PATHOLOGIC DIAGNOSIS
      • Ovarian mass, bilateral, debulking surgery (s/p C/T) — Endometrioid carcinoma, grade 3
      • Fallopain tube, bilateral, ditto — Free of tumor invasion
      • Cervix, uterus, total hysterectomy — Free of tumor invasion
      • Endometrium, uterus, ditto — Endometrioid carcinoma, favor metastatic
      • Myometrium, uterus, ditto — Adenomyosis
      • Lymph node, left iliac, dissection — Free of tumor metastasis (0/4)
      • Lymph node, left obturator, ditto — Tumor metastasis (5/5) without extracapsular extension (0/5)
      • Lymph node, right iliac, ditto — Free of tumor metastasis (0/4)
      • Lymph node, right obturator, dissection — Tumor metastasis (2/10) without extracapsular extension (0/2)
      • Lymph node, left paraaortic, dissection — Free of tumor metastasis (0/5)
      • Lymph node, right paraaortic, dissection — Free of tumor metastasis (0/5)
      • Omentum, omentectomy — Metastatic adenocarcinoma
      • Bilateral parametria — Free of tumor invasion
      • AJCC Pathologic staging — ypT3cN1b, if cM0, stage IIIC
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: debulking surgery
      • Specimen type: uterus, R’t ovary mass, L’t ovary mass, pelvic and paraaortic LNs, and omentum
      • Specimen size:
        • L’t ovarian mass: 4.5 x 3.3 x 3.2 cm, solid mass with cystic change
        • L’t fallopian tube: 3.7 cm in length, 0.5 cm in diameter
        • R’t ovary mass: 7.2 x 7.2 x 4.1 cm, cystic mass with solid area and surface involvement
        • R’t fallopian tube: 6.2 cm in length, 0.4 cm in diameter
        • Uterus: 11 x 5.9 x 4.3 cm in size and 130 gm in weight. One yellow necrotic tumor mesured 1.2 x 0.5 cm within endometrium is seen, invades less than half the myometrium
        • Omentum: 34 x 13 x 2.2 cm with some firm masses
      • Tumor site: bilateral ovary and endometrium
      • Tumor size: (A) R’t ovary: 7.2 x 7.2 x 4.1 cm, (B) L’t ovary: 4.5 x 3.3 x 3.2 cm and (C) endometrium: 1.2 x 0.5 cm
      • Tumor appearance: (A) bilateral ovary: cystic tumor with solid area (B) endometrium: yellow necrotic tumor
      • Specimen integrity: intact, tumor on surface of right ovarian mass
      • Lymph node: pelvic and bilateral paraaortic LNs
      • Representative sections as: A: left iliac LNs, B: left obturator LNs, C: right iliac LNs, D: right obturator LNs, E: left paraaortic LNs, F: right paraaortic LNs, G1-G2: bilateral parametria, G3: cervix, G4: corpus, G5-G6: endometrial tumor, H1: L’t fallopian tube, H2-H6: L’t ovarian mass, I1: R’t F-tube, I2-I8: R’t ovarian mass, J1-J2: omentum
    • MICROSCOPIC EXAMINATION
      • Histologic type: Endometrioid carcinoma
      • Histologic grade: Grade 3
      • Contralateral ovary involvement: involved
      • Tumor side ovarian surface involvement: involved
      • Contralateral ovary surface involvement: Not involved
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right &/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: N/A
      • Uterine serosa involvement: Not involved
      • Omentum involvement: tumor involved
      • Uterine Cervix involvement: absent, Nabothian cysts
      • Endometrium involvement: present
      • Myometrium involvement: present and adenomyosis
      • Lymph nodes metastasis: tumor metastasis (7/33) without extracapsular extension (0/7) in total number
      • Immunohistochemistry: PAX-8(+), ER(+), WT-1(-), PR (+) and P53(wild type)
      • Ascites: positive for tumor metastasis
  • 2023-03-23 Cytology - ascites
    • 32 cc red turbid ascites — Positive for malignancy
    • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial clusters, compatible with metastatic carcinoma. Clinical correlation is advised.
  • 2023-03-22 CXR
    • Increased bilateral lung markings.
    • Borderline cardiomegaly.
    • Thoracic spondylosis.
  • 2023-03-08 CT - abdomen
    • Indication
      • 20221215 sono: ascites, cause unknown. One hyperechoic lesion in the peritoneal cavity. Probable thickened omentum.
      • 20221221 CT: cystic adenocarcinoma of bilateral ovary is suspected. cT3cN1bM, STAGE: IIIC
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified massive ascites and omentum cake is noted again, marked decreasing in size that is c/w carcinomatosis S/P C/T with partial response.
      • Prior CT identified two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension), are noted again, marked decreasing in size to 6.8 cm (right) and 5.2 cm (left).
        • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
      • Prior CT identified several kissing enlarged nodes in left para-aortic space, left common iliac chain, left internal iliac chain, and left external iliac chain are noted again, marked decreasing in size that are c/w metastatic nodes S/P C/T with near complete response.
      • Prior CT identified few poor enhancing lesions in the uterus are not noted again.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery.
    • Impression:
      • Carcinomatosis S/P C/T show partial response.
      • Cystic adenocarcinoma of bilateral ovary S/P C/T show partial response.
      • Metastatic lymph nodes S/P C/T show near complete response.
  • 2023-01-10 Cytology - ascites
    • 42 cc orange turbid ascites — Atypia
    • The smears show some lymphocytes, neutrophils, reactive mesothelial cells and only one atypical cell cluster show hyperchromatic nuclei with vacuolated cytoplasm. Follow up.
  • 2022-12-27 Cell block cytology
    • 40 cc, red, cloudy — Adenocarcinoma
    • Smears and cell block show dense clusters of atypical cells admixed with lymphoplasmcytes, leukocytes and mesothelial cells.
    • IHC stain— CK7(+), CK20(-), PXA-8(+), WT-1(focal+).
  • 2022-12-22 Gynecologic ultrasonography
    • Ascites
    • Bilateral Ovarian mass, malignancy cannot be ruled out
    • Endometrial hyperplasia
  • 2022-12-21 CT - abdomen
    • Indication: 20221215 sono: Acites, cause unknown. One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum.
    • Findings:
      • There is massive ascites and omentum cake that is c/w carcinomatosis.
      • There are two multilocular cystic mass with some septa and enhancing mural nodules in right and left lower abdomen and pelvis, measuring 11.5 cm (right) and 10.4 cm (left) in size (the largest dimension).
        • Cystic adenocarcinoma of bilateral ovary (T3c) is suspected. Please correlate with CA125 and ascites cytology.
      • There are several kissing enlarged nodes in left para-aortic space, left common iliac chain, left interal iliac chain, and left external iliac chain that are c/w metastatic nodes.
        • The largest node in left common iliac chain measuring 2 cm in the largest dimension (N1b).
      • There are few poor enhancing lesions in the uterus that may be myomas. Please correlate with GYN. sonography.
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-12-16 Patho - stomach biopsy
    • Stomach, cardia, biopsy — Helicobacter-associated non-atrophic chronic gastritis
    • Stomach, antrum, biopsy — Helicobacter-associated non-atrophic chronic gastritis
  • 2022-12-15 SONO - abdomen
    • Fatty liver, mild
    • Suspected fatty infiltration of pancreas
    • Small amount ascites
    • One hyperechoic lesion in the peritoeal cavity. Propable thickened omentum

[surgical operation]

  • 2023-03-22
    • Surgery
      • Operation
        • Excision of intraabdominal malignant tumor
        • HIPEC
        • Tenckhoff tube insertion
    • Finding
      • s/p neoadjuvant chemotherapy
      • PCI: total = 0 (PCI = Peritoneal Cancer Index)
        • [#] region – score
        • [0] central – 0
        • [1] RU – 0
        • [2] epigastrium – 0
        • [3] LU – 0
        • [4] left flank – 0
        • [5] LL – 0
        • [6] pelvis – 0
        • [7] RL – 0
        • [8] right flank – 0
        • [9] upper jejunum – 0
        • [10] lower jejunum – 0
        • [11] upper ileum – 0
        • [12] lower ileum – 0
      • HIPEC regimen: Lipo-dox 35mg/m2 + Carboplatin AUC 5
      • Drain: 15 Fr J-VAC x2 in the pelvic cavity
  • 2023-03-22
    • Surgery
      • Diagnosis: Ovarian cancer
      • Frozen: Debulking surgery (hysterectomy + bil. salpingo-oopherectomy + BPLND + omentectomy)
    • Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder
      • Adnexa:
        • LOV: 5x4x4 cm, with enlarged mass
        • ROV: 8x8x8 cm, with papillary tumor growth
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion band to the bowel (+)
      • Ascites: bloody, about 50 ml
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: grossly normal, infracolic omentectomy completed
      • After the operation, suboptimal debulking surgery was achieved.
      • Estimated blood loss: 850 mL
      • Blood transfusion: 2U pRBC
      • Complication: nil
  • 2023-03-22
    • Surgery
      • bilateral ureter catheterization
    • Finding
      • grossly no tumor in bladder, no external compression
      • bilateral UO clean urine jet

[chemotherapy]

  • 2023-05-16 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-04-25 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + [docetaxel 30mg/m2 50mg + cisplatin 30mg/m2 50mg + gentamicin 40mg + sodium bicarbonate 2800mg + NS 1000mL] IP 1hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-21 - liposome doxorubicin 35mg/m2 60mg D5W 250mL IP 90min + carboplatin AUC 5 600mg NS 250mL IP 90min (for HIPEC in operation)

  • 2023-02-23 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1000mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr + bevacizumab 15mg/kg 1100mg NS 250mL 2hr

    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL

==========

2023-05-17

  • The patient’s vital signs are stable, labs are largely within normal limits, and no significant adverse reactions have been reported. A review of the PharmaCloud database shows that all of the patient’s recent medications were prescribed by our hospital, and no medication reconciliation issues were identified.

2023-04-26

[assessment]

  • On 2023-04-26, lab results showed normal blood cell counts, electrolytes, liver, and kidney function levels, as well as stable vital signs on the TPR panel since this hospitalization.
  • The patient experienced no significant discomfort other than mild abdominal distension following normal saline infusion via the IP tube. Naproxen was administered to relieve the abdominal pain in the IP wound area.
  • The patient’s underlying condition of hepatitis B (anti-HBc positive) is being adequately treated with Vemlidy (tenofovir alafenamide).
  • According to the PharmaCloud database, all recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700757059

230517

[exam findings]

  • 2023-04-21 CXR
    • Lung markings: emphysematous change in the bilateral lung fields
    • mild blunting bilateral costophrenic angles
    • fractures at the right ribs and left lower ribs
  • 2023-04-21 KUB
    • compression fractures at L1, L2 and L3 vertebral bodies; compression fracture at L5 vertebral body.
    • s/p right THR at right hip
  • 2023-04-21 ECG
    • Normal sinus rhythm
    • Nonspecific ST and T wave abnormality
    • Prolonged QT
    • Abnormal ECG
  • 2023-03-06, 2022-12-12, -11-28 CXR
    • linear high density structures over over Rt infrahilum, lower lung zone and left lung, may be pulmonary foreign bodies embolic priop vertebroplasty
    • reticulonodular opacities over left lung too
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/supine position
    • compression fracture of multiple vertebral bodies
    • priop vertebroplasty in many levels
    • Osteoporotic change of spine and bones of both shoulder regions
    • old fracture of multiple Lt and Rt ribs
    • Avascular necrosis of Rt humeral head, with marginal spurs
  • 2023-01-17 Clinical Dementia Rating
    • CDR score: 2
  • 2023-01-17 Mini-Mental State Examination
    • MMSE score: 13
  • 2022-12-09 MRA - brain
    • Indication:
      • suspect Multiple myeloma, DM. unknown dementia history
      • can communicate 1.5 months ago. marked cognitive decline and disorientation after admission 1 month ago.
    • Impression:
      • Brain atrophy and leukoaraiosis.
      • No evidence of recent infarct.
      • A 0.6cm enhancing bone nodule in dens, nature to be determined.
  • 2022-12-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Plasma cell myeloma
    • The sections show normocellular marrow (25%). The marrow space is largely replaced by a population of medium-sized immature and mature CD138+ plasma cells, constitue 80% of marrow cells. The plasma cells also shows lambda light chain restriction and negative for kappa light chain .
  • 2022-11-15 Electroencephalography, EEG
    • This EEG were composed by continuous diffuse theta wave with 5-6 Hz, 10-20 uv in bilateral hemisphere. There were no obvious photic driving response. This EEG suggest moderate diffuse cortical dysfunction. Advise clinical correlation.
  • 2022-11-10 MRI - T-spine
    • Multiple compression fracture of thoracic vertebrae.
    • S/P vertebroplasty of T7.
  • 2022-11-08 MRI - L-spine
    • Acute compression fracture of L4 vertebral body.
    • Severe old compression fracture of T12, L1 and L3 vertebrae.
    • Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component.
    • S/P veretebroplasty, L1-3 and T7.
  • 2022-11-07 CXR
    • Bilateral parahilar infiltrates with pleural effusion, r/o lung edema. Mild regression.
    • Deformity of right proximal humerus.
    • S/P vertebroplasty at T-L spine.
    • Diffuse osteoporosis of the bones.
    • Fractures at bilateral ribs.
  • 2022-11-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (60 - 16) / 60 = 73.33%
      • M-mode (Teichholz) = 74
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
      • Degenerative changes of mitral valve and mild mitral annulus calcification with trivial MR; mild TR.
      • Sinus tachycardia.
  • 2022-06-27 SONO - nephrology
    • Chronic parenchymal renal disease

[consultation]

  • 2022-11-16 Hemato-Oncology
    • Q
      • This 74y/o female with past history of compression fracture was admitted due to UTI,
      • lab data showed Hb:8.7 g/dL, M-peak positive
      • we need your expertise for better her condition!
    • A
      • The 74 y/o female showed M-peak (+) in serum protein electrophoresis & anemia, MM or some other myeloma related Dz is highly suspected.
      • Lab:
        • Serum protein eletrophoresis (11/9 22): positive.
        • TP (11/7 22):5.8, A/G: 3.2/ 2.6.
        • IgG, IgM, IgA (11/7 22): WNL.
        • Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 )
        • b-2 microglobulin (11/8 22): 6172, LDH:296
        • BUN / Cre (11/14 22): 23 / 0.98, Ca: 2.26
        • Hb (11/7 22):8.6, MCV:97.2, MCHC:31.5, plt:313K, WBC:7210
        • NT-proBNP (10/31 22): 1785.
      • Dx: Anemia & M-peak (+), hypoalbuminemia.
        • R/I Lambda light chain amyloidosis
        • R/I Multiple myeloma ( MM ).
        • monoclonal gammopathy of undetermined significance
          • (M-protein in serum < 3 g/dL, < 10% clonal plasma cell on BM Bx, no end organ damage).
        • Smoldering myeloma
          • (M-protein in serum > 3 g/dL, > 10% clonal plasma cell on BM Bx, no end organ damage ).
      • Medical advice:
        • Owing to IgG, IgM, IgA (11/7 22): WNL, Free light chain assay (11/10 22): FLLC / KLLC ratio: 451 ( 8487.5 / 18.8 ), Lambda light chain amyloidosis is highly suspected.
          • In light chain disease, 50% did not show SPEP M-protein (+). but serum free light chain ( FLC ) assay may show abnormality of kappa or lambda chains & kappa / lambda ratio.
          • May do 24-h urine for total protein. Urin protein electrophoresis (UPEP), urine immunofixation electrophoresis ( UIFE).
          • Will do Unilateral bone marrow aspirate + biopsy & Congo red staining for amyloid.
          • The percentage of clonal bone marrow plasma cells (≥10%) is a major criterion for the diagnosis of MM or some other myeloma related Dz.
        • Identification of light chains in the serum or urine without confirmation of the amyloid composition in tissue is not adequate, as patients with other forms of amyloidosis may have an unrelated monoclonal gammopathy of undetermined significance (MGUS).
          • Will try biopsy of organ involvement of amyloidosis
        • Kidney:
          • 24-h urine protein >0.5 g/d, predominantly albumin.
          • Mx: may do 24 hr urine collection for protein loss evaluation.
        • Nerve:
          • Peripheral: clinical; symmetric lower extremity sensorimotor peripheral neuropathy
        • Autonomic: gastric-emptying disorder, pseudo-obstruction, voiding dysfunction not related to direct organ infiltration
          • Mx: may consult neurologist to R/I peripheral neuropathy & may do electromyography (EMG) ( if clinically significant peripheral neuropathy) / nerve conduction studies.
        • Soft tissue:
          • Tongue enlargement, clinical
          • Arthropathy
          • Claudication, presumed vascular amyloid Skin
          • Myopathy by biopsy or pseudohypertrophy
          • Lymph node (may be localized)
          • Carpal tunnel syndrome
            • Mx: If tongue enlargement, may do tonue biopsy. May try abdominal fat pad sampling to confirm amyloid deposit.
        • Liver:
          • Total liver span >15 cm in the absence of heart failure or alkaline
          • phosphatase >1.5 times institutional upper limit of normal
          • Mx: if gastroparesis present, may do Gastric emptying scan.
          • May do abd ultrasound or abd CT scan to document craniocaudal liver span.
        • Heart:
          • Echo: mean wall thickness >12 mm, no other cardiac cause or an elevated
          • NT-proBNP (>332 ng/L) in the absence of renal failure or atrial fibrillation
          • the pt has higher NT-ProBNP ( 1785 ), suggestive of heart failure. R/I light chain amylodosis related.
          • Mx: may do cardiac echo.
        • LDH and beta-2 microglobulin levels reflect tumor cell characteristics.
        • Higher b2-micoglobulin ( b2M ) means larger tumor load ( but renal failure will make b2-microglobulin accumulate. This pt has poor renal function ).
        • Higher LDH may suggest MM tumor aggression.
        • If light chain amyloidosis is confirmed, preferred Regimen:
          • Daratumumab and hyaluronidase fihj / bortezomib / cyclophosphamide / dexamethasone
          • Bortezomib ± dexamethasone
          • Bortezomib/cyclophosphamide/dexamethasone
          • Bortezomib/lenalidomide/dexamethasone
          • Bortezomib/melphalan/dexamethasone (if ineligible for HCT)
  • 2022-11-12 Neurology
    • Q
      • For cognitive function assessment, is there dementia or ??? (Patient reports urinary and fecal incontinence without sensation, but sometimes says she feel bowel movements and other times says she does not feel them)
      • This 74 y/o woman is a case of type 2 DM, CKD stage 3 and anemia, cause to be determined. Operation history of
        • post lumbar spine surgery due to HIVD about 40 years ago at Gengshen Hospital
        • Pancreatic duct tumor with p-duct dilatation s/p Whipple’s operation (PPPD) in 2014
        • LUL lung nodule s/p thoracoscopic wedge resection and LN dissections in 2015
        • Right hip fracture s/p bipolar hemiarthroplasty in 2020
        • Multiple compression fracture post vertebroplasty at L3 in 2021, and vertebroplasty at L1 and L2 on 2022/04/07 at Tzu Chi H.
      • She was discharged from our isolation ward due to Covid-19 infection on 10/19, and admission again on 2022/10/31 due to urosepsis with drowsy consciousness, right lung infiltration with dyspnea, and hypokalemia.
      • After admission, she received KCL in fusion for correct hypokalemia, and antibiotics as sintrix treatment since 11/01 to 11/03, and change to Brosym 4.0 gm IVD Q12H since 11/03 for urine culture grew Escherichia coli. Improve of infection of urine and the consciousness return to near clear. Right lung edema improve after lasix use. Due to lumbar pain, paresthesia over both legs? light touch decrease at lateral aspect of lower leg and dorsum of foot? and incontinence? The T-L spine MRI was performed, showed multiple T-L compression fracture and Moderate spinal stenosis at L3/4 level, caused by posteriorly displaced bony component. Posterior decompression of L3 to L5 maybe is indication, but this moment, the patient complained incontinence condition improve? seems to feel sensation when stool output (But the words are inconsistent, sometimes says they feel bowel movements, sometimes says they don’t feel them, no sensation during urination, rectal examination: no relaxation of the anal sphincter).
      • Now, we need your help for evaluation about cognitive function assessment, whether there is dementia or other problem. Thanks.
    • A
      • the patient complainted incontinence condition improve ? seems to feel sensation when stool output
      • E4M6V4
      • Cranial nerve: intact
      • motor: all>3
      • Imp: may have dementia+ delirium
      • P: Check BUN, Crea, CBC, ALT, AST, Ca, Na, Mg, TSH free T4, ammonia
        • Arrange EEG
        • Neurology OPD f/u after this acute illness for diagnosis of dementia
  • 2022-11-07 Orthopedics
    • A
      • The 74 y/o women had T7 compression fracture post vertebroplasty on 2022/04/28
      • L1-2 compression fracture status post L1, L2 vertebroplasty on 2022/04/07.
      • Patient complain urination and defication incontinence for one week
      • She also complain numbness over anal area
      • X-ray: mutiple compression fracture
      • => transfer to our ward and arrange MRI
  • 2022-11-05 Chest Medicine
    • Q
      • The 74 y/o women had COVID 19 2 weeks ago
      • She was admited to our weard due to dyspnea and back pain and UTI
      • Pleural effusion arrange aspiration today
      • Diuretic use for r/o pulmonary edema
      • We need your help for progress dyspnea, Thanks!
    • A
      • The pleural effusion was bilaterally symmetric, CT density favor transudate, possible due to:
        • long term malnutrition with hypoalbuminemia (the albumin level was pseudo-high due to severe intravascular volume depletion)
        • bed-ridden with lung atelectasis
        • chronic hypoxic lung disease (bed-ridden related) with right side CHF
        • Repeated infection (aspiration pneumonia and UTI and recently COVID-19 infection) with SIRS
      • Suggestion:
        • May repeat chest echo at next W3AM or W4 AM for possible diagnostic tapping
        • Lung expansion therapy
        • Increase intravascular volume (including hydrostatic and oncotid fluid)
        • Keep Hb not less than 10.0
        • choking was noted, NG feeding and totally avoid oral feeding/intake is suggested
        • keep present anti
        • check thyroid and adrenal function
        • Thanks and f/u prn.

[MedRec]

  • 2023-04-07 SOAP Hemato-Oncology
    • Anemia, unspecified [D64.9]
    • Muliple myeloma, Light chain
      • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, D8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
      • #2 on 02/06 23.
      • #3 on 03/17
      • #4 on 04/07
  • 2023-01-03 SOAP Hemato-Oncology
    • #1 Velcade 1.5mg/m2 ( give 2.5mg ) SC D1 & D4, DD8, D11 Q4W x 4 plus Dexa on 1/3 23. ( fee )
    • RTC 1wk later on 1/9 23 for #2 Bortezomib / cyclophosphamide / dexa.
  • 2022-11-28 SOAP Hemato-Oncology
    • Lab
      • 2022/11/17 U-TP(24hr) = 2200.5 mg/day;
      • 2022/11/10 Free Light Chain κ/λ (blood)
        • FKLC = 18.8 mg/L;
        • FLLC = 8487.5 mg/L;
        • FK/FL ratio = 0.002215 ratio;
      • 2022/11/09 M-peak = Positive;
      • 2022/11/08 B2-Microglobulin = 6172 ng/mL;
      • 2022/11/07 IgG (blood) = 687 mg/dL;
      • 2022/11/07 IgM = 31.0 mg/dL;
      • 2022/11/07 IgA = 39 mg/dL;
      • 2022/11/07 LDH = 296 U/L;
    • Light chain Dz, lambda, ISS stage ? is highly suspected (11/28 22).
    • will do BM biopsy on 12/1 22 (11/26 22).
    • If light chain amyloidosis is confirmed, preferred Regimen:
      • Daratumumab and hyaluronidase / bortezomib / cyclophosphamide / dexa.
      • Bortezomib ± dexamethasone
      • Bortezomib/cyclophosphamide/dexamethasone
      • Bortezomib/lenalidomide/dexamethasone
    • will apply Bortezomib / cyclophosphamide / dexa (11/28 22).
    • RTC 1wk later on 12/5 22 for possible #1 Bortezomib / cyclophosphamide / dexa.
    • Diagnosis C90.0 Multiple myeloma
  • 2022-09-19 SOAP Hemato-Oncology
    • 73 y/o female was noted to have anemia (Hb:5.6) in Sep 2022 even poor renal function improves.
    • Lab 2022/09/14
      • Ferritin = 361.5 ng/mL;
      • Fe (Iron-bound) = 74 ug/dL;
      • TIBC = 237 ug/dL;
    • R/I
      • IDA
      • thalassemia
      • Vit B12 & folic acid deficiency related.
      • anemia due to chronic liver dz
      • anemia due to malnutirtion
      • anemia of chronic inflamnmation / infection ( eg: DM ).
      • hematologic dz ( eg MDS, pure red cell aplasia )
      • Viral infection related
      • hemolysis
    • will do CBC & DC, reticulocyte, RBC morphology, RF, ANA, Ferritin, Haptoglobin, LDH, BilT/D, Direct & Indirect Coombs test & abd sono R/I splenomegaly. (9/19 22).
    • will do CBC & DC, Ferritin, Fe/TIBC, SOB, LFT, RFT (9/19 22).
    • give P-RBC 2U (9/19 22).
    • SBP: 190+ mmHg noted at daycare before P-RBC, give Norvasc (9/19 22).
    • If definitive Dx is not made, will do BM biopsy (9/19 22).
    • RTC 1 wk later on 5/4 20 for IDA report.

[chemotherapy]

  • 2023-04-07 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
  • 2023-03-17 - bortezomib 1.5mg/m2 2.0mg SC 5min D1,4,8,11
  • 2023-02-06 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5,8,12
  • 2023-01-09 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,5
  • 2023-01-03 - bortezomib 1.5mg/m2 1.9mg SC 5min D1,4

[note]

Bortezomib (Velcade) plus cyclophosphamide and dexamethasone (VCD or CyBorD) for multiple myeloma 2023-04-24 https://www.uptodate.com/contents/image?topicKey=ONC%2F85687&sectionRank=1&imageKey=ONC%2F50061

  • Cycle length: 28 days.

  • Regimen

    • Bortezomib
      • 1.5 mg/m2 SC or IV
      • Given subcutaneously or as a rapid IV bolus over three to five seconds.
      • Days 1, 8, 15, and 22
    • Cyclophosphamide
      • 300 mg/m2 by mouth, once weekly
      • Dose rounding to the nearest 50 mg. Do not cut or crush. Take during or after meal in the morning.
      • Days 1, 8, 15, and 22
    • Dexamethasone
      • 40 mg by mouth, once weekly
      • Take with food (after meals or with food or milk) in the morning.
      • Days 1, 8, 15, and 22
  • Pretreatment considerations:

    • Hydration
      • Patients receiving cyclophosphamide should maintain adequate oral hydration (2 to 3 L/day during administration and for one to two days thereafter) and void every two to three hours to reduce the risk of hemorrhagic cystitis. Risk of bladder irritation is also decreased by avoiding bedtime administration.
    • Emesis risk
      • LOW or VERY LOW.
    • Prophylaxis for infusion reactions
      • Routine premedication is not indicated. If a hypersensitivity reaction occurs with cyclophosphamide, then neither oral nor IV cyclophosphamide should be readministered.
    • Infection prophylaxis
      • Bortezomib therapy may be associated with an increased risk of herpes zoster and infections not related to neutropenia. Antiviral prophylaxis (eg, acyclovir 400 mg orally twice a day) should be administered to all patients receiving VCD/CyBorD. Some clinicians also administer trimethoprim-sulfamethoxazole double strength once daily on Mondays, Wednesdays, and Fridays during treatment. Primary prophylaxis with G-CSF is not indicated.
    • Antithrombotic prophylaxis
      • While patients with multiple myeloma have an increased risk of thrombosis, the risk of thrombosis with the VCD/CyBorD regimen was ≤7% in two trials. Routine antithrombotic prophylaxis is not warranted.
    • Dose adjustment for baseline liver or kidney dysfunction
      • Bortezomib: No dosage adjustment for bortezomib secondary to kidney impairment is necessary. For patients undergoing hemodialysis, bortezomib should be administered after dialysis. Patients with moderate or severe hepatic impairment (serum bilirubin level >1.5 times the upper limit of normal) should be started on bortezomib at a reduced dose of 0.7 mg/m2 per injection during the first cycle, with further dose modifications based upon patient tolerance.
      • Cyclophosphamide: For patients with preexisting hepatic impairment, dose adjustments in cyclophosphamide dose may be needed. The need for cyclophosphamide dose reduction in patients with kidney impairment is controversial; some suggest dose reduction if the creatinine clearance is <30 mL/minute.
  • Monitoring parameters:

    • Assess CBC with differential, electrolytes, kidney function, liver function, and M protein prior to starting each cycle. A CBC should also be performed prior to the day 15 dose of bortezomib.
    • Weekly assessment for peripheral neuropathy and/or neuropathic pain.
    • Monitor for hypotension during therapy; adjustment of antihypertensives and/or administration of IV hydration may be needed.
  • Suggested dose modifications for toxicity:

    • Myelotoxicity
      • If platelets are <50,000/microL or the absolute neutrophil count is <1000/microL on day 15, hold bortezomib and cyclophosphamide. If several doses are held, reduce bortezomib dose by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2) and decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only).
    • Neuropathy
      • Dose adjustment guidelines for bortezomib in patients who develop peripheral neuropathy or neuropathic pain are available:
        • Grade 1 (asymptomatic, loss of deep tendon reflexes or paresthesia without pain or loss of function): No action required.
        • Grade 1 (with pain) or Grade 2 (interfering function but not activities of daily living): Reduce by one level (from 1.5 mg/m2 to 1.3 mg/m2; or from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2).
        • Grade 2 (with pain) or Grade 3 (interfering with activities of daily living): Hold until resolution, may reinitiate at 0.7 mg/m2 once weekly.
        • Grade 4 (life-threatening, disabling, eg, paralysis): Discontinue.
      • Rarely, bortezomib has been associated with RPLS, which can present with seizures, hypertension, headache, lethargy, confusion, blindness, or as other visual or neurological disturbances. Bortezomib should be discontinued if the diagnosis of RPLS is confirmed on brain MRI.
    • Cystitis
      • For grades 1 or 2 cystitis (minor symptoms responding to outpatient management), decrease the number of doses of cyclophosphamide given each cycle by one level (serial levels are: Days 1, 8, 15, and 22; days 1, 8, and 15; days 1 and 8; day 1 only). Cyclophosphamide should be discontinued if cystitis symptoms are distressing or affect lifestyle (grade 3 or 4).
    • Thrombotic microangiopathy
      • Rarely, bortezomib has been associated with TMA, which can present with Coombs-negative hemolysis, thrombocytopenia, kidney failure, and/or neurologic findings. If TMA is suspected, stop bortezomib and evaluate.
    • Other nonhematologic toxicity
      • For grade 3 or 4 nonhematologic toxicity other than neuropathy, bortezomib should be held. Once symptoms have resolved to grade 1 or baseline, bortezomib may be reinitiated with one dose level reduction (from 1.3 mg/m2 to 1 mg/m2; or from 1 mg/m2 to 0.7 mg/m2). Dexamethasone dose should be reduced for grade 2 muscle weakness, grade 3 gastrointestinal tract toxicity, hyperglycemia, confusion or mood alterations.
    • If there is a change in body weight of at least 10%, doses should be recalculated.

Treatment of Clostridioides difficile infection (CDI) in adults 2023-05-17 https://www.uptodate.com/contents/image?topicKey=ID%2F2698&imageKey=ID%2F53273

  • Nonfulminant disease
    • Initial episode (nonsevere or severe disease) - Management of an initial CDI episode consists of treatment with an antibiotic regimen.
      • Nonsevere disease is supported by the following clinical data: White blood cell count <=15,000 cells/mL and serum creatinine level <1.5 mg/dL
      • Severe disease is supported by the following clinical data: White blood cell count >15,000 cells/mL and/or serum creatinine level >=1.5 mg/dL
      • Antibiotic regimens:
        • Fidaxomicin 200 mg orally twice daily for 10 days
        • Vancomycin 125 mg orally 4 times daily for 10 days
        • For nonsevere disease, alternative regimen if above agents are unavailable:
          • Metronidazole◊ 500 mg orally 3 times daily for 10 to 14 days
    • Recurrent episode - Management of a recurrent CDI episode consists of treatment with an antibiotic regimen, in addition to adjunctive bezlotoxumab¶ if feasible.
      • First recurrence
        • Antibiotic regimens:
          • Fidaxomicin
            • 200 mg orally twice daily for 10 days, OR
            • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
          • Vancomycin in a tapered and pulsed regimen, for example:
            • 125 mg orally 4 times daily for 10 to 14 days, then
            • 125 mg orally 2 times daily for 7 days, then
            • 125 mg orally once daily for 7 days, then
            • 125 mg orally every 2 to 3 days for 2 to 8 weeks
          • Vancomycin 125 mg orally 4 times daily for 10 days
        • Adjunctive treatment:
          • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
      • Second or subsequent recurrence
        • Antibiotic regimens:
          • Fidaxomicin
            • 200 mg orally twice daily for 10 days, OR
            • 200 mg orally twice daily for 5 days, followed by once every other day for 20 days
          • Vancomycin in a tapered and pulsed regimen (example as above)
          • Vancomycin followed by rifaximin:
            • Vancomycin 125 mg orally 4 times daily by mouth for 10 days, then
            • Rifaximin 400 mg orally 3 times daily for 20 days
        • Adjunctive treatment:
          • Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen.
        • Role of fecal microbiota transplantation (FMT):
          • For patients who have received appropriate antibiotic treatment for at least 3 CDI episodes (ie, initial episode plus 2 recurrences), who subsequently present with a fourth or further CDI episode (third or subsequent recurrence), we favor FMT in regions where available. Pending referral for FMT, we treat with an antibiotic regimen as outlined above.
  • Fulminant disease
    • Fulminant disease is supported by the following clinical data: Hypotension or shock, ileus, megacolon
      • Absence of ileus: Enteric vancomycin plus parenteral metronidazole:
        • Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND
        • Metronidazole 500 mg intravenously every 8 hours
      • If ileus is present, additional considerations include:
        • FMT (administered rectally) OR
        • Rectal vancomycin (administered as a retention enema 500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours)
  • The standard course of treatment for an initial episode of CDI is 10 days. Some patients, particularly those treated with metronidazole or with severe disease, may have a delayed response; in such circumstances, treatment may be extended to 14 days. For patients with inflammatory bowel disease, an extended duration of 14 days is also appropriate. If continuation of antibiotic(s) for a primary infection is essential, we continue CDI treatment for one week after completion of other antibiotics.
  • The criteria proposed for defining severe or fulminant CDI are based on expert opinion and may need to be reviewed upon publication of prospectively validated severity scores for patients with CDI. Patients with severe or fulminant CDI also warrant assessment for surgical indications; refer to UpToDate topic on treatment of CDI for further discussion.
  • For patients with nonfulminant disease, we suggest a fidaxomicin-based regimen over a vancomycin-based regimen. In addition, for patients with nonfulminant recurrent disease and prior CDI in the last 6 months, we suggest adjunctive bezlotoxumab. Use of fidaxomicin or bezlotoxumab have each been associated with a small benefit with respect to CDI recurrence rates (10 to 15% decrease). In the setting of cost constraints, we prioritize use of these agents for patients at greatest risk for CDI recurrence (age >=65 years, severe CDI, or immunosuppression). Vancomycin remains an acceptable agent for treatment of initial and recurrent CDI.
  • Systemic absorption of enteral vancomycin can occur in patients with mucosal disruption due to severe or fulminant colitis; this consideration is particularly important for patients with kidney insufficiency (creatinine clearance <10 mL/minute). Therefore, monitoring serum vancomycin levels is warranted for patients with kidney failure who have severe or fulminant colitis and require a prolonged course (>10 days) of enteral vancomycin therapy.
  • Metronidazole should be avoided in patients who are frail, age >65 years, or who develop CDI in association with inflammatory bowel disease. Caution is also warranted during pregnancy and lactation.
  • The approach to antibiotic management of nonfulminant recurrent CDI is the same regardless of severity, but varies depending on the number of recurrences, as outlined above. For patients with a recurrent episode of CDI that is severe, refer to UpToDate topic on treatment of CDI for further discussion.
  • The bezlotoxumab prescribing information in the United States warns that in patients with a history of congestive heart failure, the drug should be reserved for use when the benefit outweighs the risk, given reports of increased heart failure exacerbations and associated deaths in such patients. In addition, data for use of bezlotoxumab combined with fidaxomicin are limited.
  • In contrast to the above approach, some favor FMT for patients who have received antibiotic treatment for at least 2 CDI episodes (ie, initial episode plus one recurrence), who subsequently present with a third or further CDI episode (second or subsequent recurrence).
  • Continue dosing for 10 days. If recovery is delayed, treatment can be extended to 14 days.
  • In the setting of ileus, we favor FMT over rectal vancomycin. However, such procedures are associated with risk of colonic perforation; therefore, they should be restricted to patients who are not responsive to standard therapy, and the procedure should be performed by personnel with appropriate expertise. Refer to the UpToDate topic on FMT for discussion of safety, efficacy, and delivery protocols.
  • Rectal vancomycin may be administered as a retention enema, either in addition to oral vancomycin (if the ileus is partial) or in place of oral vancomycin (if the ileus is complete). Given potential risk of colonic perforation in setting of CDI, rectal vancomycin instillation should be performed by personnel with appropriate expertise.

==========

2023-05-17

  • On 2023-05-14, the patient’s WBC was 7.37K/uL, creatinine was 1.01mg/dL, and stool occult blood was 2+. Stool culture obtained on 2023-05-15 was negative for Clostridioides difficile toxin A/B but positive for glutamate dehydrogenase (GDH). The patient had 9 and 8 bowel movements on 2023-05-15 and 2023-05-16, respectively. Therefore, the prescription of oral vancomycin at a dose of 125 mg 4 times daily is appropriate and unproblematic.

  • Now that the pathogen has been identified, the previously prescribed and currently active medication, Metrozole (metronidazole) 500mg PO Q8H, could potentially be discontinued, assuming there are no hypotension or shock, ileus, megacolon and/or other ongoing infectious conditions.

  • According to the HIS5 database, there have been no other culture reports on Clostridioides Difficile Infection (CDI) in the past 6 months. In the event of a recurrent infection, a tapered and pulsed regimen of vancomycin could be considered. Here is a possible schedule:

    • 125 mg orally four times daily for 10 to 14 days, followed by
    • 125 mg orally twice daily for 7 days, followed by
    • 125 mg orally once daily for 7 days, and then
    • 125 mg orally every 2 to 3 days for 2 to 8 weeks.

2023-04-24

[assessment]

  • The patient has been diagnosed with Multiple Myeloma (MM) and was started on VCd regimen on 2023-01-03. All of the patient’s medications listed in PharmaCloud were prescribed by our hospital. No medication reconciliation issues were identified.

  • After starting the VCd regimen, there was a decrease in the B2 microglobulin level. However, the most recent reading indicates that the level has nearly doubled from the previous low in approximately 1.5 months.

    • 2023-04-22 B2-Microglobulin 8692 ng/mL
    • 2023-03-04 B2-Microglobulin 4648 ng/mL
    • 2022-11-08 B2-Microglobulin 6172 ng/mL
  • Currently, there is no evidence that the patient is developing thrombocytopenia, peripheral neuropathy or neuropathic pain.

701179622

230517

[exam findings]

  • 2023-05-17 Sono-guide aspiration of right thyroid mass
    • IMP: right thyroid mass, s/p FNA
  • 2023-04-20 Bronchodilator Test
    • mild obstructive ventilatory impairment, FEV1/FVC = 45%, FVC = 138%, FEV1 = 81%
    • without significant reversibility
  • 2023-04-20 CT - chest
    • Indication
      • Chronic obstructive pulmonary disease, unspecified
      • Allergic rhinitis, unspecified
      • Unspecified asthma, uncomplicated
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Semi-solid nodule at left upper lobe measuring 1.6cm in largest dimension is found.
        • Moderate centrilobular Emphysematous change over both lungs is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • Cystic lesion at right lobe thyroid with calcified wall measuring 3.7cm in largest dimension is found.
      • Visible abdomen:
        • Low density lesions at both lobes of liver is found up to 3.3cm at S7. r/o liver meta.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Left upper lobe nodular lesion. 1.6cm
      • Right thyroid cystic lesion. 3.7cm, thyroid cancer?
      • Liver meta.
  • 2023-02-02 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland or other mediastinal mass
    • a small nodular opacity (polylobular borders) over LUL,
    • suggest do CT study
    • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
    • enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • 2022-11-03, -02-24 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland and other mediastinal mass
    • Increased lung volume and areas of hyperlucency and decreased upper vascular markings due to emphysematous change of both lungs upper lung predominance
    • enlarged cardiac silhoutte due to prominent pericardial fat/ prominent cardiophrenic angle mediastinal fat pad
  • 2022-02-24 Bronchodilator Test
    • moderate obstructive ventilatory impairment (FEV1/FVC: 46.4%, FVC:105%, FEV1: 62%)
    • without significant reversibility
  • 2021-03-25 CXR
    • Displacement of the tracheal axis to left at thoracic inlet and superior mediastinum probably due to enlarged thyroid gland
    • Increased lung volume and areas of lucency due to emphysematous change of both lungs
    • prominent pericardial fat/cardiophrenic fat
  • 2021-03-25 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1/FVC = 47%, FVC = 104%, FEV1 = 74%
    • without significant reversibility
  • 2020-04-16 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1/FVC = 48%, FVC = 104%, FEV1 = 63%
    • without significant reversibility
  • 2019-06-13 Bronchodilator Test
    • moderate obstructive ventilatory impairment, FEV1= 66 %
    • with significant reversibility
  • 2019-05-16 CXR
    • Senile fibrotic change is noted at lung fields.

==========

2023-05-17

  • The patient’s underlying conditions of COPD, asthma, HTN, and electrolyte imbalance are managed with appropriate medications on the active medication list. After reviewing PharmaCloud, no medication reconciliation issues were identified.

700818206

230516

[present illness] - 2023-02-23 admission note

  • Radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23~. Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C1) from 2023/02/23.

[past history]

  • Hypertension for 5 years under medication treatment.
    • Exforge F.C 5mg & 160mg 1# po QD
    • Concir 5mg 1# po QD
    • Lipanthyl Supra F.C 160mg 1# po QD
  • HIVD (herniated intervertebral disc) post operation twice at 30-year-old and 40-year-old.
  • Perianal tumor status post excision of perianal tumor on 2020/04.
  • Grade IV hemorrhoids status post hemorrhoidectomy on 2020/04.
  • Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 by L-spine MRI on 2021/04/26.   
  • Gastrorrhaphy, umbilical hernia repair and laparoscopy examination on 2021/11/10

[allergy]

  • amoxicillin: Redness and swelling of the lips and oral mucosa

    

[family history]

  • Denied any major disease or cancer history of his family member.

[exam findings]

  • 2023-05-04 Colonoscopy
    • Rectal cancer s/p CCRT with partial response
  • 2023-02-08 MRI - pelvis
    • History: Newly diagnosed rectal cancer at 8cm from AV
    • MR Imaging of the pelvis was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position with field of view 28 cm, slice thickness 5 mm and gap 1 mm.
    • Scanning protocol:
      • Axial plane: spin echo T1WI, Non-Fat-saturation FSE T2WI, and HASTE T2WI, Diffusion weighted images
      • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI
      • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
    • Findings:
      • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
        • In addition, There are two enlarged nodes in the presacral space that may be metastatic nodes (N1b).
      • There is a hyperintensity nodule 1.8 cm in right central zone of the prostate on both T2WI and DWI that is c/w hyperplasia.
      • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
      • A hepatic cyst measuring 0.5 cm in S2 is noted.
      • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
      • Others
        • There is no focal abnormality in the seminal vesicle.
        • There is no focal abnormality in the urinary bladder.
        • There is no evidence of ascites.
        • The visible IVC are grossly unremarkable.
    • IMP:
      • Rectal cancer is highly suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
  • 2023-02-03 CT - abdomen
    • CC: Hemorroidectomy at CRS on W2, Anal bleeding since then.
      • FOBT (+), External hemorrhoids
      • Anal protruding mass noted
      • Anal pain developed these days
      • Anal bleeding also noted occasionally
      • 20210202 colonoscopy: One mass in the rectum (8 cm AAV) Indication: Newly diagnosed rectal cancer for staging.
    • Findings:
      • There is asymmetrical wall thickening at left lateral aspect of the rectum, measuring 1.3 cm in wall thickness, that is c/w adenocarcinoma (T3).
        • In addition, There are three enlarged nodes in the perirecal space that may be metastatic nodes (N1b). Please correlate with MRI.
      • Abdominal aorta shows atherosclerosis and focal ectasia 2.1 cm at left lateral aspect.
      • There are several renal cysts on left kidney and the largest one measuring 3.3 cm in size at left middle pole.
      • A hepatic cyst measuring 0.5 cm in S2 is noted.
        • In addition, There is a poor enhancing lesion 1 cm in S8 of the liver dome subphrenic space or liver capsule area. Follow up is indicated.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1b (N_value) M:M0 (M_value) STAGE:IIIB(Stage_value)
  • 2023-02-03 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Borderline ECG
  • 2023-02-03 Patho - colorectal polyp
    • Intestine, large, rectum, 8 cm from nal verge, biopsy— adenocarcinoma
    • Immunohistochemical stain— EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli,and high N/C ratio.
  • 2023-02-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (123 - 29) / 123 = 76.42%
      • M-mode (Teichholz) = 76
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild AR, MR, and PR+
  • 2023-02-03 Bronchodilator Test
    • normal ventilation; non-significant bronchodilator response
  • 2023-02-02 Colonoscopy
    • D-colon polyp s/p polypectomy
    • Retcal cancer s/p biopsy
  • 2022-11-18 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Left renal cysts
  • 2022-10-21 Knee BIL standing AP and Lat views
    • Mild to moderate osteoarthritis of both knees
    • Ahlback calcification: grade 2, 2
  • 2022-10-21 Merchant view (patella 45 0) Bil :
    • Mild lateral subluxation of the patella
    • Patellofemoral osteoarthritis
    • Sperner classification: 2-3
  • 2023-02-03 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 31) / 115 = 73.04%
      • M-mode (Teichholz) = 72.8
    • Normal chamber size
    • Thickening of IVS (interventricular septum) and LVPW (left ventricular posterior wall thickness)
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV (aortic valve) sclerosis with mild AR (aortic regurgitation), mild MR (mitral regurgitation), TR (tricuspid regurgitation) and PR (pulmonary regurgitation)
    • No regional wall motion abnormalities
  • 2022-08-23 CXR
    • Atherosclerotic change of aortic arch
  • 2022-03-02 Patho - stomach biopsy
    • Stomach, antrum, GC site, biopsy — chronic gastritis. No H.pylori present
    • Stomach, middle body, GC/AW site, biopsy — fundic gland polyp. No H.pylori present
  • 2022-03-01 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade A(minimal)
      • Superficial gastritis
      • Gastric polyp, middle body, GC/AW site (A)
      • Gastric erosion, antrum, GC site, s/p biopsy (B)
      • C/W s/p gastrorrhaphy
    • Suggestion
      • Pursue biopsy result
  • 2021-11-11 Patho - stomach biopsy
    • Stomach, antrum, midline laparotomy and repair of perforation — Ulcer with perforation, H pylori NOT present
  • 2021-11-10 CT - abdomen
    • History and Indication: Abdominal pain for 3 days. INITIAL SHOULDER SORENESS AND COLD SWEATING, NO VOMITING, NO DIARRHEA
      • Allergy: amoxicillin
      • PHx: HTN, hyperlipidemia, NKDA
    • MD CT (256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There is ascites and free gas bubbles in peritoneal cavity (pneumoperitoneum) that is c/w hollow organ perforation.
        • In addition, focal fluid collection and gas bubbles in the gastrohepatic ligament is also noted.
      • Right side Pleura effusion and mild atelectasis in bilateral posterior basal lung are noted.
      • Two renal cyst 2.7 cm and 1 cm in left middle pole are noted.
      • Hyperplasia of right adrenal gland is noted.
      • Umbilical hernia with omentum fat herniation is noted.
      • Others
        • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & right kidney.
        • There is no lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • IMP: Hollow organ perforation is highly suspected.
  • 2021-04-26 MRI - L-spine
    • Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L5-S1 (with right HIVD).
  • 2021-03-15 Patho - skin cyst/tag/debridement
    • Eyelid mass, OS, excisional biopsy — Papillary squamous hyperplasia, compatible with papilloma
  • 2000-04-15 Patho - hemorrhoids
    • Colon, rectum, hemorrhoidectomy — Hemorrhoid
    • Skin, peri-anal, excision — Epidermal inclusion cyst

[MedRec]

  • 2023-05-04 SOAP Hemato-Oncology
    • P: During admission on 2023-05-04, consult dermatologist (for hand-foot syndorme) and reduce oxaliplatin to 75, DC bolus 5-FU.
  • 2023-03-22 SOAP Hemato-Oncology
    • P: Encourage patient to continue the treatment
  • 2023-02-09 SOAP Hemato-Oncology
    • O:
      • 2023/02/03 Abd CT: T3 N1b M0 STAGE:IIIB(Stage_value)
      • 2023/02/08 MRI Pelvis: Rectal cancer is highly suspected. According to AJCC staging system, 8th edition for colon cancer: T3 N1b M0, stage:IIIB
    • A/P
      • Suggest pre-op CCRT (Favor TNT) then OP
      • CCRT with FU followed by FOLFOX 12 16 weeks, then OP, the F/U

[consultation]

  • 2023-03-28 Dermatology
    • Q
      • This 65-year-old man diagnosis was rectum cancer, T3N1bM0, stage IIIB under radiotherapy for 4500cGy/25 fractions of the pelvic, and 5040cGy/28 fractions of the rectal tumor bed from 2023/02/23. He received concurrent chemoradiotherapy with 5FU(225mg/m2) from 2023/02/23-27(C1). Now, he was admitted to ward for concurrent chemoradiotherapy with 5FU(225mg/m2)(C2) from 2023/03/27.  
      • For skin lesion in palms of both hands, we need your further evaluation and management.
    • A
      • The patient had sufferred from dry, xerotic skin texture with fine excoriaiton scales.
      • Under the impression of hand-foot syndorme favor 5 FU related and xerotic dermatitis.
      • The following sugeetion:
        • add Tetracycline onit topical bid use. firts for wound.
        • enhance skin mositurization with body cream and add sinphraderm cream 1 tube topical QN use on the scaling lesions.
  • 2021-11-10 General and Digestive Surgery
    • Q
      • Abd Pain for 3 days, INITIAL SHOULDER SORENESS AND COLD SWEATING
      • NO VOMITING, NO DIARRHEA
      • Allergy: amoxicillin
      • PHx: HTN, hyperlipidemia, NKDA
    • A
      • hollow organ perforation was impressed
      • PE: peritonitis sign
      • CT: minimal free air r/o colon perforation
      • suggest laparotomy

[surigcal operation]

  • 2021-11-10
    • Surgery
      • gastrorrhaphy
      • umbilical hernia repair
      • laparoscopy examination
    • Finding
      • turbid ascites, with food debrides
      • one perforation at antrum, GC side, about 2cm in diameter, less likely malignancy
  • 2021-03-22
    • Right L5 DRG PRF (right fifth lumbar dorsal root ganglion pulsed radiofrequency)
    • Right SI (sacroiliac) joint arthorgram and injection
  • 2021-03-15
    • Surgery
      • excision biopsy (OS)
    • Finding
      • eyelid mass (OS)
  • 2020-04-14
    • Surgery
      • Excision of perianal tumor
      • Hemorrhoidectomy        
    • Finding
      • Left anterior perianal tumor 1.5x1x1cm
      • Prolasped hemorrhoids at 3,7,11 o’clock 

[radiotherapy]

[chemotherapy]

  • 2023-04-25 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 400mg/m2 750mg NS 100mL 10min + fluorouracil 2400mg/m2 4500mg NS 500mL 46hr (FOLFOX)

  • 2023-03-27 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1-4 (CCRT)

  • 2023-02-23 - fluorouracil 225mg/m2 430mg NS 100mL 10min D1, 2, 5, 7 (excluding weekend and 2/28 holiday) (CCRT)

==========

2023-05-16

  • According to the PharmaCloud database, all of the patient’s recent medications have been prescribed by our hospital, and no issues with medication reconciliation have been detected.

  • On 2023-05-15, the patient’s WBC count was observed to be 1.89K/uL, indicating leukopenia. This was first noted in the HIS5 system 3 weeks after the last administration of FOLFOX on 2023-04-25. When this event became known, Granocyte (lenograstim) was administered for two consecutive days. The nadir may occur later than expected, or blood cell monitoring should be more frequent.

  • This patient experienced hand-foot syndrome following the second dose of concurrent chemotherapy with 5-FU in late March 2023. The patient is currently undergoing FOLFOX treatment. If hand-foot syndrome reoccurs, it may be advisable to omit the 5-FU bolus.

  • The patient has underlying kidney concerns, and the NSAID Celebrex (celecoxib) is currently prescribed as needed. If the primary purpose of using celecoxib is for pain management, considering an alternative like acetaminophen could be less harmful to the kidneys.

    • 2023-05-15 BUN 34 mg/dL
    • 2023-05-15 Creatinine 1.42 mg/dL
    • 2023-05-15 eGFR 53.18

2023-02-24

[assessment]

  • No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

701346431

230512

{malignant neoplasm of unspecified site of left female breast, cT4aN3M1, stage IV}

[exam findings]

  • 2023-01-17 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the skull, some T- and L-spines, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
    • IMPRESSION:
      • In comparison with the previous study on 2021/11/08, most of the previous bone lesions are either less evident or disappeared. The scintigraphic findings suggest multiple bone metastases with some resolution.
  • 2023-01-17, 2022-12-28, -12-07, -11-14, -10-24, -09-29, -08-29, -08-05, -07-11, -06-14 - CXR
    • A nodular opacity projecting in the left middle lung shows stationary. Follow up is indicated.
    • Left CP angle Pleura effusion or thickening.
    • Left hemi-diaphragm elevation is noted, which may be due to eventration or left lower lung volume decrease.
    • Spondylosis with scoliosis of the T-spine with convex to right side
    • S/P Mastectomy, left.
  • 2022-11-16 CT - chest
    • Indication: Malignant neoplasm of unspecified site of left female breast
    • Findings - Comparison was made with previous CT dated on 20220713
      • Lungs:
        • There is interlobular septal thickening and ground-glass opacities in both lungs scatteredly, seem stationary.
        • Mediastinum and hila: a well-defined fluid density mass (33mm in longest dimension) at left thymic bed. no enlarged LN.
      • Vessels:
        • Aorta: normal caliber of thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: dilated LA and LV.
      • Pleura: minimla Rt and small Lt effusions.
      • Chest wall and visible lower neck: interval increase in size infiltrative bilateral breast tumors with overlying skin thickening as compared with previous CT.
        • two small thyroid cysts or nodules.
      • Visible abdominal-pelvic contents:
        • two small Rt hepatic cysts and an ill-defined hypodense lesion at S4 is still visible. a 5mm Lt renal cyst.
        • several small stones in gallbladder. unremarkable of the spleen, both adrenal glands, pancreas, and Rt kidney.
        • no enlarged lymph node.
      • Visualized bones: compression fracture of T7 and blastic metastasis in pedicle of T8.
    • Impression:
      • both breast cancers with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, in progression compared with CT on 20220713, a thymic cyst.
  • 2022-07-13 CT - chest
    • both breast cancers, statiionary, with pulmonary lymphangitic carcinomatosis and hepatic and bony metastases, stationary, a thymic cyst.
  • 2022-04-02 CT - chest
    • Breast cancer at both breast, in regression.
    • Diffuse intersitial change at both lungs. suspected lymphangitis carcinomatosis.
    • Bone meta and liver meta.
  • 2022-01-19 Cell Block
    • Smears and cell blockshow lymphocytes, reactive mesothelial cells, and clusters of large, pleomorphic tumor cells.
    • IHC: CK(+), GATA3(+), and Calretinin(-).
    • The results are consistent with metastatic breast carcinoma.
  • 2021-12-28 Pleural Effusion
    • 50 cc yellow cloudy pleural effusion
    • The smears show lymphocytes, reactive mesothelial cells and a few hyperchromatic atypical cell clusters, compatible with metastatic carcinoma.
  • 2021-11-09 Patho - breast biopsy
    • pathologic diagnosis
      • Breast, right, biopsy - Invasive carcinoma of no special type
      • The sections show invasive carcinoma of no special type, composed of breast tissue with nests and cords of polygonal neoplastic cells, embedded in fibrous stroma.
      • IHC:
        • ER (Ab): Negative
        • PR (Ab): Negative
        • HER-2/Neu (Ab): Positive (score= 3+)
        • Ki-67: 25%
  • 2021-11-08 Tc-99m MDP whole body bone scan with SPECT
    • The scintigraphic findings suggest multiple bone metastases in the skull, some T- and L-spine, sacrum, sternum, left scapula, bilateral multiple ribs, multiple pelvic bones, S-I joints, and femurs.
    • Increased tracer uptake at bilateral shoulders, the nature is to be determined (bone mets, DJD, or other nature ?)
  • 2021-11-08 SONO - Breast
    • Bilateral breast tumors with left axillary lymph node, suspected malignancy.
    • BI-RADS: Category 5 - highly suggestive of malignancy, appropriate action should be taken.
  • 2021-11-04 Pleural Effusion
    • diagnosis: Adenocarcinoma
    • smears show tumr cells with large hyperchromatic nuclei, pleomorphism, prominent nucleoli and mitoses.

[surgical operation]

  • 2021-11-09
    • Surgery
      • Port-A insertion, R’t after R’t cephalic vein exploration        
      • R’t breast tumor core biopsy under sonography guided       
    • Finding
      • We explore and identify the R’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
      • A 5x5x5 cm hard tumor over R’t subareolar region       

[chemoimmunotherapy]

  • 2023-02-10 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2023-01-16 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 105mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-12-28 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-12-07 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-11-14 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-10-25 - trastuzumab 6mg/kg 280mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-09-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 250mL
  • 2022-08-30 - trastuzumab 6mg/kg 290mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg + NS 500mL
  • 2022-08-05 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-07-12 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-06-15 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-05-20 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-04-21 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-03-31 - trastuzumab 6mg/kg 300mg NS 250mL 90min + pertuzumab 420mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-03-08 - trastuzumab 8mg/kg 400mg NS 250mL 90min + pertuzumab 840mg NS 250mL 1hr + docetaxel 75mg/m2 100mg NS 250mL 1hr (loading)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL
  • 2022-02-11 - docetaxel 75mg/m2 100mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + metoclopramide 10mg + NS 250mL
  • 2022-01-20 - doxorubicin 60mg/m2 80mg NS 100mL 10min + cyclophosphamide 600mg/m2 800mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-12-28 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-12-03 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-11-12 - doxorubicin 60mg/m2 90mg NS 100mL 10min + cyclophosphamide 600mg/m2 900mg NS 250mL 90min
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[blood WBC]

  • 2023-02-10 WBC 7.41 *10^3/uL
  • 2023-02-01 WBC 10.99 *10^3/uL
  • 2023-01-15 WBC 12.72 *10^3/uL
  • 2023-01-06 WBC 3.91 *10^3/uL
  • 2022-12-28 WBC 9.28 *10^3/uL
  • 2022-12-16 WBC 3.59 *10^3/uL
  • 2022-12-07 WBC 8.85 *10^3/uL
  • 2022-11-25 WBC 16.46 *10^3/uL
  • 2022-11-14 WBC 7.13 *10^3/uL
  • 2022-11-04 WBC 15.00 *10^3/uL
  • 2022-10-26 WBC 4.23 *10^3/uL
  • 2022-10-24 WBC 6.53 *10^3/uL
  • 2022-10-07 WBC 2.24 *10^3/uL
  • 2022-09-29 WBC 6.27 *10^3/uL
  • 2022-09-09 WBC 7.98 *10^3/uL
  • 2022-08-29 WBC 5.24 *10^3/uL
  • 2022-08-17 WBC 14.06 *10^3/uL
  • 2022-08-05 WBC 8.61 *10^3/uL
  • 2022-07-27 WBC 9.02 *10^3/uL
  • 2022-07-11 WBC 6.59 *10^3/uL
  • 2022-06-24 WBC 6.87 *10^3/uL
  • 2022-06-14 WBC 6.48 *10^3/uL
  • 2022-05-27 WBC 2.86 *10^3/uL
  • 2022-05-19 WBC 6.17 *10^3/uL
  • 2022-04-29 WBC 2.90 *10^3/uL
  • 2022-04-20 WBC 6.51 *10^3/uL
  • 2022-04-08 WBC 5.58 *10^3/uL
  • 2022-03-30 WBC 5.88 *10^3/uL
  • 2022-03-16 WBC 1.72 *10^3/uL
  • 2022-03-08 WBC 3.99 *10^3/uL
  • 2022-02-18 WBC 0.84 *10^3/uL
  • 2022-02-11 WBC 7.70 *10^3/uL
  • 2022-02-04 WBC 5.58 *10^3/uL
  • 2022-01-26 WBC 7.65 *10^3/uL
  • 2022-01-24 WBC 2.41 *10^3/uL
  • 2022-01-18 WBC 4.81 *10^3/uL
  • 2022-01-07 WBC 0.60 *10^3/uL
  • 2021-12-31 WBC 4.52 *10^3/uL
  • 2021-12-27 WBC 11.22 *10^3/uL
  • 2021-12-10 WBC 1.82 *10^3/uL
  • 2021-12-03 WBC 8.73 *10^3/uL
  • 2021-12-01 WBC 4.32 *10^3/uL
  • 2021-11-27 WBC 25.99 *10^3/uL
  • 2021-11-25 WBC 2.41 *10^3/uL
  • 2021-11-23 WBC 0.75 *10^3/uL
  • 2021-11-22 WBC 0.69 *10^3/uL
  • 2021-11-19 WBC 1.92 *10^3/uL
  • 2021-11-17 WBC 2.64 *10^3/uL
  • 2021-11-12 WBC 5.80 *10^3/uL
  • 2021-11-10 WBC 5.34 *10^3/uL
  • 2021-11-08 WBC 7.80 *10^3/uL
  • 2021-11-04 WBC 7.79 *10^3/uL

[G-CSF]

  • Granocyte (lenograstim) CGRAN01
    • 2022-02-18 ~ 2022-02-20 250ug SC 2022-02-18 IPD
    • 2022-01-07 ~ 2022-01-09 250ug SC 2022-01-07 IPD
    • 2021-11-22 250ug SC 2021-11-04 IPD
  • Neulasta (pegfilgrastim) CNEUL01
    • 2022-10-02 6mg SC 2022-09-29 IPD
    • 2022-08-08 6mg SC 2022-08-05 IPD
    • 2022-07-14 6mg SC 2022-07-11 IPD
    • 2022-04-02 6mg SC 2022-03-30 IPD
    • 2022-03-11 6mg SC 2022-03-08 IPD
    • 2022-01-24 6mg SC 2022-01-18 IPD

==========

2023-05-12

[tube feeding]

As of 2023-05-12, the patient’s serum potassium level was measured at 3.2 mmol/L. Currently, Const-K is the only oral potassium supplement available in this hospital. If intravenous potassium supplementation is not the preferred method, it’s recommended to crush the Const-K tablet into small enough particles to pass through the feeding tube, and administer the supplement with sufficient water. It’s preferable to give this medication with meals due to its original extended-release design.

2023-02-13

  • 2023-01-17 bone scan showed most of the previous bone lesions are either less evident or have disappeared in comparison with the previous study on 2021-11-08.
  • According to the CT scan performed on 2022-11-16, both breast cancers had pulmonary lymphangitic carcinomatosis and hepatic and bony metastases that were in progression, as compared to the earlier CT scan performed on 2022-07-13.

2022-11-15

  • 2022-11-16 CT scan suggested that the disease was progressing.
  • Following the administration of AC-THP (doxorubicin and cyclophosphamide followed by docetaxel, trastuzumab, and pertuzumab) for one year (since November 2021), it seems that the disease has gradually developed resistance to these drugs.
  • The subsequent line treatment options for the patients with HER2+ metastatic breast cancer might include trastuzumab emtansine or lapatinib, which are covered by NHI, and trastuzumab deruxtecan, which is not covered by NHI at this time.

2022-03-09

  • The patient is diagnosed with breast cancer cT4aN3M1 stage IV and bone mets, and she is fitted with AC followed by docetaxelc + trastuzumab + pertuzumab regimen (the latter two drugs started on 2022-03-08).

701465142

230511

[past history]

  • Heart:(-)

  • Chest:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-)

  • Surgical:

    • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) Paraaortic lymphadenectomy on 2022/12/29
    • Port implantation on 2023/01/31
  • Menstrual history: G2P2, menopause at age of 48

[allergy]

  • NKDA     

[family history]

  • There is no family history of cancer,hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[lab data]

2023-01-11 Anti-HBc Nonreactive
2023-01-11 Anti-HBc-Value 0.89 S/CO
2023-01-11 Anti-HBs 329.77 mIU/mL
2023-01-11 Anti-HCV Nonreactive
2023-01-11 Anti-HCV Value 0.07 S/CO
2023-01-11 HBsAg Nonreactive
2023-01-11 HBsAg (Value) 0.31 S/CO

[exam findings]

  • 2023-04-22 CT - abdomen
    • History and indication: Endometrioid carcinoma of the right ovary s/p Debulking surgery and paraaortic lymphadenectomy on 2022/12/29, pT1cN0M0, stage IC1, FIGO IC1, s/p chemotherapy with Taxol(175mg/m2)/Carboplain(AUC:6) from 2023/02/17
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Tumors (4.7cm, 7.9cm) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Recurrent tumors (4.7cm, 7.9cm, progression) at pelvic cavity with adjacent structures invasion causing right hydronephrosis and hydroureter. Some small LNs at retroperitoneum.
  • 2023-02-16 MRI - pelvis
    • Clinical history: 54 y/o female patient with Malignant neoplasm of unspecified ovary.
    • With and without contrast enhancement CT of abdomen - whole:
      • S/P hysterectomy and oophorectomy.
      • There is irregular soft tissue tumors, 5x4.9cm (RLQ) and 1.2cm in lower abdomen, suspected recurrence.
      • Cystic lesion in bilateral pelvic side wall regions (right 2.7x1.3cm and left 3.2x1.3cm), suspected lymphocele.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • Presence of some ascites in the pelvic cavity.
    • Impression:
      • S/P hysterectomy and oophorectomy. Suspected recurrnt tumors in lower abdomen.
      • Suspected lymphocele in the pelvic cavity. (Lymphoceles are collections of lymphatic fluid)
  • 2023-02-08 Gynecologic ultrasonography
    • ATH + BSO
    • Asictes (+)
  • 2023-02-07, -01-31 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-07 Mammography (magnification)
    • Dense calcifications in left breast, LOQ (around 6’region), suggest close follow up.
    • BI-RADS: Category 3: probably benign finding-short interval follow-up suggested.
  • 2023-02-07 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 13 dB HL; LE 16 dB HL
    • bil normal to moderate SNHL
  • 2023-01-12 Mammography
    • Screening digital mammography of both breasts with MLO and CC views:
    • Findings
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There is no obvious mass lesion.
      • No obvious architectural distortion.
      • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
      • No periareolar skin thickening.
      • No enlarged axillary lymph node.
    • Impression:
      • Dense breast.
      • Group amorpohrus microcalcificatios in left breast, LIQ of left breast (around 6’region posterior third portion), suggest spot magnification study.
      • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2023-01-11 SONO - breast
    • Benign neoplasm of breast, infavor of benign fibrocystic disease(FCD)
    • Regular OPD follow-up
    • BI-RADS 2 - Benign Finding
  • 2022-12-29 Patho - ovary (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, salpingo-oophorectomy (tumor intra-operative rupture) —- carcinoma.
        • IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-). Please check urinary tract and breast.
      • Ovary, left, salpingo-oophorectomy —- endometrioma
      • Fallopian tube, right, salpingo-oophorectomy —- free
      • Fallopian tube, left, salpingo-oophorectomy—– free
      • Uterus, corpus, total hysterectomy — myoma; atrophic endometrium.
      • Uterus, cervix, total hysterectomy — free
      • Omentume, omentectomy —- endometriosis.
      • Lymph node, bilateral pelvic and left para-aortic, dissection — Free.
    • MACROSCOPIC EXAMINATION:
      • Procedure-Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy) : Uterus: 170 gms, 13 x 8 x 5 cm; myoma: 7 x 5 x 3 cm; omentum: 31 x 15 x 3 cm, endometriosis; right ovary: 21 x 15 x 6 cm. Solid part: 12 x 9 x 5 cm.   
        • Pleurocentesis (pleural fluid)
      • Specimen size:
        • right ovary: 21 x 15 x 6 cm; cystic; solid part: 12 x 9 x 5 cm
        • left ovary: 2 x 1.5 x 1.4 cm;
        • right tube: 5 x 0.5 x 0.5 cm;
        • left tube: 5 x 0.5 x 0.5 cm;
        • uterus: 13 x 8 x 5 cm.
      • Specimen Integrity:
        • Specimen Integrity of Right Ovary- ruptured: intra-operative ruture
        • Specimen Integrity of Left Ovary -Capsule intact
        • Specimen Integrity of Right Fallopian Tube-Serosa intact
        • Specimen Integrity of Left Fallopian Tube- Serosa intact
      • Tumor Site: right ovary
      • Ovarian Surface Involvement - Absent
      • Fallopian Tube Surface Involvement - Absent
      • Tumor Size - 12 x 9 x 5 cm
      • Greatest dimension (centimeters): 12 cm
      • Additional dimensions (centimeters): 9 x 5 cm
      • Sections are taken and labeled as: A: left iliac lymph nodes; B: left obturator lymph nodes; C: right iliac lymph nodes; D: right obturator lymph nodes; E: left para-aortic lymph nodes; F: omentum; G1: cervix; G2: myoma; G3: endometrium; G4: right tube; G5: left adnexa; H1-5: right ovary (H1-3: solid part; H4-5: non-solid part).
    • MICROSCOPIC EXAMINATION:
      • Histologic type: carcinoma; please check urinary tract and breast. IHC stains: CK7 (+), CK20 (-), GATA-3 (+), PAX-8 (-), CDX-2 (-), P40 (-), Napsin-A (-).
      • Histologic grade: grade 3
      • Contralateral ovary involvement: absent
      • Tumor side ovarian surface involvement: absent
      • Contralateral ovary surface involvement: absent
      • Right tube involvement: absent
      • Left tube involvement: absent
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: absent
      • Uterine serosa involvement: absent
      • Omentum involvement: absent
      • Uterine Cervix involvement: absent
      • Endometrium involvement: absent
      • Myometrium involvement:absent
      • Appendix involvement: absent
      • Largest Extrapelvic Peritoneal Focus -none.
      • Peritoneal/Ascitic Fluid- N2022-04855: Negative
      • Regional Lymph Nodes: free
        • Negative for metastasis: describe locations (0/17) = A: left iliac lymph nodes (0/4); B: left obturator lymph nodes (0/1); C: right iliac lymph nodes (0/3); D: right obturator lymph nodes (0/2); E: left para-aortic lymph nodes (0/7).
      • Other organs or specimens involvement: absent.
  • 2022-12-21 CT - abdomen - urinary bladder
    • Hx: P2 NSDX2, menopause at the age of 48
      • patient noticed that she has the tumor over the right side of the ovary, she has regular follow up, covid (+) in May 2022
      • BW decreased from 72kg -> 58kg, difficulty of voiding
      • 20221221 CA125 427U/mL (<35), CA199 231U/mL (<35), CEA normal.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a huge cystic mass with enhancing mural nodules in the lower abdomen and pelvis, measuring 22.4 x 14 x 28 cm (width x depth x cranial-caudal length).
        • The uterus shows right lateral displacement.
        • Cystic adenocarcinoma of left ovary is highly suspected.
        • Please correlate with clinical oondition.
      • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Cystic adenocarcinoma of left ovary is highly suspected. Please correlate with clinical oondition.
      • There are several enlarged nods in para-aortic space and bilateral inguinal area. please correlate with clinical condition.
  • 2022-12-21 Gynecologic ultrasonography
    • Huge pelvis mass size over: 345x178mm with papillary: (1) 91x36mm (2) 51x39mm
    • Adenomyosis

[consultation]

  • 2023-02-17 Dermatology
    • Q
      • The 54 y/o ovary cancer with disease progress. Due to left heel skin itchy with redness, so we need your help for assessment. Thanks!
    • A
      • This patient suffered from erytheamtous papules on bil feet for days
      • Imp: Subacute dermatitis
      • Suggestion
        • Sinpharderm x 1 tube/bid
        • Topsym cream x 3 tubes/bid

[MedRec]

  • 2023-03-09 SOAP Hemato-Oncology
    • O
      • Now on C/T with TP
      • AE: Gr 2 Anemia
  • 2023-03-01 SOAP Hemato-Oncology
    • O
      • Cancer Treatment Radiotherapy/Targeted Therapy Side Effect Evaluation
        • Decreased white blood cells: G1: 3000 - 4000/mm3
        • Decreased white blood cells [Management]: Observation
  • 2023-02-07 ~ 2023-02-20 POMR Hemato-Oncology
    • Discharge diagnosis
      • Malignant neoplasm of unspecified ovary
      • Fever, unspecified
      • Vaginitis, U/C: Gardnerella vaginalis
      • Subacute dermatitis
    • Course of Inpatient Treatment
      • After admission, will do schedule chemotherapy, but fever was noted without chillness, check lab and follow up culture for infection survey.
      • Empirical antibiotic with Cefuroxime 750mg/vial 1500mg IVD Q8H from 2023/02/07, Acetal 500 mg/tab 1# PO PRNQ6H if BT > 38.3’C. and consult GYN for check Gynecologic ultrasonography on 2023/02/08, no special finding.
      • Naproxen 250 mg/tab 0.5# PO BID for suspect tumor fever, close monitor -> DC 2/10, start from 2/16.
      • Due to urine/culture showed Gardnerella vaginalis, given Metrozole 250mg/tab 2# PO BID 7days from 2023/02/10 to 2023/02/17.
      • Before chemotherapy, PTA and 24 Ccr were done. PTA on 2023/02/07 showed bil normal to moderate SNHL. 24hrs CCr, urine output 3700ml, CCr 70.9mL/min.
      • Mammography (Magnification) on 2023/02/07 showed dense calcifications in left breast, LOQ (around 6’region), probably benign finding.
      • Pelivs MRI for survey on 2023/02/16 showed S/P hysterectomy and oophorectomy, R/O recurrent tumors in lower abdomen, R/O lymphocele in the pelvic cavity.
      • Pre-medication as Dorison 20mg PO on 2/16 23:00 and 2/17 05:00, chemotherapy as C1 Paclitaxel 175mg/2 + Carboplatin 150mg/15mL/vial (AUC 6) on 2023/02/17.
      • Consult for erytheamtous papules on bil feet for days, suggest Sinpharderm x 1 tube/bid、Topsym cream x 3 tubes/bid use. Patient tolerated the chemotherapy without nausea and vomiting.
      • With the stable condition, she/he was discharged on 2023/02/20 and OPD followed up later.   
    • Prescription
      • naproxen 250mg 0.5# BID
      • Smecta (dioctahedral smectite 3mg) 1# PRNQ8H (if watery diarrhea > 3 times)
      • Sinpharderm Cream (urea) BID TOPI (for subacute dermatitis)
      • Topsym Cream (fluocinonide) BID EXT (for subacute dermatitis)
      • Sketa (acetaminophen 300mg, chlorzoxazone 250mg) 1# TID
  • 2023-02-02 SOAP Hemato-Oncology
    • O
      • Conclusion of the Multidisciplinary Cancer Team Meeting, Meeting Date: 20230105
        • Treatment Plan: Arrange cystoscopy (GATA-3+) and breast ultrasound examination, and then refer to the hematology department for further evaluation.
    • A/P
      • Lab
      • RTC by herself
      • Waiting for the conclusion from Breast and GU
      • Arrange admission with magnification Mammography and then C/T

[surgical operation]

  • 2022-12-29
    • Surgery
      • Diagnosis: Cystic adenocarcinoma of right ovary s/p debulking surgery.
    • Operation
      • Debulking surgery (ATH + BSO + BPLND + infracolic omentectomy)    
      • Paraaortic lymphadenectomy

[chemotherapy]

  • 2023-05-02 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-04-24 - topotecan 1.5mg/m2 2.3mg NS 70mL 30min + gemcitabine 1000mg/m2 1400mg NS 250mL
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-03-13 - paclitaxel 175mg/m2 270mg NS 300mL 3hr + carboplatin AUC 6 510mg NS 300mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-17 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 6 570mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL

2023-05-11

[assessment]

  • The PharmaCloud database reveals that the patient’s recent drugs have all been prescribed at our hospital. Currently, there are no issues detected with medication reconciliation in the active prescription.

  • The patient’s anemia, as evidenced by a decrease in hemoglobin level from 10.2 g/dL on 2023-05-02 to 8.1 g/dL on 2023-05-09, is currently being treated with a transfusion of 2 units of packed red blood cells (P-RBC), scheduled for 2023-05-11, as indicated.

  • The patient’s lab data reveals a decreasing trend in serum albumin levels, raising the possibility of a protein-losing gastroenteropathy. However, current records do not indicate the presence of edema, ascites or pleural and pericardial effusions. Furthermore, liver and kidney function appear to be within or not far from normal ranges based on the lab data, suggesting that heavy proteinuria or impaired protein synthesis due to liver disease are less likely causes. It is recommended to encourage the patient to pay more attention to nutritional supplementation to prevent malnutrition.

    • 2023-05-09 Albumin 2.8 g/dL
    • 2023-05-02 Albumin 3.1 g/dL
    • 2023-04-19 Albumin 3.0 g/dL
    • 2023-04-12 Albumin 3.1 g/dL
    • 2023-03-30 Albumin 3.1 g/dL
    • 2023-03-23 Albumin 3.1 g/dL
    • 2023-03-09 Albumin 3.2 g/dL
  • Intestinal leakage of plasma proteins occurs via one of the following mechanisms:

    • Inflammatory exudation: Mucosal injury results in exudation of protein-rich fluids across the eroded epithelium. The degree of mucosal involvement typically correlates with the severity of protein loss.
    • Increased mucosal permeability: Altered integrity of the mucosa of the stomach, small bowel, and colon due to inflammatory, infiltrative, and genetic causes results in protein leakage into the lumen.
    • Intestinal loss of lymphatic fluid: Lymphatic obstruction, congenital abnormalities of the lymphatic system, or disorders of increased central venous pressure (eg, congestive heart failure or constrictive pericarditis) result in increased lymphatic pressure.
  • The CT scan on 2023-04-22 revealed recurrent tumors in the pelvic cavity measuring 4.7cm and 7.9cm, respectively. These tumors have invaded adjacent structures, causing right hydronephrosis and hydroureter, and lymph nodes are also evident in the retroperitoneum. These findings might be related to the observed clinical phenomena mentioned above?

2023-03-14

[assessment]

  • On 2023-03-13, the second cycle of paclitaxel/carboplatin began with the addition of antiemetics (palonosetron and aprepitant) and a larger volume of normal saline for each drug compared to the first cycle which began on 2023-02-17. Specifically, the volume for both paclitaxel and carboplatin was increased from 250mL to 300mL.
  • Based on the available lab data, the patient’s HGB levels have been often below 10g/dL, and since mid-Feb, they have decreased to below 9g/dL. On 2023-03-13, the patient received a blood transfusion of 2 units of LPRBC. Please continue to monitor changes in blood cell count as always.
  • Thre is no medication reconciliation issue found in the patient.

700536063

230509

[diagnosis] - 2023-03-23 admission note

  • Adenocarcinoma of gastric antrum, pT3N1 (1/48) M0, Stage IIB, s/p Op.
  • Diabetes mellitus, type 2
  • Hypertension
  • Viral hepatitis B anti-Hbc: positive

[past history]

  • medical
    • Anemia
    • Diabetes mellitus, type 2
    • Hypertension
  • operation
    • Gallballder stones status post laparoscopic cholecystectomy on 2022/02/14

[allergy]

  • NKDA                                         

[family history]

  • Father had history of hypertension, colo-rectal cancer
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-01 CT - abdomen
    • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
      • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
      • 20220629 CT:gastric antrum cancer, cT3N1M0, cSTAGE:III
      • 20220711 S/P subtotal gastrectomy:pT3N1 (1/48) M0, Stage IIB
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P subtotal gastrectomy and S/P cholecystectomy.
      • Prior CT identified Adenoma or hyperplasia 1.2 cm in left adrenal gland is noted again, stationary.
      • A renal cyst 1.5 cm in right middle-lower pole is noted.
    • Impression:
      • There is no evidence of tumor recurrence.
  • 2022-09-28 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis with scoliosis of the T-spine with convex to right side
  • 2022-07-12 Patho - stomach subtotal/total (tumor)
    • pathologic diagnosis
      • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated
      • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
    • microscopic examination
      • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the subserosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Absent
      • Regional lymph nodes: Metastatic adenocarcinoma (1/48)
        • 0/3 (omentum), 0/5 (LN 1), 1/8 (LN 3), 0/10 (LN 4), 0/2 (LN 5), 0/5 (LN 6), 0/15 (LN 7, 8, 9, 11p), 0 (LN 12a), 0 (LN14v) (Number of LN involved/Number of LN examined) 3
      • Extracapsular extension: Absent
      • Omentum: free of tumor invasion
      • Additional pathologic findings: Helicobacter-associated non-atrophic chronic gastritis
      • Pathologic Staging: pT3N1, stage IIB, if cM0
      • IHC: HER2 (Negative, score= 1+)
  • 2022-07-07 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 43) / 118 = 63.56%
      • M-mode (Teichholz) = 63
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
  • 2022-07-05 ECG
    • Sinus tachycardia
    • Septal infarct, age undetermined
  • 2022-06-29 CT
    • History: General fatigue for months, poor appetite ++, epigastric discomfort +, Anemia (Hb 8.2), stool: OB 4+
      • 20220622 gastroscopy: One raised and nodularity mucosa lesion with clean base ulcer was noted at LC site of low body to antrum, suspected cancer, s/p biopsy. Patho: adenocarcinoma.
    • Indication: CT for gastric cancer staging
    • Findings:
      • There is lobulated wall thickening at the gastric low body and antrum, measuring 2.1 cm in wall thickness that is c/w adenocarcinoma (T3).
      • There are two lymph nodes in the gastrohepatic ligament that may be metastatic nodes (N1).
      • Adenoma 1.2 cm in left adrenal gland is suspected.
      • A renal cyst 1.5 cm in right middle-lower pole is noted.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N1 (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2022-06-22 Patho - stomach biopsy
    • Stomach, angle to LC site of antrum, biopsy — Adenocarcinoma
    • Microscopically, the sections show a picture of adenocarcinoma, poorly differentiated, characterized by tumor cells arranged in crowded nest or tubular pattern with enlarged and hyperchromatic nuclei infiltrating in ulcerative stroma with mild intestinal metaplasia.
    • Immunohistochemistry of CK(+), P53(+) and Her2/neu (2+, equivocal) for tumor.
  • 2022-06-22 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric mucosa lesion with ulcer, LC site of low body to antrum, s/p biopsy, suspected gastric cancer
      • Duodenal ulcer scar, bulb, AW site
    • Suggestion
      • PPI use
      • Pursue CLO test and biopsy result
  • 2022-02-14 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis and cholelithiasis
  • 2022-02-11 SONO - abdomen
    • Diagnosis
      • Fatty liver, moderate
      • Suspected fatty infiltration of pancreas
      • Propable GB stones
      • Heterogeneous echogenecity in somach and duodenum area(?). Please correlate with EGD
      • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
    • Suggestion
      • OPD f/u
      • Follow liver function test and AFP
      • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
      • Because of poor echo window,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months

[consultation]

  • 2022-10-17 Cardiology
    • Q
      • The 67 y/o woman has gastric cancer, stage IIB. She was admitted for chemotherapy. She regular take anti-hypertension from CV OPD. We need your help for hypertension assessment. Thanks!
    • A
      • This is a 67 years old lady who has gastric cancer for chemotherapy with FOLFOX (self-paid) IV Q2W x 12 on 20221017.
      • He recieved sevkiar and natrilix at CV OPD for BPcontrol.        
      • BP on 20221017
        • 192/ 94
        • 205/107
        • 211/115
        • 226/105
        • 141/ 82
      • Cardiac echo 2020/07/07
        • Echo EF: 63%
        • Adequate LV systolic function with normal resting wall motion
        • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
        • Mild MR and trivial TR
        • Preserved RV systolic function
      • EKG: 20220705 sinus tachycardia
      • CXR 20220928 no cardiomegaly
      • echocardiogram 20220707
        • Findings:
          • AO(mm) = 31; LA(mm) = 42;
          • IVS(mm) = 12; LVPW(mm) = 9;
          • LVEDD(mm) = 50; LVESD(mm) = 32;
          • LV mass(gm) = 201;
          • TAPSE(mm) = 27;
          • M-mode(Teichholz) = 63
          • TR: Trivial; Max pressure gradient = 27 mmHg
          • E/A ratio = 0.6
          • IVC size 14 mm with respiratory collapse > 50%
        • Conclusion:
          • Adequate LV systolic function with normal resting wall motion
          • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
          • Mild MR and trivial TR
          • Preserved RV systolic function
      • Impression
        • Hypertensive cardiovascular disease.
      • Suggestion
        • Keep sevikar + natrilix as OPD
        • Might add norvasc 1# qd and hydralazine 1# prn-Q8h if SBP > 160mmhg
        • If still poor control, add nebivolol 1# qd
        • Watch sleeping condition or pain status
  • 2022-07-20 Hemato-Oncology
    • Q
      • This 66-year-old female had history of
        • Anemia
        • Diabetes mellitus, type 2
        • Hypertension
      • She was a case of Adenocarcinoma of gastric antrum, poorly differentiated, cT3N1M0
      • Laparoscopic subtotal gastrectomy, D2 LN dissection with B-II gastrojejunostomy anastomosis was done on 20220711
      • Pathology revealed
        • Stomach, subtotal gastrectomy — Tubular adenocarcinoma, poorly differentiated (G3)
          • Tumor site: Antrum, lesser curvature, 3.2 cm from distal margin
          • Tumor size: 6.1 x 4.8 cm
        • Margins, bilateral cutting ends, subtotal gasdtrectomy — Free of tumor invasion
        • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (1/48), LN3
        • Omentum, omentectomy — Free of tumor invasion
        • AJCC Pathologic staging — pT3N1 (if cM0), stage IIB
      • We need your expertise for post-op chemotherapy +/- radiotherapy
    • A
      • Impression:
        • Adenocarcinoma of gastric antrum s/p Radical subtotal gastrectomy with D2 LN dissection on 20220711, pT3N1M0, stage IIB, pathology show tubular adenocarcinoma, poorly differentiated(G3), HER-2 negative
        • Diabetes mellitus, type 2
        • Hypertension
      • Suggestion:
        • Postoperative chemotherapy is recommended following primary D2 lymph node dissection (Capecitabine and oxaliplatin (category 1) or Fluorouracil and oxaliplatin)
        • Arrange port A insertion and arrange our OPD after discharge
        • Please check HbsAg, Anti Hbc, Anti HCV
      • PostOperative Chemotherapy (for patients who have undergone primary D2 lymph node dissection)
        • Capecitabine and oxaliplatin
          • Capecitabine 1000 mg/m2 PO BID on Days 1–14
          • Oxaliplatin 130 mg/m2 IV on Day 1
          • Cycled every 21 days for 8 cycles
        • Fluoropyrimidine and oxaliplatin
          • 1
            • Oxaliplatin 85 mg/m2 IV on Day 1
            • Leucovorin 400 mg/m2 IV on Day 1
            • Fluorouracil 400 mg/m2 IV Push on Day 1
            • Fluorouracil 1200 mg/m2 IV continuous infusion over 24 hours daily on Days 1 and 2
            • Cycled every 14 days
          • 2
            • Oxaliplatin 85 mg/m2 IV on Day 1
            • Leucovorin 200 mg/m2 IV on Day 1
            • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
            • Cycled every 14 days

[surgical operation]

  • 2022-07-11
    • Surgery
      • Radical subtotal gastrectomy with D2 LN dissection
    • Finding
      • 7 * 5 cm ulcerative mass at lesser curvature of antrum
      • Previous cholecytectomy
      • Omentum adhension
    • Procedure
      • ETGA
      • 12-12-5-3.5 mm trocars
      • Adhesiolysis
      • subtotal gastrectomy with 1,3,4,5,6,7,8,9,11p,12a,14v LN dissection
      • Frozen section : margin free of carcinoma
      • GJ B-II anastomosis with EndoGIA
      • two J-vac inserted
      • wound closed
  • 2022-02-14
    • Surgery
      • LC
    • Finding
      • two 1.2cm pigment stones iwth chroinc inflam
    • Procedure
      • ETGA
      • 10-5-3.5 mm trocars
      • cholecystectomy
      • wound closed

[radiotherapy]

  • 2022-10-31 ~ 2022-12-02 - completed RT to the stomach and adjacent lymphatic drainage area: 45 Gy/ 25 fx.

[chemotherapy]

  • 2023-05-08 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4695mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-12 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-23 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-07 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-30 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL + fluorouracil 2800mg/m2 4670mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + aprepitant 125mg PO
  • 2022-11-28 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-24 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-07 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-5 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-11-02 - + fluorouracil 200mg/m2 330mg NS 500mL 24hr D1-3 (CCRT QW)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + NS 250mL
  • 2022-10-18 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4685mg 46hr
  • 2022-09-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
  • 2022-09-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4715mg 46hr
  • 2022-08-29 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
  • 2022-08-15 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr

==========

2023-03-08

  • The patient’s underlying diabetes mellitus is well controlled. However, on admission to the hospital, her systolic blood pressure was found to be over 200 mmHg. Her current blood pressure is 142/65 mmHg.
  • Based on the lab data resulted on 2023-03-23, the patient’s results were generally within normal limits. In addition, no medication reconciliation issues were noted for the patient.

2022-11-25

  • The results of the laboratory test on 2022-11-24 were generally normal.
  • A pre-prandial blood sugar level was recorded as 181 mg/dL (2022-11-25 07:20) this morning. It might be necessary to consider additional anti-diabetic agents if the reading persists high (> 180 mg/dL) for two consecutive days.
  • Around the ULN, blood pressure fluctuates up and down. Please keep a close eye on the reading as always.

2022-09-13

  • The underlying conditions of HTN and T2DM were treated with the patient-carried medications Natrilix (indapamide), Sevikar (amlodipine + olmesartan) and Xigdou (dapagliflozin + metformin) without extremely outlier findings during this hospitalization.
  • The results of the laboratory test on 2022-09-12 were grossly normal.

2022-08-16

  • As there is no fluorouracil bolus used in the current chemotherapy regimen, the dose of leucovorin may be reduced to 200mg/m2.

700598723

230509

{not completed}

[MedRec]

  • 2023-03-02 SOAP Hemato-Oncology
    • A/P
      • Ovary, left, left salpigo-oophorectomy (20230220) — pT1c2 pN0 (if cM0); pStage: IC; FIGO stage: IC2 with clear cell component
      • Her sister worked in another hospital.
  • 2023-02-17 SOAP Obstetrics and Gynecology
    • S
      • a case of ovarian endometiroid adenocarcinoma, s/p LSC LSO + pelvic adhesion lysis + TCR-P on 2023/02/09
    • O
      • Cancer Multidisciplinary Team Meeting Conclusion, meeting date: 20230216
        • Postoperative adjuvant chemotherapy (referred to hematoma department Dr. Wan Xianglin / patient expressed desire to preserve fertility).
        • Consensus on the period: pT1c2N0M0, FIGO IC2. -> Suggest staging/debulking surgery due to pathology revealing clear cell carcinoma.

[chemotherapy]

  • 2023-05-08 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-14 - paclitaxel 70mg/m2 100mg NS 250mL 1hr + carboplatin AUC 2 565mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

  • Prior to the current chemotherapy session, WBC counts were observed to decrease approximately one week after the previous two sessions on 2023-03-14 and 2023-04-07, with levels dropping to 3.07K/uL on 2023-03-21 and 2.68K/uL on 2023-04-14. Given these observations, it is reasonable to anticipate potential leukopenia following this current session, which should be noted.
    • 2023-05-08 WBC 3.50 x10^3/uL
    • 2023-04-14 WBC 2.68 x10^3/uL
    • 2023-04-06 WBC 3.83 x10^3/uL
    • 2023-03-21 WBC 3.07 x10^3/uL
    • 2023-03-12 WBC 4.21 x10^3/uL
    • 2023-02-27 WBC 3.33 x10^3/uL
    • 2023-02-24 WBC 5.97 x10^3/uL
  • According to PharmaCloud records, all recent medications were prescribed at our hospital and no medication reconciliation issues were identified.

701457374

230509

[MedRec]

  • 2023-04-27 ~ 2023-05-08 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • Nasopharynx MRI showed squamous cell carcinoma of right tongue and floor of mouth with lymph node metastasis cT4bN3bM0 stage IVb.
      • His treatment plans were palliative chemotherapy followed by salvage surgeries.
      • lntraoral wound change dressing qd. Oral intake with clear liquid diet because of patient refused N-G placement.
      • Systemic antibiotic with Cefa 1g Q8H IV for infection control.
      • He finished modified induction chemotherapy with #1a 80% TPF (Taxotere 32mg/M2, Cisplatin 32mg/M2, 5-Fu 800mg/M2 plus Leucovorin 80mg/M2, MTX 24mg/M2) on 2023/05/3-2023/05/06.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Zinga 1 tab PO QD for zinc supplement, B-Red 1 mg IVD QD for hematogenesis, Magnesium Sulfate 10% 20 mL IVD QD for hypomagnesemia.
    • Prescription
      • Actein (acetylcysteine 600mg) 1# BID
      • Acetal (acetaminophen 500mg) 1# PRNQ6H (if pain)
      • Zinga (zinc gluconate 78mg) 1# QD
      • Foliromin (ferrous sodium citrate 50mg) 1# BID
      • loperamide 2mg 2# PRNQ8H (if diarrhea >= 4 times)
      • Promeran (metoclopramide 3.84mg) 1# PRNTIDAC (if vomit)
  • 2023-04-25 SOAP Oral and Maxillofacial Surgery
    • S: The patient has been missing for 4 months
      • Body: Apart from oral cancer, there are no other systemic diseases,
      • Mind: The patient is not anxious
      • Spirit: No specific beliefs
      • Social: Family’s financial situation is poor (rent is about 30,000, high stress), very thin
    • A: SCC of right tongue (cT3N2bM0) with local inflammation (now progressed to T4bN3bMx)
  • 2022-12-22 ~ 2022-12-26 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination which his ANC showed 3630/mm2.
      • Then we had arranged induction chemotherapy with #3b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/22 - 2022/12/24.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. No obvious of discomfort were noted excepted mild mucositis of right buccal mucosa were noted.
  • 2022-12-15 ~ 2022-12-19 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 2901/mm2.
      • Then we had arrange induction chemotherapy with #3a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) were delivered on 2022/12/15 - 2022/12/17.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Mouth care and cool soft diet were educated.
    • Prescription
      • Smecta (dioctahedral smectite 3mg) 1# PRNBID (if watery diarrhea > 3 times)
      • Acetal (acetaminophen 500mg) 1# Q8H (if pain)
      • amoxicillin 250mg 2# Q8H
  • 2022-11-28 ~ 2022-12-03 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3351/mm2.
      • Then we had arrange induction chemotherapy with #2b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/28 - 2022/11/30.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Radi-K 2 tab PO TID for prevent hypokalemia. Zinga 1 tab  PO  QD for zinc supplement. Folina 15mg 1 tab PO QD for hematogenesis. B-Red 1 mg IVD  QD for hematogenesis. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
  • 2022-11-21 ~ 2022-11-25 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 3769/mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed. Then we had arrange induction chemotherapy with #2a TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/21 - 2022/11/23.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Strocain (oxethazaine, polymigel 5mg) 1# TIDAC
      • Zinga (zinc gluconate 78mg) 1# QD
      • Folina (folinate 15mg) 1# QD
      • Eurodin (estazolam 2mg) 1# PRNHS
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-11-07 ~ 2022-11-12 POMR Oral and Maxillofacial Surgery
    • Inpatient Treatment Process
      • After admission, we had arranged physcial examination for him which ANC showed 7918 /mm2. Empirical antibiotic agents with Cefa 1g Q8H IV was prescribed.
      • Then we had arrange induction chemotherapy with #1b TPF (Taxotere 40mg/M2 + Cisplatin 40mg/M2 + 5-Fu 1000mg/M2 + Leucovorin 100mg/M2) on 2022/11/07 - 2022/11/09.
      • Hydrocortisone 100mg IV Q8H to prevent neutropenia and combine Famotidine 20mg IVD Q12H to prevent gastric ulcer.
      • Additional, hopeless tooth with local inflammation were noted, We had arranged extraction of 14 15 and curettage of the extraction socket under local anesthesia on 2022/11/11. Intraoral wound change dressing qd. Ice packing of face, mouth care and cool soft diet were educated.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • amoxicillin 250mg 2# Q8H
      • Megest (megestrol 40mg/mL) 10mL BID
  • 2022-10-24 ~ 2022-11-02 POMR Oral and Maxillofacial Surgery
    • Discharge diagnosis
      • Squamous cell carcinoma of right tongue cT4aN2bM0 stage IV in process chemotherapy
      • Malignant neoplasm of border of tongue
      • INFECTION OF TONGUE AND FLOOR OF MOUTH
      • Encounter for antineoplastic chemotherapy
      • HOPELESS CARIES OF MANY TEETH
    • CC
      • HE WAS ADMITTED BECAUSE HE HAD an ulcerative MALIGNANT mass at HIS right tongue for more than 6 weeks    
    • Illness
      • The local finding showed a BIG ulcerative malignant tumor WITH INDURATION AND LOCAL INFECTION at his right tongue border AND VENTRAL SURFACE with muscle invasion, about 5.0 cm in size. BESIDES, several palpate lymph nodes at the right neck are detected. After we had adequately explained the finding and treatment plans to the patient and his WIFE, he recided to accept our treatment plans for him. His treatment plans were induction chemotherapy follow by surgery and CCRT. Under the impression of squamous cell carcinoma of right tongue cT4aN2bM0 stage IV, he was admitted to ward for tumor work up and prepare induction chemotherapy.
    • Inpatient Treatment Process
      • The induction chemotherapy with TPF (Taxotere 40mg/M2, cisplatin 40mg/M2, 5-FU 1000mg/M2) were delivered on 10/28~10/30/2022. He did’t had nausea and vomiting after chemotherapy. Intraoral wound change dressing qd. Mouth care with Parmason solution q3h.
    • Prescription
      • Acetal (acetaminophen 500mg) 1# Q6H
      • Eurodin (estazolam 2mg) 1# HS
      • loperamide 2mg 1# ASORDER (if diarrhea > 4 times)
      • Promeran (metoclopramide 3.84mg) PRNTIDAC (if N/V)
      • Kentamin (B1 50mg, B6 50mg, B12 500ug) 1# BID
  • 2022-10-21 SOAP Oral and Maxillofacial Surgery
    • S
      • He came to our OS OPD for help because is a tongue cancer patient who had been proved in ShuangHe Hospital ENT.
    • O
      • An ulcerative SCC with local inflammation at the right tongue border with muscle invasion, about 4.0 cm in size, is noted. several palpate lymph nodes at the right neck are detected. many hopeless caries are noted. edntulous ridge of mandible was noted. gingivitis and gingival recession of residual teeth are noted. no crown, no bridges and no wisdom teeth are noted.
    • A
      • SCC of right tongue (cT3N2bM0) with local inflammation
    • P
      • Panoramic film showed no bone destruction by tumor. periodontal bone loss is noted.
      • explain the finding and treatment plan to the patient.
      • debridement and cruettage at the right tongue border to remove food debris and necrotic tissue.
      • amoxilline + scanol to control pain and infection.
      • arragne admission for further treatment

[chemotherapy]

  • 2023-05-03 - docetaxel 32mg/m2 50mg NS 100mL 1hr + cisplatin 32mg/m2 NS 150mL 3hr + fluorouracil 800mg/m2 1200mg leucovorin 80mg/m2 120mg NS 1000mL 22hr D2 + methotrexate 24mg/m2 35mg NS 100mL 30min D4
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-12-22 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-15 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-21 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-11-07 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-10-28 - docetaxel 40mg/m2 60mg NS 150mL 1hr + cisplatin 40mg/m2 NS 200mL 3hr + fluorouracil 1000mg/m2 1600mg leucovorin 100mg/m2 160mg NS 1000mL 22hr D2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

[assessment]

  • The patient’s weight dropped dramatically from 57kg on 2023-04-25 to 48kg on 2023-05-03, a loss of 9 kilograms in just 8 days. This significant weight loss could be due to a data entry error or rounding inconsistencies, as the patient had a lapse in follow-up between late December 2022 and late April 2023.
  • Even as early as November 2022, there was a need to enhance the patient’s appetite (megestrol was prescribed at discharge on 2022-11-12). As of the most recent chemotherapy session on 2023-05-03, the same regimen was used but the dose was reduced to 80% of the original. It seems unlikely that the recent chemotherapy is the sole culprit for the patient’s severe weight loss.
  • If the patient is still able to consume food orally, it would be advisable to reintroduce megestrol to help stimulate his appetite. This may potentially help to counteract the significant weight loss he has been experiencing.

701470089

230509

[lab data]

  • 2023-03-03 Anti-HBc Reactive
  • 2023-03-03 Anti-HBc-Value 6.75 S/CO
  • 2023-03-03 Anti-HBs 68.82 mIU/mL
  • 2023-03-03 HBsAg Nonreactive
  • 2023-03-03 HBsAg (Value) 0.39 S/CO
  • 2023-03-03 Anti-HCV Nonreactive
  • 2023-03-03 Anti-HCV Value 0.09 S/CO
  • 2023-02-16 MTBC PCR NOT DETECTED CFU/ml
  • 2023-02-16 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-04-29 MRI - L-spine
    • Indication: Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, stage IVB. This time, lower back pain for 1 week
    • Thoraco-lumbar spine MRI without and with IV Gd-DTPA administration shows:
      • Abnormal thick nerve roots and the filum terminale.
      • After IV contrast administration shows well nodular like enhancement along those nerve roots.
      • A small right SI joint lesion, nature?
      • Bulged and dehydrated discs seen as low signal intensity on T2WI with mild ventral dural sac compression at L4/5/S1.
    • IMP: Highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis?
  • 2023-04-27 ECG
    • Decreased disc height at L5/S1 is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-03-27 CXR
    • Fibrosis of right and left upper lung are suspected.
  • 2023-03-06 Pure Tone Audiometry
    • PTA:
    • Reliability FAIR
    • Average RE 14 dB HL, LE 15 dB HL
    • bil WNL
  • 2023-02-13 CXR
    • widening of Lt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-11 MRI - brain
    • No evidence of intracranial lesion.
  • 2023-02-10 Patho - esophageal biopsy
    • Ulcerative lesion, 19-33 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated characterized by solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma without keratin formation and ulcer with necrotic debris.
    • Immunohistochemistry of CK(+), P63(+) and P16(-) for tumor
  • 2023-02-10 SONO - abdomen
    • Suspected liver hemangioma, three
    • Renal stones, both kidney
    • Renal cyst, right kidney
  • 2023-02-10 Miniprobe Endoscopic Ultrasound
    • Highly suspected esophageal cancer, s/p biopsy*6
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2023-02-09 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the posterior aspect of right rib cage and increased activity in some middle T-spines, right 9th costovertebral junction, right S-I joint and greater trochanter of right femur in whole body survey.
    • IMPRESSION:
      • Increased activity in some middle T-spines, right 9th costovertebral junction and right S-I joint. Bone metastases should be watched out. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the posterior aspect of right rib cage and mildly increased activity in the greater trochanter of right femur. The nature is to be determined (post-traumatic change? bone metastases?). Please follow up bone scan for further evaluation.
  • 2023-02-08 PET scan
    • Glucose-hypermetabolism in the upper to middle esophagus, compatible with the primary esophageal cancer.
    • Glucose-hypermetabolism in bilateral SCF lymph nodes and bilateral pulmonary hilar and mediastinal lymph nodes, highly suspected cancer with regional lymph nodes metastases.
    • Glucose-hypermetabolism in the left axillary lymph nodes, probably reactive nodes.
    • Glucose-hypermetabolism in bilateral lungs and skeleton including T5, T6 spines, right 9th costovertebral junction, and right iliac bone, highly suspected cancer with distant metastases.
    • Esophageal cancer with regional lymph nodes, bilateral lungs and multiple bones metastases, cTxN3M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-08 Nasopharyngoscopy
    • Findings:
      • smooth NPx, OPx, HPx, mild saliva pooling at Hpx, left vocal palsy at paramedian position, congested
    • Diagnosis/conclusion
      • L vocal palsy, related to esophageal ca
  • 2023-02-07 Bronchoscopy
    • Abnormal Tracheal mucosa infiltration due to esophageal cancer invades
  • 2023-02-04 CT - chest
    • Indication: esophageal cancer
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window, 5 mm soft-tissue window slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse ground glass patches at both lungs is found.
        • Diffuse wall thickening at upper third esophagus is found about 8.5cm*1.2 in length and width.
        • Enlaged lymph nodes (n>8) are found around the main mass.
        • No evidence of bilateral pleural effusion.
        • Multiple round solid nodules (each about 0.6cm) scattered in both lungs, favor lung metastases.
      • Visible abdomen:
        • Bilateral renal stones are found.
        • The spleen, pancreas and adrenals are intact.
        • Low density lesion at liver surface measuring 1.7cm is found. Hemangioma is favored.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • IMP:
      • Long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered.
      • Diffuse ground glass pacthes at both lungs. Previous repeated inflammation is considered.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M1(M_value) STAGE:IV__(Stage_value)

[consultation]

  • 2023-05-02 Radiation Oncology
    • Q
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis. No obvious lumbar spine bone destructing lesion. A small right SI joint lesion, metastasis? Now, for evaluate palliative radiotherapy to L spine. Thank you.
    • A
      • This 52-year-old man patient is a case of Squamous cell carcinoma of upper to lower third esophagus with bilateral lung and bone metastasis, cT3N3M1, s/p CCRT.
      • Progression lower back pain for 1 week. Fall developed on 2023/04/24. Lspine MRI on 2023/04/29 showed highly suspected lumbar nerve roots, arachnoid tumor seeding/metastasis.
      • Palliative RT is indicated. CT-simulation will be arranged on 2023-05-10. Plan to deliver 30 Gy/ 10 fx to the L-spine and partial S-I joint (at least the Rt side metastatic lesion shown on PET). RT will start around 2023-05-11. Thank you very much.
  • 2023-02-11 Hemato-Oncology
    • A
      • This 52 year old man is a case of esophagus squamous cell carcinoma with lung metastasis, cT3N3M1, stage IV (initial presentation was hoarseness for 3 months and dysphagia with body weight loss). He had been admitted to HsinChu Cathay Hospital on 2023/01/30, where Panendoscope on 2023/01/31 showed esophageal tumor with stricture, biopsy show squamous cell carcinoma, moderate to poorly differentiated. We are consulted for further evaluation.
      • Systemic therapy is indicated for metastasis esophagus SCC. Palliative CCRT followed by systemic chemotherapy may consider in this case. Please arrange our OPD after discharge. Thanks for your consultation.
  • 2023-02-10 Radiation Oncology
    • A
      • This 52-year-old man, a heavy smoker and alcoholism denied any systemic disease. He has suffered from hoarseness since 3 months ago. Dysphagia even liquid diet for 2 weeks, associated with weight loss 4 kg in a month. Endoscopic biopsy was done, and pathology reported squamous cell carcinoma, moderate to poorly differentiated. Chest CT on 2023-02-04 showed long segmental wall thickening at upper third esophagus, with bilateral lung nodules. Esophageal cancer with bilateral lung metastases is considered. Stage cT3N3M1. Whole body PET and bone scan showed highly suspected spine and lung mets.
      • He can’t swallow the saliva. Palliative CCRT is indicated. CT-simulation will be arranged on 2023/02/16. Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. If the dose distribution is feasible, spine mets can be included in the RT field. RT will start around 2023/02/20 or 21.

[MedRec]

  • 2023-03-02 SOAP Hemato-Oncology
    • A
      • C15.9 Malignant neoplasm of esophagus, unspecified
    • P
      • Admission for systemic chetmoehrapy when admission, 24 hours CCr and audiometry
      • Plan: palliative radiohterapy with systemic chemotherapy followed by paliative C/T with PF
  • 2023-02-24 SOAP Radiation Oncology
    • P: Plan to deliver 45 Gy/ 25 fx to the esphagus and bil. SCF and T-spine mets. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx.

[radiotherapy]

[chemotherapy]

  • 2023-05-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-30 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3
  • 2023-03-07 - cisplatin 75mg/m2 125mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF, CCRT)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3

2023-05-09

[tube feeding]

Nexium (esomeprazole) should not be crushed. Instead, it should be dissolved in sufficient drinking water before tube feeding.

2023-04-28

[tube feeding]

  • All of the oral medications prescribed can be administered via a feeding tube.

2023-03-27

[tube feeding]

  • All of the oral medications in the patient’s active prescription are able to be administered through a feeding tube.

700070514

230508

[diagnosis] - 2023-05-07 admission note

  • K-RAS mutation Adenocarcinoma of the sigmoid colon near complete obstruction invasion to bladder with fistula formation, and carcinomatosis and liver metastases, cT4bN2bM1c, stage IVc status post T-loop colostomy on 2022/10/26
  • Iron deficiency anemia, unspecified

[present illness]

  • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.

[past history] - 2023-05-07 admission note

  • Systemic disease:
    • Major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
  • Surgery:
    • Left femoral fracture s/p THR

[family history]

  • Father has diabetes
  • No cancer history in his family

[lab data]

  • 2022-10-01 HBsAg Nonreactive
  • 2022-10-01 HBsAg (Value) 0.37 S/CO
  • 2022-10-01 Anti-HBc Reactive
  • 2022-10-01 Anti-HBc-Value 5.99 S/CO
  • 2022-10-01 Anti-HCV Nonreactive
  • 2022-10-01 Anti-HCV Value 0.15 S/CO

[exam findings]

  • 2023-05-02, -04-24, -04-22, -03-19 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w lung metastases after correlate with CT.
  • 2023-03-07 CT - abdomen
    • History and indication: Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected and urinary bladder fidtula, cT4bN2bM1c, stage IV
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LN/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
      • S/P left THR.
      • Minimal ascites.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Mild regression of S-colon cancer and peritoneal invasion but progression of LNs/ lung/ liver and left sacral metastases.
      • Left hydronephrosis.
  • 2023-02-03 Tc-99m MDP bone scan
    • Increased activity in the sacrum. Please correlate with other imaging modalities for further evaluation and to rule out the possibility of bone metastasis.
    • Mildly increased activity in the lower C-spine, some middle and lower T-spines. Degenerative change may show this picture. However, please keep follow-up to rule out other possibilities.
    • Some hot and faint hot spot in bilateral rib cages and increased activity in the right clavicle and right ischium. The nature is to be determined (bone metastases? post-traumatic change? ). Please correlate with other clinical findings for further evaluation.
  • 2023-02-01 Long Bones series
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • S/P total hip arthroplasty, left hip
  • 2022-12-02 CT - abdomen
    • History
      • 20221202 CC: Started to have a fever this morning, vomiting, general weakness, abdominal pain, blood pressure in the right hand 79/52mmhg
      • 20220921 CC: diarrhea for 1/2 yrs. bw loss 14 kg. CEA 33.86; anemia (initial 8.2); favor IDA (iron deficiency anemia)
      • 20220921 sigmoidoscopy: Suspected colon ca, R-S juncton s/p biopsy
      • 20220923 CT: R-S juncton cancer, cT4b(UB)N2bM1c, cSTAGE:IVC
    • Indication: sepsis
    • Findings: Comparison: prior CT dated 2022/09/23.
      • Prior CT identified long segmental sigmoid colon cancer is noted again, stable in size.
        • S/P colostomy at right transverse colon.
        • There is no gas in the urinary bladder.
        • Prior CT identified Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space are noted again, mild increasing in size and number that are c/w progressive disease.
        • In addition, There is mild hydroureteronephrosis and delayed contrast excretion of left kidney and the etiology is due to metastatic node in left common iliac chain with passive compression left side ureter.
      • There are newly-developed multiple poor enhancing masses on both hepatic lobes that are c/w liver metastases with progressive disease.
        • The largest one measuring 5.9 cm in S6/7.
      • Prior CT identified smuddgy appearance of the omentum is noted again, stationary. Follow up is indicated.
      • There are multiple newly-developed soft tissue nodules on both lung that are c/w lung metastases.
      • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & right kidney.
      • There is no evidence of ascites.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Multiple liver and lung metastases c/w progressive disease.
      • Multiple Metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space show progressive disease.
  • 2022-10-31 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (101 - 35) / 101 = 65.35%
      • M-mode (Teichholz) 65
    • Adequate LV systolic function with normal resting wall motion
    • Septal hypertrophy
    • Mild MR, trivial TR
    • Preserved RV systolic function
  • 2022-10-31 CXR
    • Pneumoperitoneum (note: Pneumoperitoneum is the presence of air or gas in the abdominal (peritoneal) cavity. It is usually detected on x-ray, but small amounts of free peritoneal air may be missed and are often detected on computerized tomography (CT).)
    • A nodule at RLL.
  • 2022-10-25 Barium Enema with water soluble contrast medium
    • Findings
      • Obstruction at sigmoid colon.
      • A defect at between sigmoid colon and urinary bladder. Prominent air the the urinary bladder.
    • Impression
      • Obstruction at sigmoid colon
      • c/w sigmoid colon-vesical fistula (may be dominate at proximal end)
  • 2022-10-05 Whole body PET scan
    • Glucose-hypermetabolic lesions in the lower abdomen, pelvis, and in a left para-arotic lymph node, highly suspected S-colon cancer with carcimatosis.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected colon cancer with liver metastasis.
    • Increased uptake of FDG at the left hip joint, probably benign in nature.
    • S-colon cancer with carcimatosis and liver metastases, cTxN2bM1c, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-10-03 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • Detected (KRAS condon 61 CAA>CTA, p.Q61L)
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-30 ECG
    • Sinus rhythm with short PR
    • Nonspecific ST abnormality
    • Abnormal ECG
  • 2022-09-23 CT - abdomen
    • Findings:
      • There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction.
        • In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b).
        • In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b).
      • There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). Please correlate with sonography or MRI.
        • The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2b (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
  • 2022-09-22 Patho - colon biopsy
    • Colon, R-S junction, biopsy — Adenocarcinoma, moderately differentiated
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-09-21 Colonoscopy
    • Diagnosis
      • Highly suspected colon cancer, R-S junction, s/p biopsy
      • Mixed hemorrhoid
      • Incomplete colonoscopy due to tumor stricture
    • Suggestion
      • F/U pathology report
      • Further image for cancer staging may be indicated.
    • Complication
      • No immediate complication
  • 2022-08-30 Patho - stomach biopsy
    • Esophagus, EC junction, biopsy — Barrett’s esophagus
    • Microscopically, it shows chronic inflammation with lymphoplasmacytic infiltrate and intestinal metaplasia with goblet cells present.
  • 2022-08-29 SONO - abdomen
    • suspected liver parenchymal disease.
  • 2022-08-29 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Hiatus hernia
      • Suspect Barrett’s esophagus, s/p biopsy, C1M3
      • Superficial gastritis
      • Gastric polyp, high body, GC/PW site
    • Suggestion
      • Pursue biopsy result
  • 2022-08-25 ECG
    • Sinus tachycardia
    • Nonspecific ST abnormality
    • Abnormal ECG

[consultation]

  • 2022-12-07 Colorectal Surgery
    • A: Diver-T-loop colostomy was done, please control underline disease
  • 2022-11-22 Radiation Oncolgoy
    • A
      • The 57 y/o man has adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC. s/p T-colonostomy. Palliative C/T has been started on 2022/11/21.
      • Palliative CCRT is indicated. CT-simulation will be arranged on 11/28. Plan to deliver 45 Gy/ 25 fx to the S-colon tumor and adjacent carcinomatoses. r/o IVC thromboemboli shown on abd. CT (2022/09/23) with PVT? I will consult radiologist Dr. Yu later. Thank you very much.
      • no PVT. just r/o IVC thromboemboli.
  • 2022-10-06 Colorectal Surgery
    • Q
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022/10/04 and PET was arrange on 2022/10/05.
      • we had explained the current condition to patient and family,they agreed to do the T-loop colostomy. We need your expertise for further management, thanks
    • A
      • This is a 57-year old man with the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC,
      • protective T-loop colostomy will be considered
      • we will arrange operation for him
  • 2022-10-05 Radiation Oncology
    • Q
      • This 57-year-old male has past history of major depressive disorder comorbid with alcohol dependence under medication treatment at our PSY OPD.
      • He had suffered from watery diarrhea with body weight loss 17kg in half year. The condition is worse than before within this year. EGD on 2022/08/29 showed Reflux esophagitis LA Classification grade A. Hiatus hernia. Suspect Barrett’s esophagus, s/p biopsy, Superficial gastritis. Gastric polyp, high body, GC/PW site. Biopsy proved Barrett’s esophagus.
      • He came to our GI OPD and colonscopy was performed on 2022/09/21 which showed Highly suspected colon cancer, R-S junction, s/p biopsy. Mixed hemorrhoid. Biopsy proved Adenocarcinoma, moderately differentiated.
      • CT of abdomen was performed on 2022/09/25 revealed There is a long segmental lobulated wall thickening with irregular contour at the sigmoid colon, measuring 10 x 5.3 cm in size, causing lumen narrowing and proximal colon dilatation that is c/w adenocarcinoma of the sigmoid colon with near complete obstruction. In addition, there is fistula formation between the sigmoid colon mass and the urinary bladder, causing air-fluid level in the urinary bladder that is c/w tumor invasion (T4b). In addition, There are multiple enlarged nodes in the sigmoid mesocolon and perirectal space, the largest one measuring 4 cm, that are c/w metastatic nodes (N2b). There is a poor enhancing mass measuring 0.9 cm in S6 of the liver. Liver metastasis is highly suspected (M1a). The omentum shows smuddgy appearance that may be tumor seeding (M1C).
      • Under the impression of Adenocarcinoma of the sigmoid colon with near complete obstruction, tumor seeding and liver metastasis is highly suspected, cT4bN2bM1c, stage IVC, pending RAS report. He was admitted for further management. Port-A insertion on 2022-10-04. We need your expertise for radiotherapy evalaution, thanks
    • A
      • He was persuaded to have colostomy first.
      • CCRT will be arranged thereafter.
  • 2022-08-26 Psychosomatic Medicine
    • A
      • MSE: thin and cachexia, impaired attention focus and sustain, low mood, poor energy, psychomotor retardation, suicidal ideation, alcohol drinking all day long.
      • PE: mild upper limb tremor, yellowish skin, icteria scerdela
      • IMP:
        • Major depressive disorder, recurrent, severe
        • Suspected alcohol induced mood disorder
        • Alcohol use disorder, in withdrawal status.
      • Suggestion:
        • Correct electrolytes, treat physical condition
        • Saline hydration with B-complex 1 amp QD, with kentamin supply for B12 defiency.
        • Add dosage of our medications: keep zoloft 50mg 1# QN, add utapine to 25mg 2# HS, Eurodin 1# HS, and add anxiedin to 2# Q12H
        • Arrange psy OPD f/u.

[MedRec]

  • 2023-03-19 ~ 2023-03-24 POMR Hemato-Oncology
    • Inpatient Treatment Process
      • After admission, C6 Avastin plus C2D1 FOLFIRI was administered on 2023/03/21-23.
      • Dizziness and headache was noted during chemotherapy and adequate hydration was done.
      • With the relatively stable condition, he was discharged on 2023/03/24 and will OPD follow up later.
  • 2022-11-29 SOAP Hemato-Oncology
    • A/P: Bevacizumab 5 mg/kg iv q2wks for 36 wks (18 wks each apply) colostomy in late Oct. 2022
  • 2022-09-30 SOAP Hemato-Oncology
    • A/P: Discussed the suggestion of a protective T-loop colostomy with the patient and his wife (which could also help reduce the risk of urinary tract infections). The patient indicated that he is currently able to have bowel movements and would like to try chemotherapy and radiation first.

[surgical operation]

  • 2022-10-26 T loop colostomy        
    • adenocarcinoma of Sigmoid colon with invasion to bladder and fistula formation    
    • short T-colon with adhesion to liver and middle colic mesentery region 

[radiotherapy]

  • 2022-11-29 ~ 2023-01-10 - completed RT to the pelvisthe S-colon tumor, partial bladder, and adjacent carcinomatoses: 45 Gy/ 25 fx.

[chemoimmunotherapy]

  • 2023-04-06 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-21 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 2150mg NS 500mL 46hr (FOLFIRI, 5FU infusion 50% off due to encephalopathy during last time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-03-01 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-02-13 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-27 - bevacizumab 5mg/kg 240mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL
  • 2023-01-09 - bevacizumab 5mg/kg 245mg NS 100mL 90min + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4300mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 5mg/kg 255mg NS 100mL 90min + oxaliplatin 85mg/m2 135mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-13 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-21 - oxaliplatin 85mg/m2 133mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2800mg/m2 4400mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-05-08

  • From 2022-11-21 to 2023-01-09, the patient was treated with Avastin plus FOLFOX for his K-RAS-mutated sigmoid colon adenocarcinoma. However, a CT scan on 2022-12-02 showed progressive disease with multiple liver and lung metastases, as well as metastatic nodes in the mesentery, left common iliac chain, sigmoid mesocolon, and perirectal space. As a result, the regimen was changed to Avastin plus FOLFIRI on 2023-01-27. Due to dizziness and headache experienced during chemotherapy on 2023-03-01, the fluorouracil dose was reduced by half starting on 2023-03-21.

  • After the new regimen was applied, the tumor marker CEA has remained relatively unchanged; however, the readings are approximately twice as high as they were before.

    • 2023-04-21 CEA (nuclear medicine) 1376.700 ng/ml
    • 2023-04-03 CEA (nuclear medicine) 1203.450 ng/ml
    • 2023-03-17 CEA (nuclear medicine) 1261.1 ng/ml
    • 2023-02-24 CEA (nuclear medicine) 1322 ng/ml
    • 2023-02-14 CEA (nuclear medicine) 1371.12 ng/ml
    • 2023-01-27 CEA (nuclear medicine) 667.3 ng/ml
    • 2023-01-09 CEA (nuclear medicine) 627.64 ng/ml
    • 2022-12-29 CEA (nuclear medicine) 907.05 ng/ml
    • 2022-11-29 CEA (nuclear medicine) 382.654 ng/ml
    • 2022-10-07 CEA (nuclear medicine) 52.567 ng/ml
  • The Covid-19 fast screen was positive on 2023-04-24, but the patient has since recovered. Vital signs are currently stable. CT and CXR revealed lung mets with multiple nodular opacities in both lungs, which do not significantly impair the patient’s respiratory function yet.

  • The underlying conditions are currently being managed with appropriate medications: anemia is treated with Foliromin (ferrous sodium citrate), toe numbness is treated with Kentamin (B1, B6, B12), right upper quadrant abdominal and rib area pain is treated with Tramacet (tramadol, acetaminophen) and Neurontin (gabapentin), respiratory symptoms are treated with Romicon-A (dextromethorphan, cresolsulfonate, lysozyme), oral candidiasis is treated with Mycostatin (nystatin), and intermittent diarrhea is managed with loperamide and Smecta (dioctahedral smectite) as needed (PRN).

2023-01-10

[drug interaction]

  • The ability of oral iron preparations to reduce the absorption of oral quinolones is well established and has been demonstrated in numerous pharmacokinetic studies. Various oral iron preparations have been reported to reduce quinolone AUCs by the following percentages: ciprofloxacin (33% to 70%), levofloxacin (19%), lomefloxacin (14%), moxifloxacin (61%), norfloxacin (51% to 73%), ofloxacin (25%), and sparfloxacin (28%). The maximum serum concentrations of oral quinolones were reduced by the following percentages: ciprofloxacin (46% to 75%), levofloxacin (45%), lomefloxacin (28%), moxifloxacin (41%), norfloxacin (75% to 82%), ofloxacin (36%), and sparfloxacin (46%). It is recommended to administer oral quinolones at least several hours before (4 h for moxifloxacin and sparfloxacin, 2 h for others) or after (8 h for moxifloxacin, 6 h for ciprofloxacin and delafloxacin, 4 h for lomefloxacin, 3 h for gemifloxacin, 2 h for enoxacin, levofloxacin, norfloxacin, ofloxacin, pefloxacin, or nalidixic acid) oral iron preparations.

  • Due to the fact that Cravit (levofloxacin) and Foliromin (ferrous sodium citrate) were prescribed as QDAC and BID, respectively. To maintain Cravit’s effectiveness, Foliromin might be moved to QL and QN.

  • Please monitor for diminished effects of the quinolone if dose separation cannot be achieved.

2023-01-09

  • Oxaliplatin is associated with high incidence of peripheral neuropathy (76%, grades 3/4: 7%; acute: 65%, grades 3/4: 5%; delayed (persistent): 43%, grades 3/4: 3%) Ref: UpToDate
  • The acute neurotoxicity that is seen frequently in the 72 to 96 hours after each infusion of oxaliplatin is often linked to cold exposure (drinking cold liquids, inhaling cold air, placing hands in the freezer). Avoidance of cold during this time frame should mitigate this toxicity to some extent, but not all symptoms (eg, perioral numbness, hand cramping) are related to cold. As of now, no evidence of peripheral neuropathy has been recorded.
  • The patient vomited several times throughout the week as documented in the record of 2023-01-06. A prescription for metoclopramide has been issued.

2022-12-26

  • The patient is receiving bevacizumab for the first time during this hospital stay. The patient was recently diagnosed with gastro-esophageal reflux disease (2022-11-17), however, no CVD related records have been kept for the past three months. As bevacizumab is associated with concerns regarding gastrointestinal perforation/fistula, heart failure, and hemorrhage. There may be a need for regular monitoring.

2022-12-05

  • The patient’s body temperature fluctuated between 36.2 and 38.2, with two peaks at around 08:00 and 22:00 on a daily based cycle roughly.
  • In this instance, tapimycin (piperacillin + tazobactam) is used, which has been shown to be effective against the 2022-12-02 blood cultured Escherichia coli (MIC <= 4 mcg/mL according to the lab report).
  • There was a downward trend in renal function, especially in late November 2022, which should be noted. In the event of CrCl < 40mL/min, the dose of tapimycin should be reduced to two thirds.
    • 2022-12-02 Creatinine 0.91 mg/dL
    • 2022-11-28 Creatinine 0.96 mg/dL
    • 2022-11-21 Creatinine 0.59 mg/dL
    • 2022-11-17 Creatinine 0.58 mg/dL
    • 2022-10-31 Creatinine 0.48 mg/dL
    • 2022-10-24 Creatinine 0.43 mg/dL
    • 2022-10-17 Creatinine 0.41 mg/dL

2022-11-21

  • Glomerular hyperfiltration (eGFR 150 2011-11-21, recent peak 229 2022-10-17) was noted. Intraglomerular hypertension, resulting from the transmission of systemic pressures or via glomerular-specific processes, may be deleterious over the long term. The use of NSAIDs (celecoxib in current prescription as a patient-carried item) should be limited to the necessary duration and should not be prolonged.

2022-10-03

  • Hypoalbuminemia (2.8 g/dL 2022-09-30) <= decreased hepatic albumin synthesis <= possible liver mets? (2022-09-23 CT)
  • The use of Alglutol (acamprosate 333mg/tab) 2# TID may be considered as a means of helping the patient quit alcohol following his withdrawal symptoms.

700138669

230508

[diagnosis] - 2023-04-26 admision note

  • Hemoptysis
  • Malignant neoplasm of nasopharynx, unspecified
  • Essential (primary) hypertension
  • Hypertensive heart disease without heart failure

[past history] - 2023-04-26 admision note

  • Nasopharyngenl Carcinoma T4N3M1, stage IVB, proved at 2020/05 at Wan Fang Hospital (No biopsy) s/p radiotherapy to the C- and T- spine bone mets: 21 Gy/ 7 fx. on 2023-01-03 ~ 11, (early termination due to the patient reject) at our hospital
  • hypertension for years with Concor 5mg/tab 0.5tab QD, Bokey 100mg/cap 1cap QD, Cozaar 50mg/tab 0.5tab QD, Norvasc 5mg/tab 0.5tab QD control and the clinic follow-up.
  • hyperlipidemia for years with Lipitor 40mg/tab 1tab QD control and the clinic follow-up.
  • L3 compression fracture without surgery for years.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-25 Nasopharyngoscopy
    • Findings: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
    • Conclusion: nasopharyngeal carcinoma
  • 2023-02-17, -01-13 Nasopharyngoscopy
    • Findings: rt NP tumor
    • Conclusion: NPC
  • 2022-12-28 Bone Scan
    • Hot areas at the skull base, some C-, T- and lower L-spine, NPC with bone mets shoulde be consideded, suggesting PET scan for further evaluation.
    • Suspected benign lesions in the maxilla, mandible, bilateral shoulders, and knees.
  • 2022-12-19 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Right nasopharynx tumor mass, with skull invasion, extending to right Foramen of ovale, up to 4.5 cm.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • Multiple right necrotic LAPs were noted down to supraclavicular fossa.
      • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • Destruction of right transverse process of T1 also was noted indicating bony metastasis.
    • IMP: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Nasopharyngeal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:1(M_value) STAGE:IVB (Stage_value)
  • 2022-12-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopahrynx, biopsy — Non-keratinizing carcinoma, undifferentiated (lymphoepithelialcarcinoma) (WHO-2B).
    • IHC stains: CK highlights infiltrative epithelum. EBV (-).
  • 2022-11-23 Nasopharyngoscopy
    • rt NP tumor
  • 2022-11-23 ENT Hearing Test
    • Tymp:
      • R’t type B; L’t type A.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 70 dB HL; LE 56 dB HL.
      • R’t moderaet to profound MHL.
      • L’t mild to severe HL. (BC masking dilemma)
      • Dialogue: R’t 65 dB HL; L’t 45 dB HL.
      • SDT: R’t 60 dB HL; L’t 40 dB HL.
  • 2021-10-26 MRI - L-spine
    • Multiple old compression fractures at T11, L2,3, poor healing at upper L3 body. A left T10/11 perineural cyst.
  • 2018-08-07 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.674 gms/cm2, about 1.2 SD below the peak bone mass (84%) and 1.8 SD above the mean of age-matched people (131%).
    • IMP: osteopenia

[lab data]

  • 2022-12-24 EBV DNA quantative PCR <120 copies/mL
  • 2022-12-01 EB VCA IgA Borderline Ratio
  • 2022-12-01 EB VCA IgA Value 0.9 Ratio
  • 2022-12-01 EBV EA/NA IgA Negative EU/mL
  • 2022-12-01 EBV EA/NA IgA Value 2.97 EU/mL

[consultation]

  • 2023-04-25 Ear Nose Throat
    • Q
      • Chief complaint: coughing of blood with clots this morning
        • difficult swallowing, poor intake, nausea and vomiting, easy choking after eating for months
        • denied fever, respiratory symptoms, or urinary discomfort
      • Past Medical History: NPC, T4N3M1 stage IVB (2020/05)
        • currently R/T at bone metastasis areas
        • hypertension, hyperlipidemia
        • L3 compression
      • History of Operation: denied
      • Regular Medications: Aspirin
    • A
      • A case of NPC end stage, under palliative treatment
      • dysphagia recently, and family ask for NG insertion
      • scope: massive blood-coating mass over right nasopharynx, much sputum over hypopharynx
      • status post NG insertion under scope
      • sugget CXR f/u before feeding from NG tube

[MedRec]

  • 2023-04-14 SOAP Hemato-Oncology
    • Plan: referred to hospice care
  • 2023-01-13 SOAP Radiation Oncolgoy
    • She decided to quit RT.
  • 2022-12-30 SOAP Radiation Oncolgoy
    • Plan: CT-simulation will be arranged on 20230102. Plan to deliver 30 Gy/ 10 fx to the C- and T- spine and Rt shoulder bone mets. RT will start around 20230104.
  • 2022-12-23 SOAP Radiation Oncolgoy
    • Plan: arrange bone scan for palliative bone mets RT.
      • RTC: around 1 wk.
  • 2022-12-23 SOAP Hemato-Oncology
    • O
      • 2022/12/19 MRI Nasopharynx: Right NPC with multiple right neck LAPs and right T1 bony metastasis. T4N3M1 stage IVB (AJCC 9th edition).
    • Assessment:
      • NPC, T4N3M1 stage IVB
    • Plan:
      • apply for major disease
      • refer to the radiation oncologist
      • pain control
  • 2022-11-23 SOAP Hemato-Oncology
    • S
      • She was referred on account of NPC proved at 202005 at Wan Fang Hospital. (No biopsy)
      • No treatment was applied from that time. Hospice care from that time.
      • Headache for 3 weeks, bilateral ear cannal ulceration without discharge from one month ago.
      • Hearing loss progressed
    • Assessment
      • NPC, staging
      • Check MRI
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR
      • refer to the ENT

==========

2023-05-08

  • On 2023-05-08 at 06:05, the patient’s SpO2 dropped to 69%, accompanied by an increased heart rate of 100 bpm. This indicates possible respiratory distress or compromised oxygenation, and an O2 mask is placed appropriately.

  • If the patient continues to experience hemoptysis, inhaled tranexamic acid could be considered as a potential treatment option to reduce bleeding. This antifibrinolytic agent has been shown to effectively control bleeding and may provide relief to the patient.

2023-04-27

  • Alpraline (alprazolam 0.5mg) 1# HS QD for 28 days and Bokey (aspirin 100mg) 1# QD for 28 days were prescribed at RenJi Hospital on 2023-02-28, with the 2nd refill on 2023-03-27. These medications are not currently shown in the patient’s medicine list. Please consider adding them back if they are still needed for the patient’s ongoing care. (Aspirin should be added to the patient’s medication list only after the hemoptysis has resolved.)

2023-04-26

  • Hemoptysis was noted in the patient. The solitary pulmonary nodule in the left mid-lung zone seen on chest x-ray 2023-04-25 was not seen on chest x-ray 2023-04-26. However, ground-glass opacities remain in the right lower lobe. The patient is currently being treated with Amsulber (ampicillin and sulbactam), Mycostatin (nystatin), and Hemoclot (tranexamic acid) without issues.
  • On 2023-04-26 at 10:31, the patient’s blood pressure was recorded as 177/85. If this elevated level persists, it is recommended that the dosage of Norvasc (amlodipine 5mg) be increased from 0.5 tablet once daily to 1 tablet once daily. If the blood pressure still remains high, then consider increasing Cozaar (losartan 50mg) from 0.5 tablet once daily to 1 tablet once daily as well.

701199326

230508

[exam findings]

  • 2023-05-05, -05-01, -04-24, -04-17, -04-10, -04-08, -03-28, -03-15, -03-01, -02-24 CXR
    • Osteolytic defect in left humeral head is suspected.
    • Please correlate with CT to R/O bony metastasis.
    • S/P port-A implantation.
    • Blunting of bilateral right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2023-04-05 CXR
    • Deformity of left humeral head.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacities in bil. lungs.
    • Presence of ileus.
    • Normal appearance of trachea and bil. main bronchus.
    • Right pleural effusion.
  • 2023-04-05 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Possible Inferior infarct , age undetermined
    • Abnormal ECG
  • 2023-03-10 SONO - joint soft tissue
    • Finding:
      • Bulging of the left ACJ.
      • Heterogeneous hypoechoic appearance of the left supraspinatus tendon.
    • Impression And Suggestions:
      • Left AC distention.
      • Left supraspinatus tendinosis. Please correlate with the clinical presentations.
  • 2023-03-01 Shoulder LT
    • Osteolytic defect and deformity of left humeral head and neck is noted. Please correlate with CT to R/O bony metastasis.
  • 2023-01-04, 2022-12-15, -10-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-12-17 CT - chest
    • Indication: Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Nodular and mass like lesions (n>5) at both lungs up to 4.09 cm in largest dimension at left lower lobe is found. Lung meta is considered. In comparison with CT dated on 2022-04-14, the lesions enlarged.
        • Miliary lesions scattered at both lungs are found. Lung meta is considered.
        • Collapsed right lower lobe with soft tissue like change attaching to right hemidiaphragm is found.
      • Visible abdomen:
        • s/p RFA at S7, S4 and S6 of liver. No evidence of recurrent/residual tumor at both lobes of liver.
        • The GB is well distended without soft tissue lesion
        • Right hydronephrosis and hydroureter is found. Distal obstruciton is considered
    • Imp:
      • Rectal cancer with bilateral lung meta and bone meta. In progression.
      • Liver meta s/p RFA. NO recurrent/residual tumor at both lobes of liver.
      • Right hydronephrosis and hydroureter, suggest double J catheter placement.
  • 2022-11-02 SONO - abdomen
    • Poor echo window due to bowel gas
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
    • Hydronephrosis, right kidney
  • 2022-10-20 CT - abdomen
    • History and indication: rectal ca
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Rectal cancer with liver/ lung metastases s/p operation and RFA.
      • Multiple nodules at bil. lungs.
      • Right hydronephrosis. Bil. renal cysts (up to 1.3cm).
      • A cystic lesion (4.0cm) at LUQ.
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
  • 2022-09-29 Cell block cytology
    • one panc tumor was noted at neck with downstream P duct dilate, s/p FNB.
      • a case of rectal cancer with liver and lung mets
    • 15 cc pink clear fluid — Atypia
    • The smears and cell block show few epithelial clusters with mild enlarged nuclei. Please correlate with S2022-16564 for conclusive diagnosis.
  • 2022-09-29 Patho - pancreas biopsy
    • Labeled as “pancreas”, needle biopsy — benign pancreas tissue with fibrosis.
    • IHC stains: CK highlights regular acinar structures. CD56 (-).
  • 2022-08-16 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis, body
    • Duodenal ulcer scar, bulb, AW site
  • 2022-07-20 CT - abdomen
    • History: Rectal cancer with liver and lung metastasis, stage IV
      • rectal ca with liver mets at inital s/p op then two liver mets s/p RFA at VGH, then lung mets, refer for r/o liver mets
      • 20220120 CT: Several poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
      • 20220211 S/P MWA for liver tumor
    • Findings:
      • There are four poor enhancing lesions measuring 3.5 cm in S8, 6.7 cm in S4/8, 8.7 cm (the largest dimension) in S7 liver and 2.4 cm in S5 liver that are c/w metastases S/P MVA.
      • Some soft tissue nodules in RUL, RLL, LUL, and LLL of the lung are noted that are c/w lung metastases.
        • In addition, There are several enlarged nodes in paratracheal space that are c/w metastatic nodes.
      • Encapsulated fluid collection in right CP angle pleura space with passive atelectasis and few linear hyperdense shadow are noted. please correlate with clinical history.
      • S/P LAR with autosuture retention over the rectum.
  • 2022-07-20 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion and atelectasis?
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at right upper lung.
  • 2022-06-14 SONO - abdomen
    • Chronic liver parenchymal disease
    • Hepatic tumors, two C/W mets s/p MWA
    • Renal cysts, bil
  • 2022-06-14 Esophagogastroduodenoscopy, EGD
    • Suboptimal study due to much food residual retention at stomach
    • Reflux esophagitis LA Classification grade A (minimal)
    • Superficial gastritis,body, s/p CLO test
    • Duodenal ulcer scar, bulb, AW site
    • Duodenal shallow ulcer, 2nd portion
  • 2022-04-14 CT - lung/mediastinum/pleura
    • Bilateral pulmonary metastasis with progression.
    • Consolidation over right lower lobe with right pleural effusion.
    • Heterogeneous low density lesions are found at residual right lobe liver is found. Liver hematoma is favored.
  • 2022-02-16 Abdominal Ultrasonography
    • chronic liver parenchymal disease
    • hepatic tumors, three c/w mets s/p MWA
    • ascites, mild
    • subcapsule hematoma
    • GB sludge
  • 2022-02-11 CT - liver, spleen, biliary duct, pancreas
    • Hematoma in S4-8 of the liver subcapsule is noted.
    • Hematoma or bloody ascites in subphrenic space, perisplenic space, and bilateral paracolic gutter space.
  • 2022-01-20 CT - liver, spleen, biliary duct, pancreas
    • Rectal cancer with liver/lung metastases s/p operation and RFA. Segeral poor enhancing tumors (up to 5.4cm) in liver c/w metastases.
    • Right pleural effusion with adjacent lung collapse. Some nodules at bil. basal lungs c/w metastases.
  • 2022-01-13 CT- lung/mediastinum/pleura
    • Colon cancer with liver and lung meta s/p op. and RFA at both lungs. Recurrent/residual tumor at both lungs and liver, suggest further treatment.
  • 2021-09-28 Patho - pleura/pericardial biopsy
    • Lung and pleura, right, decortication
      • empyema
      • metastatic adenocarcinoma, moderately differentiated, consistent with colonic origin
    • IHC: CK7(-), CK20(-), CDX2(focal +), and TTF-1(-). The results are consistent with metastatic colonic adenocarcinoma.
  • 2021-09-21 CT - lung/mediastinum/pleura
    • S/P right lung operation. Right pneumothorax with right lung collapse. Right pleural effusion. Some patchy densities at left lung.
  • 2021-07-27 CT - lung/mediastinum/pleura
    • bilateral pulmonary metastatic tumors, in progression compared with CT on 20210311.
  • 2021-03-29 Patho - lung wedge biopsy
    • Pathologic Diagnosis
      • Lung, left, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lung, left, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colonic tumor
      • Lymph node, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
    • Microscopic Description
      • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobe (S2021-4686)
      • Histologic Type (select all that apply): Adenocarcinoma; The morphology is consistent with metastatic colonic tumor.
      • Histologic Grade: G2: Moderately differentiated
      • Spread Through Air Spaces (STAS): Not identified
      • Visceral Pleura Invasion: Not identified
      • Lymphovascular Invasion (select all that apply): present
      • Direct Invasion of Adjacent Structures: No adjacent structures present
      • Margins (select all that apply): All margins are uninvolved by carcinoma
      • Treatment Effect: No known presurgical therapy
      • Regional Lymph Nodes: group 9: 0/1
      • Extranodal Extension: Not identified
      • Additional Pathologic Findings: No tumor is seen in specimen A.
  • 2021-03-11 CT - chest
    • Multiple spiculated nodules, in enlargement. Compatible with lung mets.
  • 2021-03-04 CT - abdomen
    • Mild decreased size of liver metastases. Small nodules at bil. lower lungs.
    • Left hydronephrosis and hydroureter. Bil. tiny renal stones.
  • 2020-12-30 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • Two lung metastases show stable disease.
  • 2020-09-23 CT - abdomen
    • Two metastases in S7/8 and S7 show stable disease.
    • A metastasis 5 mm in LUL of the lung is suspected.
    • Left L/3 ureter stone causing hydroureteronephrosis and delayed contrast excretion of left kidney.
  • 2020-07-19 CT - chest
    • right pneumothorax
    • suspicious a nodular lesion, about 20mm, in the lower lobe of the right lung.
  • 2020-07-02 Patho - lung wedge biopsy
    • Lung, right, middle lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Lung, right, lower lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
  • 2020-07-01 Patho - lung wedge biopsy
    • Lung, right, upper lobe, wedge resection —- Adenocarcinoma, moderately differentiated, consistent with metastatic colorectal origin
    • Tumor Focality: Separate tumor nodules of same histopathologic type in different lobes (S2020-8766 and S2020-8767)
    • IHC: MSH2(+), MSH6(+), MLH1(+), and PMS2(+).

[consultation]

  • 2023-04-18 Ear Nose Throat
    • Q
      • for tinnitus & obstruction sensation for one day
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. He complained of tinnitus & obstruction sensation for one day. We need expertise to evaluate his condition thanks!
    • A
      • S
        • Hx of COM and OME?
        • Complained of aural fullness, s/s relieved intermittently via Vasalva maneuver
      • O
        • Ear: bil intact, no sign of OME
        • NPx: smooth via scope
      • Imp: Eustachian tube dynsfuction
      • Plan:
        • May try Sindecon nasal spray 2 puff QD per NA
        • Explained th further tx of ventilation tube insertion and tuboloplasty to patient
  • 2023-04-06 Family Medicine
    • Q
      • for share care or hospice care
      • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted due to dyspnea & pneumonia for anti treatment. Owing to disease progression noted and we explained his poor condition to patient and DNR was consented. We need expertise to evaluate his condition thanks!
    • A
      • 59 y/o gentleman Advanced Colon cancer
      • DNR(+)
      • Our share care would follow up.
      • Would put p’t on hospice ward list if family agree.
  • 2023-03-23 Infectious Disease
    • Q
      • The 59 y/o male was Dx: (1) COVID-19 (2) Pneumonia (3) Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis . Allergy: Penicillin. We need your expertise for further treatment. Thank you very much
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRP
  • 2023-02-27 Rehabilitation
    • Q
      • for left hand pain & limited of activity (unable to raise hands)
      • for nerve block or steroid treatment
      • This 60-year-old man, a patient of colon cancer with liver & lung mets S/P C/T. He was admitted due to pneumonia for anti treatment. He complained of left hand pain & limited of activity (unable to raise hands) for days. We need expertise to evaluate his condition thanks!
    • A
      • The patient complained left shoulder pain and ROM limitation for at least 1 year, rather than left hand pain or weakness.
        • Due to left shoulder pain and ROM limitation, we were consulted for further evaluation and treatment.
        • Present illness: The patient fell in 2021/11 with hitting to left shoulder. The pain and ROM limiation progressed. He had a diagnosis of left rotator cuff tear 0.5cm over left shoulder in other rehab clinic, and recieved prolo-injection with glucose, amniotic membrane (2022/09) or steriod injection, but all in vain during 2022 ~ 2023.
      • Left shoulder ROM(a/p)
        • Flex: 30’/90’
        • ABD: 30’/80’
        • Ext.: 70’/75’
        • Int: 15’/15’
      • Left shoulder sonogram at 2023/2/27 1700:
        • No tear was noted. (but we could not see all tendon part due to severe ROM limiation)
        • SS tendinitis.
      • Assessment
        • Rectal cancer with liver and lung metastasis, stage IV status post microwave ablation on 2022/02/11 with capsule hematoma and hepatitis
        • r/o left frozen shoulder
      • Plan
        • Please send patient to 5F Sono Room at 20230303 08:30 for treatment
        • Please arrange left shoulder X ray
        • Please arrange rehab OPD follow up after discharge
  • 2022-09-29 Ophthalmology
    • Q
      • this consultation is for right eye foreign body sensation management.
      • We have arranged EUS FNB for gastric submucosal lesion on 2022/09/28. After he came back from examination room, he complained right eye foreign body sensation and painful sensation. The symptom persisted after ice packing. He had no blurred vision, visual field defect. There was also no swelling nor subconjuntival hemorrhage noted. Due to above reason, we sincerely need your expertise for right eye foreign body sensation management.
    • A
      • S OD FBS since yesterday
      • O
        • FBS, tearing
        • EUS FNB under aesthesia yesterday
        • rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B
        • denied oph hx
        • nka
        • BCVA od 0.8x-1.75/-1.0x25 os 0.9x-1.50/-0.50x80
        • IOP 14/13mmHg
        • Pupil 3/3 +/+
        • conj np ou
        • K od peripheral ED 3*2.8mm, no infiltration os clear
        • AC D/cl ou
        • Lens ns+ ou
      • A Corneal ED od
      • P
        • Cravit 1gtt qid + duratear 1qs bid od
        • inform the risk of infection, if worsen vision, come back asap
        • the patient will follow at LMD first
  • 2022-09-24 General and Gastroenterological Surgery
    • Q
      • this consultation is for gastric submucosal lesion management.
      • This 59 y/o man is a case of rectal cancer with liver and lung metastasis, DU, hypothyroidism and chronic hepatitis B. He had sudden onset of epigastric pain on 2022/09/22 and went to Tamsui Mackey’s ER for help. PES and abdominal CT showed a huge submucosa tumor around 6.2cm at posterior wall of the body. He was suggested admission but patient refused and visited our ER for his previous medical record at our hospital.
      • Due to above reason, we sincerely need your expertise for gastric submucosal lesion management. Thanks!
    • A
      • A case of rectal ca with liver and lung meta s/p tx
      • sudden on set of upper abd pain and CT scan revealed an submucosal gastric mass that was not noted at last two months CT scan.
      • gastric submucosal tumor with bleeding may considered. I wound like to suggested EUS and aspiration cystology to proved any tumor present, Thanks and let me know if there is any tumor present.
  • 2022-02-11 Diagnostic Radiology
    • Q
      • FOR ANGIO.
      • this is a 58 y/o, a case of rectal ca with liver and lung meta. s/p RFA on 2022/02/11.
      • CTA showed HYPODENSE LESION over RUQ, r/o hematoma after RFA.
      • we need your expertise for angio.
    • A
      • According to the clinical condition and imaging findings, angiography is indicated.
  • 2021-09-21 Thoracic Surgery
    • Q
      • dyspnea.
      • chest ct in 2021/07: bilateral pulmonary metastatic tumors, in progression compared with CT on 2021/03/11.
    • A
      • The patient had metastastic lung cancer s/p RF, Rt. treatment recently.
      • Dyspnea, hemoptysis and hemopneumothorax was found today
      • Suggestion:
        • Catheter drainage
        • ICU monitoring
  • 2021-09-17 Diagnostic Radiology
    • Q
      • Purpose: for lung nodules RFA, right
      • This 58-year-old a case of Rectum cancer metastasis to liver and lung.
      • Rectum cancer with liver and lung metastases, cT3N1M1, stage IVB s/p neoadjuvant short radiotherapy s/p subsegmentectomy, ypT3N2aM1,s/p chemotherapy and RFA
      • There were no discomfort was told, included cough, sputum, chest pain, chest tightness and hemoptesis.
      • We need your help to arrange right lung nodules RFA on 2021-09-16 12:30. Thank you very much.
    • A
      • CT guided RFA for lung tumor is scheduled at 12:30 2021/09/16. Thank you for your consultation.
  • 2020-07-20 Thoracic Surgery
    • Q
      • PH: rectal cancer ; lung cancer s/p op this July
      • allergy: penicillin
    • A
      • I will take over this case. Thanks for your consultaiton!!

[surgical operation]

  • 2022-02-11 MWA, Microwave ablation

    • Procedure
      • Liver metastatic tumors, three (5.5 cm, 2.5 cm and 1.9 cm) s/p MWA x (total 11 sessions)
    • Course
      • By sono-guided, MWA probe was inserted to the 1st tumor (total 9 sessions; 100 W, 5 mins). MWA probe were inserted to the other two tumors (total 2 sessions; 70 W, 3 mins). The patient tolerated the procedure. IV anesthesia was performed during the procedure.
    • Findings
      • A 5.5 cm tumor was noted at S7 near diaphragm. A 2.5 cm mass at rt post seg near liver surface. A 1.9 cm mass at rt ant seg near liver surface.
  • 2021-09-27 VATS, decortication

    • Loculated serosanguenous pleural effusion with fibrotic debris over visceral and parietal pleura
    • Necrotic RLL parenchyma were bleeding during debridement s/p 4D field hemostatic powder treatment
  • 2021-03-29 VATS, LUL and LLL wedges resection for metastasectomy + pneumolysis

    • multiple solid nodules over LUL and LLL r/o rectal cancer metastasis
    • LUL nodules x7 and LLL nodules x3 were resected with one of the maximum about 1cm in diameter
    • no noted pleural effusion. Intrapleural cavity adhesion s/p pneumolysis
  • 2021-09-16 RFA, Radiofrequency Ablation

  • 2021-08-19 RFA, Radiofrequency Ablation

  • 2020-07-01 3D VATS RUL, RML and RLL wedge resections + LND. decortication        

    • Multiple lung nodules were noted over right lung field.
  • 2018-03-29 laparoscopic lower anterior resection w/ TaTME and S3, S8 subsegmentectomy + S5 cyst unroofing (Taipei Veterans General Hospital)

[radiotherapy]

  • 2018-002-01 ~ 2018-02-06 - neoadjuvant short radiotherapy of 25Gy/5fx for adenocarcinoma of lower rectum with liver mets, at Taipei Veterans General Hospital

[chemoimmunotherapy]

  • 2023-01-31 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 300mg NS 100mL 1.5hr + oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + irinotecan 175mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04
  • 2022-12-15
  • 2022-11-21
  • 2022-10-31
  • 2022-09-05
  • 2022-08-16
  • 2022-07-19
  • 2022-06-30
  • 2022-06-06
  • 2022-05-03
  • 2022-04-19 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-07-14 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-06-21
  • 2021-05-27
  • 2021-05-04 - pembrolizumab 100mg NS 100mL 1hr + bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 320mg D5W 250mL 90min + leucovorin 400mg/m2 740mg NS 250mL 2hr + fluorouracil 2800mg/m2 5200mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-17 - bevacizumab 5mg/kg 400mg NS 100mL 1.5hr + oxaliplatin 75mg/m2 140mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2021-02-02
  • 2021-01-13
  • 2021-12-30
  • 2020-12-09
  • 2020-11-25
  • 2020-11-10
  • 2020-10-27
  • 2020-10-13
  • 2020-09-29
  • 2020-09-15
  • 2020-09-01 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 175mg/m2 330mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-18 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 160mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2020-08-03 - oxaliplatin 60mg/m2 100mg D5W 250mL 2hr + irinotecan 140mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOXIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[note]

FOLFOXIRI chemotherapy for metastatic colorectal cancer 2023-04-25 https://www.uptodate.com/contents/image?topicKey=ONC%2F2503&imageKey=ONC%2F70559

  • Cycle length: 14 days.

  • Regimen

    • Irinotecan
      • 165 mg/m2 IV
      • Dilute with 500 mL D5W to a final concentration of 0.12 to 2.8 mg/mL and administer over 60 minutes.
      • Day 1
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute with 500 mL D5W and administer over two hours after irinotecan. Administer concurrently with leucovorin in separate bags via y-line connection. Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Levoleucovorin
      • 200 mg/m2 IV
      • Dilute with 250 mL D5W and administer over two hours, concurrent with oxaliplatin.
      • Day 1
    • Fluorouracil (FU)
      • 2400 to 3200 mg/m2 IV
      • Dilute in 500 to 1000 mL D5W and administer over 48 hours, after leucovorin. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL). The original protocol used 3200 mg/m2, but many United States oncologists use a lower starting dose (2400 mg/m2) and escalate as tolerated to reach a final dose of 3200 mg/m2.
  • Pretreatment considerations:

    • Emesis risk
      • HIGH (>90% frequency of emesis).
    • Prophylaxis for infusion reactions
      • There is no standard premedication regimen.
    • Vesicant/irritant properties
      • Oxaliplatin and fluorouracil are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
    • Infection prophylaxis
      • Routine primary prophylaxis with G-CSF is not warranted (estimated risk of febrile neutropenia 5%). However, given the high rate of grade 3 or 4 neutropenia (approximately 50%), primary prophylaxis may be considered for high-risk patients.
    • Dose adjustment for baseline liver or renal dysfunction
      • A lower starting dose of oxaliplatin and irinotecan may be needed for patients with severe renal insufficiency.[4,5] A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
    • Maneuvers to prevent neurotoxicity
      • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
    • Cardiac issues
      • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
  • Monitoring parameters:

    • CBC with differential and platelet count prior to each treatment.
    • Assess electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
    • Irinotecan is associated with early and late diarrhea, both of which may be severe. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine for later cycles.
    • Assess changes in neurologic function prior to each treatment.
  • Suggested dose modifications for toxicity (The specific dose alteration parameters for the FOLFOXIRI regimen in colorectal cancer patients were not published in the original phase III trial. The following suggestions are based upon dose reductions used in a trial using a comparable regimen (FOLFIRINOX) for advanced pancreatic cancer.)

    • Myelotoxicity
      • Do not retreat unless granulocyte count >= 1500/microL and platelet count is >= 75,000/microL.
      • Neutropenia:
        • If day 1 treatment delayed for granulocytes < 1500/microL or febrile neutropenia or grade 4 neutropenia > 7 days, reduce irinotecan dose to 150 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. If nonrecovery after two weeks, delay or third occurrence of granulocytes < 1500/microL on day 1, or febrile neutropenia or grade 4 neutropenia at any time during cycle, discontinue treatment.
      • Thrombocytopenia:
        • If day 1 treatment delayed for platelet count is < 75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 150 mg/m2. If nonrecovery after two weeks delay or third occurrence of platelets < 75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 150 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
    • Diarrhea
      • Do not retreat with FOLFOXIRI until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 150 mg/m2 and the continuous FU dose to 75% of original dose. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
    • Mucositis or palmar-plantar erythrodysesthesia
      • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
    • Neurotoxicity
      • For transient grade 3 paresthesias/dysesthesias or grade 2 symptoms lasting more than seven days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
      • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
    • Pulmonary toxicity
      • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
    • Cardiotoxicity
      • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
    • Other toxicity
      • Any other toxicity >= grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
      • For other nonhematologic toxicities, if grade 2, hold treatment until ≤grade 1; if grade 3 or 4, hold treatment until ≤grade 2.[5]
    • If there is a change in body weight of at least 10%, doses should be recalculated.

2023-05-08

  • Blood culture results from 2023-05-04 and 2023-04-27 indicate that Acinetobacter nosocomialis is susceptible to cefepime with a MIC of 2 ug/mL and levofloxacin with a MIC of less than 0.12 ug/mL. Cefepime has been administered since 2023-04-25, while levofloxacin was administered between 2023-04-06 and 2023-04-20. Since the 2023-05-08 CXR shows no significant improvement in the pneumonia, it might be appropriate to consider including meropenem or imipenem-cilastatin as potential next candidate antibiotics for treatment.

[tube feeding]

  • Since Harnalidge (tamsulosin 0.4mg PO QDAC) is not suitable for tube feeding, it is recommended to switch to Urief (silodosin 8mg PO QD) as an alternative for the patient’s needs.

2023-04-25

  • On 2023-04-25, the patient’s CRP was 4.03mg/dL, WBC count was 23.36K/uL, and neutrophils were at 89.1%. Tachycardia and tachypnea were also observed, along with a body temperature exceeding 38 degrees Celsius in the morning. Signs of lung infection remain evident. Cefim (cefepime) at 2000mg Q8H has been administered, and blood culture results are pending. Cravit (levofloxacin) was used for 2 weeks prior to cefepime.
  • Ipratran (ipratropium bromide), Sindecon (oxymetazoline), Actein (acetylcysteine) and Medason (methylprednisolone) are used to relieve respiratory symptoms.
  • The patient’s underlying conditions are being managed with appropriate medications: hypothyroidism is treated with Eltroxin (levothyroxine), HTN with Amtrel (amlodipine and benazepril), constipation with Through (sennoside), BPH with Harnalidge (tamsulosin), oral thrush with Mycostatin (nystatin) and pain with morphine and fentanyl.
  • No medication reconciliation issues have been identified after reviewing the PharmaCloud database. As the lab results indicate generally normal liver and kidney function, there is no need to adjust the drug dosages for liver or kidney-related reasons.
  • The patient has experienced a weight loss of more than 5 kg in the past two weeks (48.7 kg on 2023-04-05 and 54.5 kg on 2023-04-19). Adequate nutritional support may be needed to address this problem.

2022-04-20

  • This patient has MMR-proficient lower rectal cancer with liver and lung metastases (2020-07-01 pathology). The lung mets were confirmed to be in progress (2022-04-14 CT) followed by the MWA (2022-02-11) for the liver mets.
  • During this hospital stay, the patient resumed using FOLFOXIRI plus self-paid bevacizumab and pembrolizumab as a palliative treatment, the same regimen was used during 2021-05-04 to 2021-07-14. Before that, FOLFOXIRI plus bevacizumab were also used from August 2020 to February 2021.
  • Lab data reported on 2022-04-19 revealed that liver and kidney function, serum electrolytes, and blood cell counts were generally normal.
  • The nursing note does not indicate any intolerances so far since this hospitalization. No issue with current medication.

700358146

230505

{not completed}

[MedRec]

  • 2023-05-05 POMR progress note
    • Leukocytosis, suspect CML
      • Assessment: improved (WBC 225330 -> 72330 -> 71950 -> 64290 /uL)
      • Plan:
        • Bone marrow biopsy performed on 2023/05/02
        • Plasma exchange + Vitacal 60mL IVD for calcium supplement on 2023/05/02
        • Hydrea 500 mg/cap 2# BID start from 2023/05/02
    • Type 2 diabetes mellitus
      • Assessment: stable
      • Plan:
        • Januvia 100mg/tab 1# QD
        • Glucose one touch QDAC
        • Diet modification
    • Hypertension and hyperlipidemia
      • Assessment: stable
      • Plan:
        • Norvasc 5mg/tab 1# QD
        • Crestor 10mg/tab 0.5# QD
    • Hypokalemia + hypomagnesemia
      • Assessment: improving
      • Plan:
        • 0.298% KCl in 0.9% NaCl Injection 500 mL BID
        • Magnesium Sulfate 10% 20mL BID
  • 2023-04-27 SOAP Hemato-Oncology
    • S
      • Referred for leukocytosis noted on 2023-04-27.
      • Occupation touched paint solvent in the past
    • O
      • 2023/04/26
        • Band = 12.0 %;
        • Neutrophil = 51.0 %;
        • Lymphocyte = 2.0 %;
        • Monocyte = 6.0 %;
        • Eosinophil = 0.0 %;
        • Basophil = 1.0 %;
        • Metamyelocyte = 10.0 %;
        • Myelocyte = 3.0 %;
        • Promyelocyte = 15.0 %;
        • WBC = 104.08 x10^3/uL;
        • RBC = 3.61 x10^6/uL;
        • HGB = 11.6 g/dL;
        • HCT = 34.9 %;
        • MCV = 96.7 fL;
        • MCH = 32.1 pg;
        • MCHC = 33.2 g/dL;
        • PLT = 380 x10^3/uL;
        • RDW-CV = 16.1 %;
        • MPV = 11.1 fL;
    • A/P
      • Admission for BM study and leukopheresis
      • Already request patient to ER if any condition

[exam findings]

  • 2023-05-02 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Myeloproliferative neoplasm (Differential diagnosis: Chronic myeloid leukemia and, … etc.)
      • NOTE: Correlation of bone mrrow smear, peripheral blood data, molecular genetic study (BCR/ABL), flow cytometery and clinical findings is recommended.
    • Microscopically, it shows nhyper cellularity (> 95%), 10:1 of M:E ratio. Both myeloid and erythroid lineages demonstrate maturation. Megakaryocytes are present in increased in numbers (6~8 per HPF) and demonstate hypholobulated morphologic pattern. Blast-like cells (CD117+, < 5%) are present.
    • Immunohisotchemical stain reveals CD34(-), CD138(focal+, 1~2%), MPO(+), CD71(focal +), CD61(+).

[assessment - not posted]

  • Hyperleukocytosis has been mitigated by the administration of Hydrea (hydroxyurea 500mg) 2# BID since 2023-05-02.
    • 2023-05-05 WBC 64.29 x10^3/uL
    • 2023-05-04 WBC 71.95 x10^3/uL
    • 2023-05-03 WBC 72.33 x10^3/uL
    • 2023-05-02 WBC 225.33 x10^3/uL
    • 2023-05-02 WBC 107.47 x10^3/uL
    • 2023-04-30 WBC 90.67 x10^3/uL
    • 2023-04-29 WBC 93.95 x10^3/uL
    • 2023-04-26 WBC 104.08 x10^3/uL
  • While allopurinol or febuxostat might be considered for prophylaxis of potential tumor lysis syndrome, laboratory data shows a decrease in serum uric acid levels.
    • 2023-05-03 Uric Acid 6.9 mg/dL
    • 2023-04-30 Uric Acid 8.1 mg/dL
    • 2023-04-29 Uric Acid 8.3 mg/dL

700514733

230505

[exam findings]

  • 2023-04-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette
  • 2023-04-13 All-RAS + BRAF
    • ALL-RAS: Detected(KRAS codon 12 GGT>AGT, p.G12S)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-31 CT - abdomen
    • CC: BW loss (+), anemia
      • 20230320 colonoscopy: An ulcerative tumor with lumen obstruction was noted at level probably at ascending colon
      • PATHO: Adenocarcinoma, moderately differentiated
    • Findings:
      • There is segmental circumferential asymmetrical wall thickening at the ascending colon with irregular contour and adjacent omentum fatty stranding, measuring 8 cm in length that is c/w adenocarcinoma (T4b).
        • In addition, there are seven enlarged nodes in the adjacent mesocolon (N2b).
      • There is mild ascites in the cul-de-sac.
      • There is a small soft tissue nodule in RLL of the lung, measuring 3 mm in size at lung window setting.
        • Follow up chest CT 3 months later is indicated.
      • There are several stones in the distal CBD.
        • In addition, there are multiple gallstones.
      • The spleen shows prominence in size (long axis:11.4 cm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-27 Bronchodilator Test
    • Normal ventilatory function
    • Not significant bronchodilator reversibility
  • 2023-03-21 Patho - colon biopsy
    • Colon, ascending, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2023-03-20 Colonoscopy
    • Colon cancer, ascending colon, s/p biopsy
    • Colon polyp, transvers colon, s/p biopsy
    • Internal hemorrhoid
  • 2023-03-20 Esophagogastroduodenoscopy, EGD
    • Superfical gastritis, antrum
    • Duodenal ulcer scar, bulb, LC
  • 2023-03-03, -02-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Interstitial and alveolar infiltrates involving predominantly the mid-and lower-lung fields, and mild pleura effusions are seen. Acute pulmonary edema is highly suspected.
  • 2023-02-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (171 - 64) / 171 = 62.57%
      • M-mode (Teichholz) = 62
    • Conclusion
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA and LV, elevated LA filling pressure
      • Mild to moderate TR, moderate MR, PR
      • Pulmonary hypertension
  • 2023-02-23 ECG
    • Sinus tachycardia
    • Nonspecific ST and T wave abnormality
  • 2023-02-23 SONO - nephrology
    • No significant abnormality from echography for both kidneys.
    • Bilateral plerual effusion.

[MedRec]

  • 2023-04-12 ~ 2023-04-15 POMR Hemato-Oncology
    • Discharge diagnosis
      • adenocarcinoma, moderately differentiated of colon cancer T4N2bM0 stage IIIC S/P C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
      • chronic viral hepatitis B without delta-agent HBsAg positive
    • CC
      • for C1 chemotherapy with Erbitux (self-paid)/FOLFIRI
    • Discharge prescription
      • Baraclude (entecavir 0.5mg) 1# QDAC 7D
      • loperamide 2mg 1# PRNQ6H 7D (if watery diarrhea > 3 times)
      • Roumin (prochlorperazine maleate 5mg) 1# TID 7D (note: used to treat severe nausea and vomiting)
  • 2023-04-07 SOAP Hemato-Oncology
    • O
      • 2023/04/07 CA-199 (NM) = 192.235 U/ml;
      • 2023/04/07 CEA (NM) = 347.620 ng/ml;
    • A/P
      • arrange admission on April 10 + port-A chemotherapy
  • 2023-04-06 SOAP Colorectal Surgery
    • A/P
      • Lung nodule, cause ?? metastasis ??
      • Advanced A-colon cancer with retroperitoneal invasion;
      • Suggest systemic chemotherapy +/- target therapy for tumor shrinkage and may increase resectability
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/08 FKLC = 39.3 mg/L;
      • 2023/03/08 FLLC = 51.0 mg/L;
      • 2023/03/08 FK/FL ratio = 0.77 ratio;
      • 2023/03/04 M-peak = Positive;
      • 2023/03/04 Stool OB (LIA) = Positive;
      • 2023/03/04 Occultblood (LIA) quantitative value = >999 ng/mL;
      • 2023/03/03 B2-Microglobulin = 2906 ng/mL;
      • 2023/03/02 Ferritin = 23.1 ng/mL;
      • 2023/02/27 WBC = 9.48 x10^3/uL;
      • 2023/02/27 HGB = 8.7 g/dL;
      • 2023/02/27 PLT = 412 x10^3/uL;
      • 2023/02/24 OB = Negative;
      • 2023/02/24 Fe (Iron-bound) = 363 ug/dL;
      • 2023/02/24 TIBC = 442 ug/dL;
      • 2023/02/24 UIBC = 79 ug/dL;
    • A/P
      • suggest to check bone marrow
      • patient is scheduled to check colonfibroscopy at 2023/03/20
      • wait the colonfibroscopy result.
  • 2023-02-23 ~ 2023-02-27 POMR Cardiology
    • Discharge diagnosis
      • Heart failure, EF 62%, moderate MR, NT pro BNP 1812
      • Anemia, Fe 363, stool OB negative
      • Essential (primary) hypertension
      • Hypoalbuminemia, proteinuria(+/-)
    • CC
      • bilateral lower limbs edema and exertional shortness of breath progressively for the past 2 weeks
    • Discharge prescription
      • spironolactone 25mg 0.5# QD 5D
      • Zanidip (lercanidipine 10mg) 0.5# QD 5D
      • Ulstop (famotidine 20mg) 1# BID 5D
      • Torsix (torsemide 5mg) 1# QD 5D
      • Torsix (torsemide 5mg) 0.5# PRNQD 5D (prepared for BW increase > 0.5kg or edema)
      • Blopress (candesartan 8mg) 1# QD 5D
  • 2023-02-23 SOAP Nephrology
    • S
      • Bilateral lower leg edema for one week
      • DOE (+) for one week
      • Orthopnea (-) PND (-)
      • Foamy urine (-)
      • PH: DM (-) HTN (-) Drug allergy: denied
      • Herb use : denied
      • To ER for CHF with severe anemia.
    • O
      • BP:170/54; HR:105;
      • BW not measured
      • Leg edema (+++)
      • CVA knocking pain (-)
      • BS: clear
      • NT-proBNP elevated
      • Bilateral pleural effusion
      • Hb 4.4
      • MCV 56.9
      • Urine examination: not collected
    • A/P:
      • Refer to ER for suspected CHF with severe anemia.

[chemoimmunotherapy]

  • 2023-05-04 - cetuximab 500mg/m2 700mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3360mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL
  • 2023-04-13 - cetuximab 400mg/m2 500mg 2hr + irinotecan 160mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3400mg NS 500mL 46hr (cetuximab + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg PO + acetaminophen 500mg PO + NS 250mL

[assessment]

  • Microcytic anemia, possibly caused by iron deficiency, has been present in the patient’s laboratory data for months, with low RBC, HGB, MCV, MCH, MCHC, and high RDW, even before the start of Cetuximab/FOLFIRI chemoimmunotherapy. Iron supplementation is recommended. After the planned blood transfusion, the addition of an oral form such as Foliromin tablets (ferrous sodium citrate 50mg) or Ferrum Hausmann drops (ferric hydroxide polymaltose complex) or an injectable form such as Ferrum (ferric hydroxide sucrose) may be considered.
    • 2023-05-04 HGB 7.7 g/dL
    • 2023-04-21 HGB 8.5 g/dL
    • 2023-04-12 HGB 7.0 g/dL
    • 2023-03-31 HGB 7.1 g/dL
    • 2023-02-27 HGB 8.7 g/dL
    • 2023-02-24 HGB 7.7 g/dL
    • 2023-02-23 HGB 4.4 g/dL
    • 2023-05-04 MCV 76.8 fL
    • 2023-04-21 MCV 76.8 fL
    • 2023-04-12 MCV 74.9 fL
    • 2023-03-31 MCV 74.3 fL
    • 2023-02-27 MCV 71.1 fL
    • 2023-02-24 MCV 66.6 fL
    • 2023-02-23 MCV 56.9 fL
    • 2023-05-04 MCH 22.3 pg
    • 2023-04-21 MCH 22.9 pg
    • 2023-04-12 MCH 21.7 pg
    • 2023-03-31 MCH 21.0 pg
    • 2023-02-27 MCH 20.4 pg
    • 2023-02-24 MCH 19.6 pg
    • 2023-02-23 MCH 14.9 pg
    • 2023-05-04 MCHC 29.1 g/dL
    • 2023-04-21 MCHC 29.8 g/dL
    • 2023-04-12 MCHC 28.9 g/dL
    • 2023-03-31 MCHC 28.3 g/dL
    • 2023-02-27 MCHC 28.7 g/dL
    • 2023-02-24 MCHC 29.5 g/dL
    • 2023-02-23 MCHC 26.2 g/dL
    • 2023-05-04 RDW-CV 22.7 %
    • 2023-04-21 RDW-CV 23.5 %
    • 2023-04-12 RDW-CV 27.0 %
    • 2023-02-24 RDW-CV 30.5 %
    • 2023-02-23 RDW-CV 21.2 %

700732120

230505

{not completed}

[MedRec]

  • 2021-03-30 ~ 2021-05-06 POMR General and Digestive Surgery
    • Discharge diagnosis
      • Adenocarcinoma of renmant anterior gastric with liver S2-3 invasion, pT4bN2(cM0); pStage: IIIB, status post total gastrectomy with splenectomy + en block S2-3 resection and lymph node dissection on 2021/04/22. ECOG:2
      • Malignant neoplasm of stomach, unspecified
      • Distal common bile duct stone status post common bile duct explore with stone resection with scope and common bile duct primary repair on 2021/04/22.
      • Bacteremia due to Acinetobacter ursingii related
      • Hypoalbuminemia
    • CC
      • RUQ abdominal pain with radiation to back for over 1 week

[surgical operation]

  • 2021-04-22
    • Surgery
      • total gastrectomy with splenectomy
      • en block S2-3 resection
      • retreoperitoneal LN dissection
      • CBDE with stone retraction with scope and CBE primary repair
    • Finding
      • 7 x 6.5 cm ulcerative mass at renmant anterior stomach with S2-3 invasion
      • multiple LN enlarge at 7,8,9
      • multiple pigment stones at distal CBD with CBD 1.8cm diameter

[medication]

2023-03-15 ~ 2023-03-29 - UFT (tegafur 100mg, uracil 224mg) 2# BID

2022-02-08 ~ 2022-04-25 - TS-1 (tegafur, gimeracil, oteracil) 2# BID

2021-09-09 ~ 2021-10-15 - Xeloda (capecitabine 500mg) 2# BID

B-Red (hydroxocobalamin 1mg)

700930564

230505

[diagnosis] - 2023-03-22 SOAP

  • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
  • gastric adenocarcinoma in situ

[past history]

  • Denied TB, Asthma, DM, HTN or Malignancy diseases.
  • No known allergens
  • Denied other admission or operation history.    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-05-02 Ascites Tapping
    • 3000ml yellowish color ascites were drained.
  • 2023-04-28 ECG 24hr portable
    • Sinus rhythm
    • Occasional isolated apcs
    • Frequent apc couplets
    • Paroxysmal atrial flutter-fibrillation
    • Occasional isolated vpcs
    • No long pause
  • 2023-04-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 10) / 53 = 81.13%
      • M-mode (Teichholz) = 81
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis and prominent posterior mitral annulus calcification with mild AR; mild MR.
      • Sinus tachycardia.
      • Ascites and pleural effusions.
  • 2023-04-27 ECG
    • Supraventricular tachycardia
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2023-03-27 Ascites Tapping
    • Indication: Ascites
    • Symptoms: Abdominal fullness
    • Course: 18G needle was inserted at RLQ under echo guided insertion.
    • Findings: 3000 ml straw color ascites was drained.
  • 2023-03-26 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Spondylosis with scoliosis of the L-spine with convex to right side
  • 2023-03-17 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
  • 2023-03-09 Patho - pancreas biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pancreas, FNB — Ductal adenocarcinoma, poorly differentiated
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of tan gray soft tissue, labeled pancreas, measuring up to 1.0 x 0.1 x 0.1 cm. All for section.
    • MICROSCOPIC EXAMINATION
      • The sections show a picture of adenocarcinoma, composed of nests, cords, and single pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation and mucin secretion can be found. Tumor necrosis is present also.
  • 2023-03-08 Endoscopic Ultrasound
    • Diagnosis
      • Pancreatic body tumor, s/p CH-EUS & EUS/FNB
      • Pancreatic cystic tumor, body
      • Lymphadenopathy, periarotic area
    • Suggestion
      • Pursue pathology result
      • regular F/U
  • 2023-03-03 MR Cholangiography, MRCP
    • History
      • 20230226 CC: Abdominal Pain
      • 20230226 CT: A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases.
      • 20230227 CA199:582 U/mL (< 35), CEA: normal.
    • Findings:
      • There is a mass lesion in the pancreatic body and tail, 7.8 x 3.2 cm in size, showing hypointensity on T1WI, mild hyperintensity on T2WI and DWI. During contrast enhanced study, this lesion shows poor enhancement in arterial phase, portal venous phase, and delayed phase images.
        • Adenocarcinoma of the pancreatic body and tail (T3) is noted.
        • In addition, there is non-visualization of the splenic vein that is c/w tumor invasion.
      • There are five enlarged nodes in the celiac trunk, gastrohepatic ligament, and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There are two masses 1.8 cm and 1.2 cm in S7 of the liver, shows mild hyperintensity on both T2WI and DWI, and poor enhancement.
        • Two liver metastases (M1) are noted.
      • There is massive ascites and multiple soft tissue nodules in the omentum that is c/w carcinomatosis (M1).
        • Please correlate with ascites cytology.
      • Bil. renal cysts (up to 6.6cm).
      • Hyperplasia of left adrenal gland.
    • IMP:
      • Adenocarcinoma of the pancreatic body and tail with liver metastases and carcinomatosis is suspected.
      • According to American Joint Committee on Cancer (AJCC) staging system,8th edition for pancreatic cancer: T3 N2 M1, stage: IV
  • 2023-03-01 Patho - stomach biopsy
    • Duodenum, SDA to second portion, biopsy (A) — chronic inflammation and Brunner’s gland hyperplasia.
    • Stomach, Gastric ulcer, AW of lower antrum, s/p biopsy(B)— Chronic gastritis with intestinal metaplasia, H pylori NOT present
    • Stomach, Gastric erosion, PW of upper antrum, s/p biopsy(C)— ulcer with adenocarcinoma in situ (AIS), demonstrated with IHC stain of cytokeratin.
    • Stomach, Gastric lesion, GC of upper antrum, s/p biopsy(D)— Chronic gastritis, H pylori NOT present
  • 2023-02-27 Cell Block - Ascites
    • DIAGNOSIS:
      • SMEARS and CELLBLOCK: positive for malignancy; IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-).
    • GROSS DESCRIPTION:
      • 21 ml turbid
    • MICROSCOPIC DESCRIPTION:
      • SMEARS and CELLBLOCK: clusters of papillae with large nuclei and large cytoplasmic vacuole, a picture od adenocarcinoma.
      • IHC stains: CK7 (+), CK20 (-), CDX2 (-), CA19-9 (-), CK19 (-). The picture does NOT support gastric or pancreato-biliary origin.
  • 2023-02-26 CTA - abdomen
    • A poor enhancing lesion (3.2x5.1cm) at pancreatic body and tail with SMA and SMV invasion r/o malignancy. R/O peritoneal carcinomatosis and liver metastases. Massive ascites. Enlargement of prostate.

[MedRec]

  • 2023-03-22 SOAP Hemato-Oncology
    • S
      • This 78 year old man is a case of pancrease cancer with liver and peritoneal metastasis, stage IV, and gastric adenocarcinoma in situ.
      • The patient is currently unaware of the pancreatic cancer situation and only knows about the presence of a gastric tumor.
    • O
      • Lab
        • 2023-02-27 CA199 582.59 U/mL
        • 2023-02-27 CEA 1.82 ng/mL
      • Will on Abraxane plus gemcitabine
    • A
      • pancrease cancer with liver metastasis and perinteal seeding stage IV, with maligancy ascites
      • gastric adenocarcinoma in situ
    • P
      • admiited for port A insertion, family meeting, symptom control, discuss with palliative chemotherapy
      • refer to ER for ascites tapping and then admission for further management.
  • 2023-02-26 ~ 2023-03-09 POMR Gastroenterology and Hepatology
    • Discharge diagnosis
      • Suspicious pancreas cancer of body and tail with liver and peritoneum metastasesis T3N2M1, stage: IV, ECOG:2, status post paracentesis, status post endoscopic ultrasound-guided fine needle biospy on 2023/03/08
      • Gastric adenocarcinoma in situ
      • Gastric ulcer
      • Duodenal erosion
      • Colon polyps, cecum, proximal ascending and transverse colon, status post polypectomy
    • CC: abdominal distention for days
    • Prescription
      • spironolactone 25mg 2# QD
      • Nexium (esomeprazole 40mg) 1# QDAC
      • Through (sennoside 12mg) 1# HS
      • Curam (amoxicillin 875mg + clavulanic acid 125mg) 1# Q12H 3D

[chemotherapy]

  • 2023-04-24 - Nab-paclitaxel 80mg/m2 100mg 90min + gemcitabine 800mg/m2 800mg NS 100mL 30min (D1) dose reduced due to adverse reactions
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-04-03 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-03-27 - Nab-paclitaxel 100mg/m2 120mg 90min + gemcitabine 1000mg/m2 1200mg NS 100mL 30min (D1,8,15)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

[note]

hyperbilirubinemia - ref: 2023-05-05 UpToDate

  • An increase in unconjugated bilirubin in serum results from overproduction, impairment of uptake, or impaired conjugation of bilirubin. Unconjugated hyperbilirubinemia may be caused by:
    • Hemolysis
    • Extravasation of blood into tissue
    • Dyserythropoiesis
    • Stress situations (eg, sepsis) leading to increased production of bilirubin
    • Impaired hepatic bilirubin uptake
    • Impaired bilirubin conjugation
  • An increase in conjugated bilirubin is due to decreased excretion into the bile ductules or leakage of the pigment from hepatocytes into serum. Conjugated hyperbilirubinemia may be caused by:
    • Biliary obstruction (eg, gallstones, pancreatic or biliary malignancy, AIDS cholangiopathy, parasites)
    • Viral hepatitis
    • Alcoholic hepatitis
    • Nonalcoholic steatohepatitis
    • Primary biliary cholangitis
    • Drugs and toxins
    • Ischemic hepatopathy
    • Liver infiltration
    • Inherited disorders (eg, Dubin-Johnson syndrome, Rotor syndrome, progressive familial intrahepatic cholestasis)
    • Total parenteral nutrition
    • Postoperative jaundice
    • Intrahepatic cholestasis of pregnancy
    • End-stage liver disease
    • Organ transplantation (eg, bone marrow, liver)

CA199, CEA - ref: 2023-05-05 ChatGPT

  • CA199: Elevated levels of CA199 can be associated with certain types of cancer, particularly pancreatic cancer. It may also be elevated in other malignancies such as colorectal, gastric, liver, and bile duct cancers.
  • CEA: CEA is a tumor marker, which means that its levels in the blood can become elevated in the presence of certain types of cancer, particularly colorectal cancer. However, CEA is not a specific marker, and its levels can also be elevated in other malignancies, such as lung, breast, stomach, pancreas, and ovarian cancers.

==========

2023-05-05

  • Nab-paclitaxel and gemcitabine treatment was first initiated on 2023-03-27 and is currently ongoing. The 3rd dose was administered on 2023-04-24 with a 20% reduction in dosage due to dizziness, nausea, and vomiting. The patient also experienced conscious disturbance and abdominal fullness, which led to ascites tapping on 2023-05-02.

  • After receiving 3 doses of the regimen, the patient’s tumor marker CA199 remains relatively unchanged, while there is a significant increase in CEA levels.

    • 2023-05-05 CA199 1087.93 U/mL
    • 2023-04-11 CA199 1161.06 U/mL
    • 2023-03-28 CA199 (Nuclear Medicine) 1151.56 U/ml
    • 2023-02-27 CA199 582.59 U/mL
    • 2023-05-05 CEA 5.54 ng/mL
    • 2023-04-11 CEA 3.78 ng/mL
    • 2023-03-28 CEA (Nuclear Medicine) 1.869 ng/ml
    • 2023-02-27 CEA 1.82 ng/mL
  • The TPR panel indicated no bowel movement on 2023-05-03 and 2023-05-04. It is suggested to assess whether the patient has developed constipation, as bisacodyl is prescribed as needed (PRN) for this issue.

2023-05-02

[tube feeding]

  • As of 2023-05-01, the patient’s serum potassium level has returned to the normal range of 3.5 mmol/L. However, the current prescription for Const-K will expire on 2023-05-04, and it may be worth considering discontinuing this medication. It should be noted that the potassium content of fruits is relatively low (for example, about 2.2 mEq/inch or 0.9 mEq/cm in bananas), meaning that it would take about two to three bananas to provide 40 mEq. Const-K is an extended-release formulation containing 10 mEq/tab, which is less potassium than is found in one banana. If injectable potassium supplementation is not preferred (Const-K remains the only oral potassium supplement available today), please crush the tablet into particles and administer it with water.

  • For patients who have difficulty swallowing Protase (pancrelipase) capsules, the capsule can be opened and the enteric-coated granules can be released into a small amount of liquid food with a pH not exceeding 5.5. Tube feed the drug particles with drinking water or juice to ensure complete ingestion.

  • As for Megejohn (megestrol acetate), since our hospital has Megest (megestrol 40mg/mL, 120mL/bot) in stock, it is suggested to switch Megejohn to the Megest oral suspension.

2023-03-25

  • The patient has been diagnosed with stage IV pancreatic cancer with liver metastasis and peritoneal seeding, as well as in situ gastric adenocarcinoma. Although the patient is currently only aware of the stomach tumor, the pancreatic cancer is more advanced and should be prioritized for treatment.
  • It is possible that the modified FOLFIRINOX regimen could be considered for this patient, provided that the patient has an ECOG score of 0 or 1.

700279535

230504

[allergy]

  • NKDA

[family history]

  • Aunt: DM
  • Uncle: Colon ca
  • Father: heart disease, ESRD under hemodialysis

[exam findings]

  • 2023-05-03 Endoscopic Ultrasound, EUS
    • Pancreatic body cancer, s/p CH-EUS & EUS/FNB (B)
    • Hepatic tumors, s/p CH-EUS & EUS/FNB (A)
    • Lymphadenopathy
  • 2023-05-02, -04-27 CXR
    • Fibrosis of right upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2023-04-17 CT - abdomen
    • Indication:
      • HBV f/u, elevated CEA and CA-199
      • multiple liver tumor, suspicious pancreatic tumor with liver metastasis.
    • Abdominal CT with and without enhancement revealed:
      • Soft tissue mass at pancreatic body/neck junction measuring 2.9cm in largest dimension is found. Pancreatic cancer is considered. The distal pancreatic duct is obstructed with dilatation.
      • Low density lesions scattered at both lobes of liver measuring 2.8cm are found. Liver meta is considered.
    • IMP: Pancreatic cancer with liver meta.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-04-15 SONO - abdomen
    • Diagnosis
      • Liver tumors, favor metastatic tumors
      • pancreatic tumor
      • mild fatty liver, suspected mild liver parenchyma disease
    • Suggestion
      • 4 phase CT or dynamic MRI study
  • 2022-10-08 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • fatty infiltration of pancreas
      • suspected pancreatic lesion: hypoechoic
    • Suggestion
      • suggest further image study such as CT scan or MRI or EUS
  • 2022-03-26 SONO - abdomen
    • Diagnosis
      • Liver tumor favor hemangioma
      • mild fatty liver, suspected mild liver parenchyma disease
      • some parts of pancreas not shown
    • Suggestion
      • Regular F/U

[consultation]

  • 2023-05-04 Dermatology
    • Q
      • Patient was 50 years old men, history of HBV carrier regular follow up.
      • For suspect pancreatic cancer with liver meta. cT2N0M1, This time, admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion.
      • He has psoriasis more than ten years, we need your consultation for evaluation.

[MedRec]

  • 2023-04-19 SOAP Hemato-Oncology
    • A: Suspect pancreatic cancer with liver meta. cT2N0M1
    • P: Admission for EUS biopsy and/or CT-guided biopsy, Chest CT, Port A insertion

701158070

230504

[exam findings]

  • 2023-05-02 CT - abdomen
    • Without contrast enhancement CT of abdomen shows:
      • Presence of splenomegaly. Focal fluid density at its dorsal part, r/o infarct.
      • Right renal stone. Mild dilatation of right urotract.
      • Suspect increased density of bony structures.
    • Impression
      • Splenomegaly with suspected splenic infarct
      • Increased density of bony structures

[assessment]

  • Hyperleukocytosis (leukostasis) was confirmed by laboratory tests, and the patient has been treated with Hydrea (hydroxyurea 500mg) 2# TID since 2023-05-03, which has helped to control the high WBC count.

    • 2023-05-04 WBC 237.23 x10^3/uL
    • 2023-05-03 WBC 295.36 x10^3/uL
    • 2023-05-02 WBC 412.38 x10^3/uL
    • 2023-04-24 WBC 364.18 x10^3/uL
    • 2023-05-04 Blast 1.0 %
    • 2023-05-03 Blast 1.0 %
    • 2023-05-02 Blast 11.0 %
  • Leukostasis can be diagnosed when a biopsy of affected tissue shows white cell clots in the microvasculature (2023-05-02 CT: suspected splenic infarct). Please be aware of possible clinical signs of leukostasis, such as

    • Pulmonary signs and symptoms: dyspnea, hypoxia with or without diffuse interstitial or alveolar infiltrates on imaging studies. Pulse oximetry provides a more accurate assessment of O2 saturation in this setting.
    • Neurologic signs and symptoms: visual changes, headache, dizziness, tinnitus, gait instability, confusion, somnolence, and occasionally coma.
  • Feburic (febuxostat) is used as prophylaxis for potential tumor lysis syndrome. Lab data show that elevated serum uric acid levels have returned to normal following administration of the drug.

  • Caution should be exercised when using intravenous contrast at a time when renal function may be compromised by leukostasis or tumor lysis syndrome and dehydration. (2023-05-04 BUN 29mg/dL, Cre 1.10mg/dL, eGFR 70.75, normal values in K. The patient is currently hydrated with NS 500mL BID. No apparent renal insufficiency at this time).

701476884

230504

[lab data]

  • 2023-05-03 Anti-HBc Reactive
  • 2023-05-03 Anti-HBc-Value 8.55 S/CO

[exam findings]

  • 2023-04-14 Patho - pancreas biopsy
    • Pancreas, EUS FNA/B — Ductal adeocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, moderately differentiated, composed of nests, cords and single large pleomorphic neoplastic cells in fibrous stroma. Focal tubular formation and mucin secretion can be found.
  • 2023-04-14 Endoscopic Ultrasound, EUS
    • Diagnosis
      • Pancreatic head cancer s/p CH-EUS & EUS/FNB
      • MPD and CBD dilatation
      • Reflux esophagitis
    • Suggestion
      • Follow up pathology
  • 2023-04-14 SONO - abdomen
    • Diagnosis
      • Pancreatic tumor favor cancer
      • Dilated CBD
      • GB polyp
      • Parenchymal liver disease
    • Suggestion
      • further investigation
  • 2023-04-07 CT - abdomen
    • Indication: 2023/03/28 abdominal pain off and on for several months, BW loss (+)
      • PI: appetite: good
      • PHx: HTN (+), HBV carrier
    • Findings:
      • There is a well-defined poor enhancing mass measuring 4.5 x 3.4 cm in the pancreatic neck, causing upstream pancreatic duct dilatation. This mass shows direct attachment and narrowing of the trifurcation of portal vein, superior mesenteric vein, and splenic vein that is c/w portal vein invasion and encasement.
        • Adenocarcinoma of the pancreatic neck (T4) is highly suspected.
        • Please correlate with CA199 and EUS.
        • In addition, there are four lymph nodes in gastrohepatic ligament and hepatoduodenal ligament that are c/w metastatic nodes (N2).
      • There is mild dilatation of IHDs and CHD that is due to upper described pancreatic neck mass with directly invasion the CHD.
      • There is an ill-defined equivocal faint poor enhancing area in S7 of the liver that may be flow artifact.
        • The differential diagnosis includes metastasis.
        • Please correlate with sonography and MRI.
      • There is a renal stone 0.9 cm in left lower pole and another tiny renal stone in left upper pole.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T4(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)

[MedRec]

  • 2023-04-26 SOAP Hemato-Oncology
    • P
      • Family request admission
  • 2023-04-25 SOAP Hemato-Oncology
    • O
      • 2023/04/14 Fine needle aspiration cytology - Pancreatic aspiration (Pancereas) — Malignancy
      • 2023/04/14 HBsAg = Reactive;
      • 2023/04/14 HBsAg (Value) = 4773.38 S/CO;
      • 2023/04/14 2023/04/14 Anti-HCV = Nonreactive;
      • 2023/04/14 2023/04/14 CEA = 11.25 ng/mL;
      • 2023/04/14 2023/04/14 CA199 = 2507.98 U/mL;
      • 2023/04/14 planning: neoadjuvant C/T first
      • 2023/04/14 arrange Port-A
    • A
      • May try OPD C/T with biweekly FOLFIRINOX.

[note]

FOLFIRINOX chemotherapy for metastatic pancreatic cancer 2023-05-04 https://www.uptodate.com/contents/image?topicKey=ONC%2F2475&imageKey=ONC%2F79571

  • Cycle length: 14 days.
  • Regimen
    • Oxaliplatin
      • 85 mg/m2 IV
      • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
      • Day 1
    • Leucovorin
      • 400 mg/m2 IV
      • Dilute in 250 mL D5W and administer over two hours (after oxaliplatin).
      • Day 1
    • Irinotecan
      • 180 mg/m2 IV
      • Dilute in 500 mL D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
      • Day 1
    • Fluorouracil (FU)
      • 400 mg/m2 IV bolus
      • Give undiluted (50 mg/mL) as a slow IV push over five minutes (administer immediately after leucovorin).
      • Day 1
    • FU
      • 2400 mg/m2 IV
      • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours (begin immediately after FU IV bolus). To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
      • Day 1

[chemotherapy]

  • 2023-05-02 - irinotecan 120mg/m2 200mg D5W 250mL 90min + oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 500mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + NS 250mL + aprepitant 125mg D1-3

[assessment]

  • This is the first time the patient has received FOLFIRINOX chemotherapy for his pancreatic cancer, with a reduced dose of irinotecan (180mg/m2 reduced to 120mg/m2) and oxaliplatin (85mg/m2 reduced to 65mg/m2). Thus far, no significant adverse reactions have been observed.

  • 2023-05-03 Anti-HBc Reactive
    2023-05-03 Anti-HBc-Value 8.55 S/CO

701432621

230503

[diagnosis] - 2023-05-02 admission note

  • Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
  • Iron deficiency anemia, unspecified

[exam findings]

  • 2022-12-26 PET
    • Increased FDG uptake in several celiac lymph nodes, gastric cancer with regional lymph nodes involvement should be considered, suggesting further investigation.
    • Increased FDG uptake in the right lobe of the liver, highly suspected gastric cancer with distant metastases.
    • Increased FDG uptake in the right nasopharynx, the nature is to be determined (inflammation/infection process or other nature ?), suggesting further investigation.
    • Gastric cancer s/p treatment with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-11-28 CT - abdomen
    • Indication: Adenocarcinoma of gastric middle body anterior wall, pT4aN1M0 stage IIIA status post total gastrectomy with lymphadenectomy of station 1 to 12 and 14V, retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-05.
    • Abdominal CT with and without enhancement revealed:
      • s/p gastrectomy.
      • Hepatic tumors at S7 about 3.2cm and S6 about 2.9cm in largest dimension is found. Liver meta is considered. In comparison with CT dated on 2022-07-19, the tumors are enlarged.
    • Imp:
      • s/p gastrectomy.
      • Liver meta. In progression.
  • 2022-09-06 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Tubular adenocarcinoma
      • Margins, bilateral cutting ends and radial, total gastrectomy — Free of tumor invasion
      • Lymph nodes, LN dissection — Metastatic adenocarcinoma (2/40)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN1(cM0), stage IIIA
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 36 cm long greater curvature and 19 cm along lesser curvature, (b) Omentum: 35 x 20 x 5.0 cm
      • Number of lesions: Solitary
      • Tumor site: Middle body, anterior wall, lesser curvature, 6.0 cm from distal margin
      • Tumor size: 9.2 x 7.5 x 3.5 cm
      • Tumor configuration: Fungating tumor with central ulceration
      • Representative sections as follows: A1= proximal margin, A2= distal margin, A3-A9= tumor, A10= lesser curvature LN, B= LN 1, C= LN 2, D= LN 3, E1-E2= LN 4, F= LN 5, G= LN 6, H1-H2= LN 7,8,9,11,12, I= LN 10, J= LN 14v, K1-K3= omentum
    • MICROSCOPIC EXAMINATION
      • Histologic type: Tubular adenocarcinoma (Lauren classification: intestinal type)
      • Histologic grade: Moderately differentiated (G2)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 3 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (2/40)
        • 1/1 (lesser curvature LN), 0/2 (LN 1), 0/3 (LN 2), 1/4 (LN 3), 0/6 (LN 4), 0 (LN 5), 0/8 (LN 6), 0/13 (LN 7, 8, 9, 11, 12), 0/3 (LN 10), 0 (LN14v) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Non-atrophic chronic gastritis
      • Pathologic Staging: pT4aN1(cM0), stage IIIA
      • IHC (S2022-12775): HER2 (Positive, score= 3+)
  • 2022-08-30 MRI - liver, spleen
    • History and indication: Gastric cancer, suspect liver metastasis
    • With and without contrast MRI of liver revealed:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Two enhancing tumors (2.7cm, 2.9cm) at S5 and S7 of liver without venous wash out pattern. Another small enhancing nodules at both hepatic lobes.
      • Tiny liver and renal cysts.
    • IMP:
      • Gastric cancer with peritoneal seeding and LNs metastases.
      • Suspected liver hemangiomas.
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (205 - 59) / 205 = 71.22%
      • M-mode (Teichholz) = 71
    • Conclusion:
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis.
      • (suboptimal parasternal echo window barrel chest)
  • 2022-08-04 Patho - stomach biopsy
    • Stomach, AW side of mid body, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • The immunohistochemical stains reveal CK(+) and Her-2/neu (Ab): Positive (3+).
  • 2022-08-04 Esophagogastroduodenoscopy, EGD
    • Highly suspected gastric malignancy, s/p biopsy
    • Reflux esophagitis LA grade A
    • Superficial gastritis
  • 2022-07-19 CT - abdomen
    • History: easy hunger(+),
      • weight loss 72 (before) -> 68.5 (2022/04) -> 63kg (2022/06)
      • 2022/07/07 exertional dyspnea recent months.
      • 2022/07/18 s/p one week iron supplement, no adverse effect
    • Indication: Abnormal weight loss
    • Findings:
      • There is lobulated circumferrential irregular wall thickening at the stomach fundus and body, measuring 2.8 cm in the maximal wall thickness (T3).
        • Lymphoma is highly suspected.
        • The differential diagnosis include signet ring cell carcinoma.
        • Please correlate with gastroscopy.
        • In addition, There are ten enlarged nodes in the adjacent omentum, gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N3a).
      • There are two ill-defined homogeneous enhancing lesion measuring 2.5 cm in S7 and 2.2 cm in S5 of the liver at arterial phase images but isodensity (no contrast washout) in portal venous phase and delayed phase images.
        • The differential diagnosis include Atypical hemangioma, FNH and metastasis. Please correlate with MRI.
      • There are several small poor enhancing lesions on both hepatic lobes, the largest one 5 mm, that may be cysts?
        • However, they are too small to chracterize.
      • Please correlate with sonography.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N3a (N_value) M:M0 (M_value) STAGE:III(Stage_value)
  • 2022-07-12 SONO - abdomen
    • Diagnosis
      • Liver tumors, S5 and S7
      • Possible small para-aortic pymph nodes
    • Suggestion
      • 4 phase CT or dynamic MRI study

[consultation]

  • 2022-08-30 Gastroenterology
    • Q
      • This is a 61 year-old male, without underlying disease, admitted because of body weight loss 5 kg in 3months.
      • Panendoscope revealed one massive ulcerative tumor at gastric body. Pathology showed adenocarcinoma.
      • Abdominal CT also revealed 2 Liver tumor, differential diagnosis included atypical hemangioma, FNH and metastasis.
      • We need your expertise for TPN support
    • A
      • A case of gastric cancer who request pre-op nutrition support.
        • General appearance: ill looking
        • GI tract: Dysphagia (-), Abd pain (-), Abd distension (-), Nausea (-), Vomiting (-), Diarrhea (-), Poor appetite (-), Poor digestion (-), BW loss (+, 5kg/3Ms) , stool (+), Bowel sound (-)
        • Feeding: as tolerance
        • Allergy: NKA
        • Nutrition assessment:
          • BH 176cm BW 64.5kg
          • IBW 68.2kg 95%IBW BMI 20.8
          • BEE 1421kcal TEE 2217kcal
        • Lab data: Alb 3.7 K 4.2 TP 7.0 BS 98
        • According to the patient’s present conditions, parenteral nutrition plus enteral feeding (as tolerance) will be suitable for nutrition supply. We will follow this case for adjustment of optimal nutrition support.
      • PN Use Suggestion:
        • DC SMOFkabiven peri 1440ml QD (KCL 10ml)
        • SMOFkabiven central 1477ml QD, 61.5ml/hr
        • Lyo-Povigent 4ml/QD (add in TPN) (when out of stock, switch to adding B-complex 1ml/QD and Vitacicol 2ml/QD in TPN)
        • Addaven 10ml/QD(add in TPN)
      • Items to monitor during PN (Parenteral Nutrition) use:
        • TPN is used with single route, do not mix with other medications besides TPN drugs.
        • Check BW QW5 and record I/O Q8H
        • Check one touch Q6H x 2days, if stable QD check
        • Please control BS <200 mg/dl with RI sliding scale
        • QW1 check CBC/DC
        • QW1 check BUN. Cr. AST. ALT. T/D Bil. TG. ALP. rGT. Na. K. Cl. Ca. P. Mg. Zinc. Alb. Prealbumin or Transferrin
        • When TPN is insufficient, substitute with YF5 or D10W
        • On the day of surgery, temporarily hold the lipid emulsion
        • Kabiven requires daily pump set replacement

[MedRec]

  • 2022-12-27 SOAP Hemato-Oncology
    • S
      • PET scan (12/26 22):
        • several celiac LNs, gastric CA wt regional LNs involvement should be considered.
        • Lesion at R lobe of the liver, R/I mets. Imp: Gastric CA s/p Tx wt suspected regional LNs & liver mets, cTxN2M1, stage IVB (AJCC 8th ed.).
      • Liver mets poved by PET scan post post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (12/27 22).
      • Adm 2 wk later on 1/9 23 for #1 2nd line palliative C/T wt FOLFIRI IV Q2W x 6.
  • 2022-09-24 SOAP Hemato-Oncology
    • S
      • adjuvant C/T wt mFOLFOX IV Q2W x 12 & post-Op adjuvant CCRT (9/24 22).
      • HBsAg, anti-HCV (7/26 22): negative. will do anti-HBc (9/24 22).
      • will consult Dr in Radiation Oncology for R/T to gastric tumor bed. (9/24 22).
      • will give post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 then post-Op adjuvant CCRT wt 5-FU 24hr QD x 5 per wk x 6 plus R/T then post-Op adjuvant C/T wt mFOLFOX (self-paid) IV Q2W x 6 (9/24 22).
      • Adm 1 wk later on 10/3 22 for #1 post-Op adjuvant C/T wt mFOLFOX ( self-paid ) IV Q2W x 6.
    • A
      • Gastric CA, pT4aN1 (2/40) cM0, stage IIIA, s/p total gastrectomy on 9/5 22
  • 2022-08-11 SOAP Gastroenterology and Hepatology
    • Assessment
      • Consider gastric cancer with LN metastasis
      • the liver tumor may be not metastasis but may arrange MRI to check if it was hemangioma or FNH.

[surgical operation]

  • 2022-09-05
    • Surgery
      • Total gastrectomy with lymphadenectomy of station 1 to 12a and 14v.
      • Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA.
    • Finding
      • 8x7x4 cm tumor at middle body anterior wall of stomach invaded the serosa.
      • Lymph node enlargement at station 3.
      • Scarring around gastroduodenal junction.
      • No ascites, no peritoneal seeding and no liver surface metastasis.
      • cT4aN2M0 stage III.

[chemoimmunotherapy]

  • 2023-05-02 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4090mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-04-07 - trastuzumab 440mg NS 100mL 1.5hr + irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-03-17 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-21 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2400mg/m2 4100mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-02-06 - irinotecan 180mg/m2 300mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - irinotecan 170mg/m2 285mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2400mg/m2 4000mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 2mg + NS 250mL
  • 2022-12-23 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-25 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-10 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-24 - oxaliplatin 85mg/m2 140mg D5W 2hr + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4700mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-05 - oxaliplatin 70mg/m2 100mg D5W 2hr + leucovorin 400mg/m2 680mg NS 250mL 2hr + fluorouracil 2800mg/m2 4760mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient was diagnosed with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05, followed by FOLFOX treatment starting on 2022-10-05.

  • A CT scan on 2022-11-28 showed liver metastases in progression, and a PET scan on 2022-12-26 revealed that the gastric cancer had progressed, with suspected regional lymph nodes and liver metastases, cTxN2M1, stage IVB. After receiving six doses of FOLFOX (with the last dose administered on 2022-12-23), the patient’s regimen was changed to FOLFIRI starting on 2023-01-12.

  • The patient was admitted to the hospital for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, making this the 2nd dose). The patient tolerates the regimen well, and no significant adverse reactions have been observed.

  • After partial or total gastrectomy, the availability of gastric acid and intrinsic factor, both essential for vitamin B12 absorption, is reduced or eliminated. As a result, individuals who have undergone partial or total gastrectomy would benefit from supplementing their diet with oral vitamin B12 or receiving intramuscular or subcutaneous injections of vitamin B12. B-Red (hydroxocobalamin) is appropriately administered as a daily supplement for this patient.

  • The patient’s underlying condition of chronic viral hepatitis B is appropriately treated with Baraclude (entecavir).

  • A review of the PharmaCloud database reveals that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

The patient was proved with gastric adenocarcinoma, pT4aN1M0 stage IIIA in July 2022. Total gastrectomy with lymphadenectomy was performed on 2022-09-05 then FOLFOX was applied since 2022-10-05.

2022-11-28 CT showed liver mets in progression and 2022-12-26 PET showed the gastric cancer progressed with suspected regional lymph nodes and liver mets, cTxN2M1, stage IVB. After administration of 6 times of FOLFOX (last dose on 2022-12-23), then the regimen changed to FOLFIRI since 2023-01-12.

The patient admitted this hospitalization for his 6th dose of FOLFIRI (trastuzumab was added to the regimen since 2023-04-07, this time the 2nd dose). The patient tolerates the regimen well and no obvious adverse reaction is found.

The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

700758055

230502

[diagnosis]

  • Malignant neoplasm of left renal pelvis, small cell neuroendocrine carcinoma, ypT4NxcM0, ypStage IV

[past history]

  • hypertension
  • type II diabetes mellitus
  • dyslipidemia
  • insomnia
  • OP history: appendectomy 30 years ago, left laparoscopic nephroureterectomy on 2021-08-30.      

[family history]

  • Father - CVA.
  • Mother - hepatoma.

[exam findings]

  • 2023-04-29 CT - abdomen
    • Indication: Small cell neuroendocrine carcinoma of left kidney, ypT4NxcM0, ypStage IV s/p chemotherapy with Topotecan from 2023/01/16
    • With and without contrast enhancement CT of abdomen shows:
    • Imaging Protocol: 5mm slice thickness, axial scan and coronal reconstruction
      • s/p left nephrectomy.
      • Para-aortic mass lesions, in progression.
      • Enlarged lymph nodes along bilateral iliac vessels.
      • Small nodular lesions, up to 0.8cm, in liver.
      • No ascites or extraluminal free air.
      • No bony destructive lesion on these images.
    • Impression
      • s/p left nephrectomy
      • Para-aortic mass lesion, in progression; DDx: recurrent tumor, lymph node metastasis
      • Suspect liver metastasis
  • 2023-02-06, -01-23, -01-16 Standing KUB
    • Fecal material store in the colon.
  • 2023-01-27 PD-L1 IHC 28-8
    • S2021-11516A9, renal pelvic cancer
    • Tumor cell (TC) staining assessment: >= 1% and <5%
    • Percentage of PD-L1 expressing tumor cells (TC):1%
  • 2023-01-27 PD-L1 IHC 22C3
    • Combined Positive Score (CPS) assessment: >=1 and <10
    • Combined Positive Score (CPS) : 2
  • 2023-01-05 CT - abdomen
    • History and indication: renal pelvis tumor, s/p OP
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • Non-contrast CT of abdomen-pelvis revealed:
      • S/P left nephrectomy. Soft tissues in paraaortic region and pelvic cavity (progression).
      • Collapse of gallbladder.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • S/P left nephrectomy. Progression of tumor recurrence.
  • 2022-11-09 Gynecologic ultrasonography
    • EM: 3.7mm
  • 2022-11-02 KUB
    • Disc space narrowing at L4/5.
  • 2022-10-07 CT - abdomen
    • History:
      • 20210510 CT: left renal pelvis UC with LN metastases, cT3N1M1
      • 20210830 left nephrectomy: pT4Nx (if cM0), pstage:IV
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.
        • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
      • Findings:
        • S/P left nephrectomy.
          • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
            • In addition, Prior CT idenified enlarged nodes in right para-cava space are noted again, stable in size.
            • Follow up is indicated.
        • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
      • IMP:
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, increasing in size that are c/w metastatic nodes S/P C/T with progressive disease.
  • 2022-09-23 Tc-99m MDP whole body bone scan
    • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the right rib cage. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, wrists, hips, knees and feet, compatible with benign joint lesions.
  • 2022-07-22 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Prior CT idenified metastatic nodes in left para-aortic space are noted again, mild decreasing in size that are c/w metastatic nodes S/P C/T with partial response .
  • 2022-04-07 CT - abdomen
    • Findings
      • S/P left nephrectomy. Soft tissues in paraaortic region.
    • IMP:
      • S/P left nephrectomy. Soft tissues in paraaortic region suspected tumor recurrence.
  • 2022-01-05 CT - abdomen
    • Findings:
      • S/P left nephrectomy.
        • There is lobulated soft tissue lesions in left para-aortic space and left common iliac chain that may be metastatic nodes.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L4-5.
    • IMP:
      • Metastatic nodes in left para-aortic space and left common iliac chain are suspected.
  • 2021-09-06 Cystography
    • Cystography via foley catheter administration revealed:
      • The bladder capacity is about 100cc.
      • No evidence of contrast medium leakage.
  • 2021-08-31 Patho - kidney partial/total resection
    • Diagnosis
      • A
        • Kidney, left pelvis, laparoscopic nephroureterectomy — Small cell neuroendocrine carcinoma, s/p chemotheraphy, AJCC 8th edition: ypStage IV, ypT4Nx(if cM0)
        • Ureter, left, nephrectomy — Negative for malignancy
        • Blood vessel, left, nephrectomy — Negative for malignancy
        • Capsule, left kidney, nephrectomy — Small cell neuroendocrine carcinoma, by direct invasion
      • B: Soft tissue, labeled as “para-aortic lymph node”, excision — Negative for malignancy (0/0)
    • Gross Description
      • Procedure: laparoscopic nephroureterectomy
      • Laterality: Left
      • Specimen size:
        • Kidney: 7.4 x 4.0 x 2.5 cm; 60 gm
        • Ureter: 15.9 cm in length and 0.4 cm in maximal diameter
        • Adrenal gland: not received
      • Tumor size: 1.5 x 1.5 x 1.2 cm
      • Tumor site: Renal pelvis, parenchyma, hilar soft tissue, and invasion through the capsule to the perinephric fat
      • Tumor appearance: fibrosis
      • Tumor focality: Unifocal
      • A piece of tissue, labeled as “para-aortic lymph node”, is received.
      • Sections are taken and labeled as: A1: ureteral resection margin; A2: capsule; A3: blood vessel; A4: kidney, non-tumor; A5: ureter; A6-7: hilar soft tissue; A8-13: tumor (A11: with upper ureter); A14-16: tumor with capsule and the perinephric fat; B: para-aortic lymph node.
    • Microscopic Description
      • Histological type:: Small cell (neuroendocrine) carcinoma;
        • The immunohistochemical stains reveal CK(+), CD56(+), Synaptophysin(+), Chromogranin A(focal +), CD10(-), PAX8(-), CK5/6(-), and GATA3(-).
        • The Ki-67 is < 5%.
      • Histological grade: poorly differentiated
      • Pathological staging (pTNM, AJCC 8th edition):
        • TNM Descriptors: (required only if applicable) (select all that apply): y (posttreatment)
          • Primary tumor (pT): pT4: Tumor invades adjacent organs, or through the kidney into the perinephric fat
          • Regional lymph nodes (pN): pNx: Regional lymph node cannot be assessed
          • Distant metastasis (pM): (required only if confirmed pathologically in this case): if cM0
      • Section margins: Uninvolved by invasive carcinoma; 15.9 cm away from the ureteral resection margin; 0.8 cm away from the hilar soft tissue resection margin; 0.5 cm away from the perinephric fat resection margin.
      • Lymphovascular invasion: Present
      • Pathologic findings in ipsilateral nonneoplastic kidney: lymphocytic infiltration and fibrosis
      • Additional pathologic findings: No lymph node is seen in “para-aortic lymph node” specimen.
      • Perineural invasion is seen.
  • 2021-08-29 CXR
    • Intimal calcification of thoracic aorta.
  • 2021-08-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 32) / 79 = 59.49%
      • M-mode (Teichholz) = 59
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA; septal hypertrophy; LV diastolic dysfunction, Gr 1
    • Mild MR and trivial TR
    • Preserved RV systolic function
  • 2021-08-10 CT - abdomen
    • Clinical history: 76 y/o female patient with right renal pelvis UC with lymph node metastasis, cT3N1M1, PD-L1 all negative.
    • WITHOUT contrast enhancement CT: ABD — whole abdomen, pelvis:
      • Regression of left renal tumor and paraaortic soft tissue, could be due to regression of renal pelvis UC with lymph nodes metastasis.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • Left renal UC with lymph nodes metastasis, regression.
  • 2021-06-09 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma
      • PD-L1 Expression: <5% IC
      • Scores: Immune cells (IC): <1%; Tumor cells (TC): 0%
  • 2021-05-29 KUB
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Mild lumbar spondylosis.
  • 2021-05-29 Bladder Sonography
    • PVR 10.7mL
  • 2021-05-24 Patho - kidney biopsy
    • Kidney, left, CT guided biopsy — Compatible with invasive urothelial carcinoma, high-grade
    • The sections show sheets of spindle to oval-shaped pleomorphic neoplastic cells with hyperchromatic nuclei, embedded in fibrous stroma. Severe crush artifact is present.
    • IHC: GATA3(focal +), CK5/6(focal +), PAX8(-), CD10(focal +), and Vimentin(focal +).
    • The finding is compatible with high-grade invasive urothelial carcinoma. Renal cell carcinoma is less likely.
  • 2021-05-24 Body fluid cytology - urine
    • Diagnosis: Atypia
    • Macroscopic examination: L’t ureter: 6 cc colorless clear urine by URS
    • Microscopic examination: Smears show a few urothelial cells with mild enlarged nuclei. No morphologic evidence of high grade, but low grade urothelial carcinoma can not be excluded completely due to cytologic limitation. Please correlate with the biopsy result for conclusive diagnosis.
  • 2021-05-23 ECG
    • Normal sinus rhythm
    • Cannot rule out Inferior infarct, age undetermined
    • T wave abnormality, consider anterior ischemia

[chemotherapy]

  • 2023-03-31 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-03-06 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-4
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-4
  • 2023-02-13 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-18 - topotecan 0.75mg/m2 1.2mg NS 30mL 30min D1-3 (topotecan 1.5mg/m2 adjusted to 0.75mg/m2 due to impaired renal function)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-3
  • 2023-01-16 - topotecan 1.5mg/m2 2mg NS 50mL 30min D1-5
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL] D1-5
  • 2022-07-21 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-06-23 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3 + granisetron 1mg D1
  • 2022-05-26
  • 2022-04-28
  • 2022-01-04
  • 2021-12-07
  • 2021-10-28
  • 2021-10-05 - [etoposide 100mg/m2 120mg NS 500mL 2hr + cisplatin 25mg/m2 30mg NS 200mL 3hr] D1-3
    • [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-3
  • 2021-08-10 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-08-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-20 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-07-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-29 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-22 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-08 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)
  • 2021-06-01 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + cisplatin 70mg/m2 50mg NS 500mL 3hr
    • dexamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
    • furosemide 20mg (post chemotherapy)

==========

2023-05-02

  • On 2022-10-07, 2023-01-05, and 2023-04-29, CT scans demonstrated disease progression, with the most recent scan also revealing possible liver metastases. This information highlights the need for close monitoring and potentially re-evaluating the patient’s treatment plan.

  • The patient’s renal function improved according to the most recent lab values.

    • 2023-04-28 Creatinine 0.92 mg/dL
    • 2023-04-19 Creatinine 1.46 mg/dL
    • 2023-04-11 Creatinine 1.44 mg/dL
    • 2023-03-28 Creatinine 1.47 mg/dL
    • 2023-04-28 eGFR 62.91
    • 2023-04-19 eGFR 36.92
    • 2023-04-11 eGFR 37.52
    • 2023-03-28 eGFR 36.63
  • If the initial consideration for reducing the dose of topotecan was due to the patient’s inadequate renal function, this reason becomes less important. However, the patient also experienced leukopenia and thrombocytopenia after the standard dose of 1.5 mg/m2 topotecan in January 2023. The full standard dose may potentially lead to episodes of leukopenia and/or thrombocytopenia. A moderate titration to 0.9 or 1.0 mg/m2 from 0.75mg/m2 could be considered as a feasible option to balance treatment efficacy and side effect profile if the same regimen is intended to be continued.

2023-03-07

  • This patient has a tendency to develop leukopenia and/or thrombocytopenia after receiving the normal dose of 1.5mg/m2 topotecan. However, after the dose was reduced to 0.75mg/m2, no further high-grade adverse reactions were observed.

    • 2023-03-02 WBC 5.87 x10^3/uL

    • 2023-02-23 WBC 12.24 x10^3/uL

    • 2023-02-16 WBC 3.07 x10^3/uL

    • 2023-02-13 WBC 4.44 x10^3/uL

    • 2023-02-09 WBC 22.96 x10^3/uL

    • 2023-02-06 WBC 2.70 x10^3/uL

    • 2023-02-03 WBC 2.09 x10^3/uL

    • 2023-02-01 WBC 2.32 x10^3/uL

    • 2023-01-30 WBC 1.66 x10^3/uL

    • 2023-01-27 WBC 0.71 x10^3/uL

    • 2023-01-26 WBC 0.70 x10^3/uL

    • 2023-01-22 WBC 2.41 x10^3/uL

    • 2023-01-16 WBC 5.05 x10^3/uL

    • 2023-03-02 PLT 234 x10^3/uL

    • 2023-02-23 PLT 109 x10^3/uL

    • 2023-02-16 PLT 275 x10^3/uL

    • 2023-02-13 PLT 308 x10^3/uL

    • 2023-02-09 PLT 270 x10^3/uL

    • 2023-02-06 PLT 123 x10^3/uL

    • 2023-02-03 PLT 65 x10^3/uL

    • 2023-02-01 PLT 47 x10^3/uL

    • 2023-01-30 PLT 50 x10^3/uL

    • 2023-01-27 PLT 154 x10^3/uL

    • 2023-01-26 PLT 38 x10^3/uL

    • 2023-01-22 PLT 155 x10^3/uL

    • 2023-01-16 PLT 312 x10^3/uL

2023-02-14

  • S2021-11516A9 (renal pelvic cancer) 2023-01-27 PD-L1 IHC lab results:

    • [28-8]
      • Tumor cell (TC) staining assessment: >= 1% and <5%
      • Percentage of PD-L1 expressing tumor cells (TC): 1%
    • [22C3]
      • Combined Positive Score (CPS) assessment: >=1 and <10
      • Combined Positive Score (CPS): 2
  • PD-L1 expression is not high, suggesting that certain PD-L1 targeted drugs are less likely to be effective against the tumor.

  • In light of the patient’s diarrhea episodes last month, please keep an eye on her bowel movements. Topotecan is associated with nausea (grade 3/4 8-10%), diarrhea (grade 3/4 6%), and vomiting (grade 3/4 10%). Since the administration days and daily dose of topotecan have been reduced (1.5mg/m2 -> 0.75m2/m2; 5 days -> 3 days), the adverse reaction should be mitigated. As well, Smecta (dioctahedral smectite) 3mg PO PRNTIDAC has been prescribed.

2023-01-27

  • 2023-01-27 WBC 710 cells/uL, Neutrophil 5%, ANC < 500 cells/uL, grade 4 neutropenia developed, Granocyte (lenograstim) and Cefim (cefepime) have been initialized since 2023-01-26 morning. Since 2023-01-26 19:00, the patient’s body temperature has not exceeded 37.5 degrees Celsius.
  • During the period of 2023-01-24 to 26, there were 3, 2, 3 bowel movements, and Nako No.5 (electrolyte supplement) was administered appropriately.
  • As far as the active prescription is concerned, there is no problem.

700509855

230428

[diagnosis] - 2023-04-27 admission note

  • Malignant neoplasm of stomach, unspecified
  • Secondary malignant neoplasm of right ovary
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Essential (primary) hypertension

[exam findings]

  • 2023-04-27 KUB
    • S/P port-A insertion.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Lumbar spondylosis.
    • T12 and L1 compression fractures.
  • 2023-04-27 CXR
    • Emphysematous change of bilateral lungs.
    • No cardiomegaly.
    • Thoracolumbar spondylosis.
    • R/O old fractures at left ribs.
  • 2023-04-24 Cytology - ascites
    • 17 cc yellow turbid ascites — Atypia (before IP C/T)
  • 2023-04-20 CT - chest
    • Indication: GIST with peritoneal and ovarian metastasis, stage IV s/p HIPEC and operationr/o other metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified dot at subpleural space of right lower lobe is found measuring 0.24cm in largest dimension.
        • Bilateral apical pleura fibrosis is found.
        • Calcified coronary arteries is found.
        • There is moderate bilateral pleural effusion.
      • Visible abdomen:
        • Moderate ascites formation is found. Dirty appearance of the mesentery is found. Cancerous peritonitis is considered. In comparison with CT dated on 2022-12-13, the lesion is stationary.
        • Bilateral hydronephrosis and hydroureter is found. Stable.
        • Dilatation of the IHDs and CBD is noted.
        • The intestines are dilated.
    • IMp:
      • Moderate bilateral pleural effuison and massive ascites with cancerous peritonitis
      • Bilateral hydronephrosis and hydroureter. Stable
      • Dilatation of the IHDs and CBD
  • 2023-04-19 Tc-99m MDP bone scan with SPECT
    • The hot spot in the lateral aspect of a left lower rib (10th rib ?) comes to faint compared with the previous study on 2023-01-04, probably post-traumatic change.
    • However, there are several new lesions of increased tracer uptake in the posterior aspect of the left rib cage and in three lower T- and upper-L-spine, bone metastasis and/or pathological fracture should be considered, suggesting MRI for investigation.
    • Suspected benign lesions in the maxilla, both rib cages, bilateral shoulders, and hips.
  • 2023-04-17 ECG
    • Low voltage QRS
  • 2023-03-27 L-spine Ap + Lat (including sacrum)
    • Degeneration and spondylosis of L-S spine.
    • Atherosclerosis of the aorta.
  • 2023-03-27 Peripheral Vascular Test - vein, lower limbs
    • Conclusion
      • No evidence of venous thrombosis at bilateral lower limbs venous systems.
      • No significant venous refluxes at biateral lower limbs venous systems.
      • Tissue edema at bilateral lower legs.
      • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2023-03-10 ECG
    • Sinus rhythm with Premature atrial complexes
  • 2023-02-16 SONO - abdomen
    • Hepatic cysts
    • Bil hydronephrosis
    • Ascies, mild
    • CBD dilatation
    • Rt renal cyst
  • 2023-01-13 Patho - peritoneum biopsy
    • DIAGNOSIS:
      • Peritoneum, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Soft tissue, right pelvic tumor, biopsy — metastatic adenocarcinoma, consistent with gastric origin
      • Ovary, right, oophorectomy — Metastatic adenocarcinoma, consistent with gastric origin — Serous cystadenoma
      • Fallopian tube, right, salpingectomy — Metastatic adenocarcinoma, consistent with gastric origin
    • MICROSCOPIC DESCRIPTION:
      • Section shows fibroadipose tissue with infiltration of signet-ring cells.
        • The immunohistochemical stain of CK is positive. Metastatic adenocarcinoma from stomach is favored. Please correlate with the clinical presentaion.
      • Sections show ovary with metastatic glandular and signet-ring tumor cells. An ovarian cyst lined by a single layer of benign serous epithelium is also seen. The fallopian tube reveals transmural invasion of glandular and signet-ring tumor cells. Lymphovascular and perineural invasion is seen.
        • The immunohistochemical stains reveal CK7(+), CK20(+), CDX2(+), and PAX8(-). The results are consistent with metastatic adenocarcinoma from stomach.
  • 2023-01-04 Tc-99m MDP bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the lateral aspect of a left lower rib (10th rib ?), faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, and S-I joints, in whole body survey. Radiotracer retention in bilateral kidneys was noted.
    • IMPRESSION:
      • A hot spot in a left lower rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, and S-I joints.
      • Radiotracer retention in bilateral kidneys, the nature is to be determined, suggesting further evaluation.
  • 2022-12-29 Cell block
    • Clinical Finding: ovary cancer
    • 50cc, turbid, orange — Positive for malignancy
    • Smears and cell block show atypical neoplastic cells with abundant clear cytoplasm and pushing nuclei with signet ring-like picture.
  • 2022-12-28 CT - chest
    • Indication: moderate right pneumothorax.
    • Findings
      • lungs: dependent partial atelectasis of RLL and band subsegmental atelectasis of RUL. tiny granuloma (3mm) at LLL and two tiny granulomas (3mm) at RLL. two noncalcified solid nodules (up to 6mm) and several faing lobular GGOs at LUL. suspicious cylindrical bronchiectasis at LLL.
      • Mediastinum and hila: no enlarged LN or mass. mild calcified plaques of the LAD and LCX coronary arteries.
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers..
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents:
        • massive ascites and soft tissue densities in the omentum, along peritoneum.
        • a ulcerative tumor at posterior wall of the body of stomach.
        • Lt heaptic cyst 7cm, Rt renal cyst 1.6cm, and bilateral hydronephrosis.
        • normal appearance of gall bladder. unremarkable of the spleen, both adrenal glands, and pancreas.
        • no enlarged lymph node.
      • Visualized bones: unremarkable. .
    • Impression:
      • moderate right pneumothorax. tiny granulomas in RLL and LLL and small nodules in LUL (favor benign nodules) of lung.
      • gastric cancer with massive ascites and peritoneal carcinomatosis
  • 2022-12-27 Patho - stomach biopsy (Y1)
    • Stomach, upper body, PW, biopsy — Adenocarcinoma, signet ring-like, non-cohesive.
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and signet ring-like neoplastic cells.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • ADDENDUM: IHC stains: PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2022-12-26 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis, lower esophagus, LA classification, grade A
    • Superfical gastritis, antrum
    • Advanced gastric cancer, type III, upper body, PW, s/p biopsy
  • 2022-12-26 Colonoscopy
    • The scope had been inserted up 20 cm above anal verge, probably at level of rectal-sigmoidal juncction. Futher insertion is difficult because acute angle. Thus, the exam was stopped
    • Diagnosis
      • Internal hemorrhoid
      • Incomplete study
  • 2022-12-19 ECG
    • Low voltage QRS
    • Nonspecific T wave abnormality
  • 2022-12-19 CXR
    • Mild cardiomegaly.
    • Tortuous thoracic aorta with intimal calcification.
    • Thoracic spondylosis.
    • Osteoporosis of the bones.
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Normal LV filling pressure; impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis with mild AR; mild MR; mild TR.
      • Mild aortic root calcification with multiple protruding atheromas (4-5 mm of thickness).
  • 2022-12-13 CT - abdomen
    • Clinical history: 77 y/o female patient with p3 (NSD)
      • prev abd op(-), low abd pain, leukorrhea and dysuria, low abd pain, leukorrhea and dysuria
      • 2022/12/12 sonar: EM 0.85cm RASD mass 7.3x7cm, solid?? uterine myoma or ROV tumor? ovarian malignancy cannot be excluded ROV cyst 5.3 x 5cm ascites > 500 c.c
    • With and without contrast enhancement CT of abdomen–whole:
      • Heteregneous cystic tumor, 7.6cm in right adnexa, r/o right ovarian malignancy.
      • Dilatation of the appendix with enhancement, r/o appendiceal malignancy.
      • Presence of massive ascites and soft tissue densities in the omentum, along peritoneum, r/o peritoneal carcinomatosis.
      • Large cystic tumor, 6.9cm in left lobe liver, r/o liver cyst.
      • Bilateral renal cysts, up to 1.6cm in right kidney.
      • Bilateral hydronephrosis.
      • No enlarged lymph node in the paraaortic region.
    • Impression:
      • Peritoneal carcinomatosis.
      • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
      • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Liver and renal cysts.
      • Bilateral hydronephrosis.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-12 Gynecologic Ultrasonography
    • Uterus Position: AVF
      • Size: 68 x 40 mm
    • Endometrium
      • Thickness: 8.5 mm
    • IMP
      • Ascites
      • R/O Rt mass or bowel ?? 73x33mm
      • R/O Rt cyst: 51x46mm

[consultation]

  • 2023-04-18 Hemato-Oncology
    • Q
      • This is a 78 y/o female with diagnosis of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12.
      • She received neoadjuvant intraperitoneal and systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP Q4W on 2023/02/14. However, general malaise, oral ulcer, poor appetite, skin rash , bilateral lower limbs edema and diarrhea were noted after first cycle of chemotherapy and was admitted during 2023/03/14 ~ 28.
      • Due to above reason, we would like to consult your expertise on evaluation and recommendation on chemotherapy for the patient, thank you!
    • A
      • This 78 year old woman is a case of gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, stage IV, s/p laparoscopic examination and tumor excisional biopsy + laparoscopic HIPEC + IP port implantation + laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis on 2023/01/12, s/p systemic chemotherapy with Oxaliplatin 130mg/m2 IV + Xeloda 1000mg BID PO + Paclitaxel 20mg IP on 2023/02/14. Due to symptom after first cycle chemotherapy, we are consulted for furhter evaluation.
        • Perform HER2, programmed death ligand 1 (PD-L1), and microsatellite testing (if not done previously).
        • If intolerable to CapOx or FOLFOX, might consider docetaxel (30-35 mg/m2) plus 5-FU 2000-2600 mg/m2 and leucovorin 200 mg/m2 with or without cisplatin (20-30 mg/m2) Q2W.
        • Thanks for your consultation.
  • 2023-02-14 Gastroenterology
    • Q
      • for pre-chemotherapy HBV treatment
      • This 78 y/o female a case of gastric cancer with ovarian and peritoneal metastasis. She underwent HIPEC on 20230112. Further neo-adjuvant chemotherapy will arrange. However, we check hepatitis showed HBsAg and anti-HCV (-), but anti-HBc (reactive). We need your expertise for pre-chemotherapy HBV treatment. Thanks for your times.
    • A
      • P
        • Check HBV DNA
        • Arrange abdominal sonography
        • Vemlidy 25mg (GFR > 15 no adjustment; GFR < 15 contraindicated; HD: no adjustment, after HD)
        • GI OPD follow up
  • 2022-12-30 Anesthesiology
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. She ever tried right neck for CVC insertion, but failure and iatrogenic pneumothorax was noted. Following CXR showed pneumothorax with pleural effusion of right side, thus pig-tail was inserted on 20221229. We need your expertise for CVC insertion. Thanks for your times. On femoral, thanks.
    • A
      • Finding
        • The sonography reported small, much thrombosis and overlapped with artery at right IJV and SCV.
        • After positioning via Trendelenburg position,head rotated, elevated shoulder, the skin was sterilized and anesthetized with 2% lidocaine 2 ml.
        • We performed 3-lumen 7 fr CVC insertion to LEFT internal jugular vein under Seldinger technique
        • The CVC was fixed at 16cm
        • The pt tolerant the procedure well.
        • There was no sign of hematoma, pneumothorax, infection after the procedure.
      • The recommandation is as followed:
        • Please check chest roentgenography for localization.
        • Change IV set QD if TPN used or Q4D if general fliud.
        • Change OP site at least every week. IF loosening or blood accumulation please change it ASAP.
        • We do not recommand routinely change the CVC unless there are some infectious signs.
      • Thanks for your consultaion.
  • 2022-12-27 Thoracic Surgery
    • Q
      • For CVC insertion
      • This 77y/o female a case of suspect gastric cancer with ovarian metastasis. She had poor appetite and body weight loss was noted. She need TPN for nutrition supplement. We need your expertise for CVC insertion. Thanks for your times.
    • A
      • Central venous catheterization has been tried but failed. Please consult ANES for the procedure. Thanks for your consultation.
  • 2022-12-26 Urology
    • Q
      • For on D-J catheterization.
      • This 77-year-old female with ovarian cancer was admitted for Debulking surgery at 20221227 . We need your evaluation of her condition for on D-J catheterization. Thanks for your help!
    • A
      • CT showed massive ascites and mild bilateral hydronephroiss
      • We will arrange bilateral DBJ insertion.
  • 2022-12-26 General and Digestive Surgery
    • Q
      • For combine surgery
      • This 77-years-old female with ovarian cancer and ascites was admitted Debulking surgery.
      • The abdomen CT scan revealed
        • Peritoneal carcinomatosis.
        • Dilatation of appendix with focal enhancement, r/o appendiceal malignancy.
        • Right ovarian cystic tumor, r/o right ovarian malignancy.
      • Debulking surgery will arrange on 20221227 . We need your evaluation of her condition for combine surgery. Thanks for your help!
    • A
      • BW loss 7kg (49 -> 42) in past one month
      • suggest
        • we will performe combined surgery for her tomorrow
        • we will resected GI tract if necessary
        • PN support after operation
        • consult urologist for double J catheter implantation
        • We did not discuss with the family about HIPEC due to too weak to receive HIPEC
    • Supplementary reply 2022-12-26 17:41:10
      • PES: Advanced gastric cancer, type III, upper body, PW
      • impression: gastric cancer with peritoneal carcinomatosis and krukengerg tumor
      • suggest
        • debulking surgery is not indicated now
        • pending the report of pathology
        • nutrition support
        • may consider neoadjuvant intraperitoneal and systemic chemotherapy (NIPS) with following total gastrectomy, cytoreductive surgery, BSO and HIPEC
      • we wound like to take over this case if the patient and her family agree

[MedRec]

  • 2023-04-06 SOAP General and Gastroenterological Surgery
    • S
      • fair appetite
      • tarry stool passage?
      • SOB?
    • O
      • smooth respiration
      • pink conjunctiva
      • bilateral lower limb pitting edema
    • P
      • admit for TS-1 and IP chemotherapy
  • 2023-03-07 SOAP General and Gastroenterological Surgery
    • S
      • poor appetite, bilateral lower limbs edema
      • pink conjunctiva
    • O
      • smooth respiration
      • but poor general condition
      • hold xeloda and dexamethasone
  • 2023-01-27 SOAP General and Gastroenterological Surgery
    • S
      • Gastric adenocarcinoma with peritoneal carcinomatosis and ovarian metastases, cT4aN2M1, STAGE:IV post status laparoscopic examination and tumor excisional biopsy, laparoscopic tumor excision/debulking with right salpingo-oophorectomy, laparoscopic HIPEC and IP port implantation on 2023/01/12
      • Postprocedural pneumothorax status post thoracentesis on 2022/12/28
      • Malignant ascites
    • P
      • admission on 20230206 for bidirectional chemotherapy

[surgical operation]

  • 2023-01-12
    • Surgery
      • Diagnosis: suspected gastric cancer with ovarian metastasis (Krukenberg tumor?); pelvic bowel adhesion
      • laparoscopic tumor excision/debulking with right salpingo-oophorectomy + right pelvic tumor excision and adhesiolysis
    • Finding
      • previous gastric biopsy – malignancy (adenocarcinoma)
      • suspected gastric cancer with ovarian metastasis (Krukenberg tumor?)
      • right ovary and tube: 9x8cm, two parts–solid part 7x7cm, fragile, suspected metastastic cancer? ; cystic part 5x4cm with clear fluid
      • right tube -np (ROV + tube)
      • right pelvic tumor –2x2cm, solid suspected metastastic cancer?
  • 2023-01-12
    • Surgery
      • laparoscopic examination and tumor excisional biopsy
      • laparoscopic HIPEC
      • IP port implantation
    • Finding
      • serous ascites, about 2700ml
      • diffuse peritoneal carcinomatosis, total PCI: 23/39
      • RUQ 2
      • epigastrium 2
      • LUQ 2
      • right flank 1
      • central 1
      • left flank 1
      • RLQ 3
      • pelvis 3
      • LLQ 2
      • small bowel PCI: 2+2+1+1/12
      • HIPEC: oxalipatin 400mg + paclitaxel 120mg in D5S 3000ml, 90min, 42 degree

[chemotherapy]

  • 2023-04-21 - docetaxel 30mg/m2 38mg D5W 250mL 1hr + leucovorin 200mg/m2 250mg NS 250mL 2hr + fluorouracil 2000mg/m2 2515mg NS 500mL 24hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 4200mg] IP 1hr (NIPS)

  • 2023-02-14 - oxaliplatin 130mg/m2 150mg D5W 250mL 2hr + [paclitaxel 20mg NS 1000mL + gentamicin 40mg + sodium bicarbonate 2800mg] (with 2023-02-16 ~ 2023-03-14 oral capecitabine)

  • 2023-01-12 - [oxaliplatin 400mg + paclitaxel 120mg + D5W 2500mL] IP 90min

Xeloda (capecitabine 500mg) KXEL)01

  • 2023-02-16 ~ 2023-03-14 2# BID

[assessment]

  • Significant weight loss has been observed in the patient, from 43.5kg on 2023-01-06 to 33.3kg on 2023-04-27. Megestrol has been prescribed intermittently between late Dec 2022 and late Feb 2023. If the patient can still tolerate oral intake and there are no contraindications, it may be beneficial to consider adding megestrol back into the patient’s treatment plan to help increase appetite and promote weight gain.

  • Additionally, providing nutritional support and guidance, including a consultation with a dietician, may further assist in addressing the patient’s weight loss.

  • The patient has had 7 episodes of diarrhea since 2023-04-26, as noted in the admission record. It is recommended that the number of bowel movements be included in the TPR panel along with the I/O data. If the symptom persists, the addition of loperamide may be beneficial in the management of diarrhea.

  • Both docetaxel and fluorouracil are associated with diarrhea as a side effect. If diarrhea is suspected to be more related to fluorouracil (2000mg/m2 D1), reducing the dose of fluorouracil (70~80% of the intended dose) at the next treatment may be an option to consider.

701445069

230428

[exam findings]

  • 2023-04-26 CXR
    • extensive heterogeneous consolidation in both hypoinflated lungs due to severe pulmonary fibrosis in progression as compared with the previous image
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • enlarged cardiac silhoutte due to dilated prominent pericardial fat/prominent cardiophrenic angle mediastinal fat pad/ supine position
  • 2023-04-21 CT - chest
    • Indication: Malignant neoplasm of unspecified part of left bronchus or lung
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • There is enlarged lymph nodes in the mediastinum. In comparison with CT dated on 2023-02-17, these lymph nodes increased in size and numbers
        • There is interstitial change at both lungs with honey combing mostly at bilateral peripheral and lower lungs. In comparison with CT dated on 2023-02-17, the extension and severity progressed slightly.
        • Minimal pericardial effusion is found.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
    • Imp:
      • Interstitial change of both lungs. In progression.
      • Enlarged lymph nodes in the mediastinum. In enlargement.
      • Minimal pericardial effusion.
  • 2023-03-22, -03-15, -02-15, -01-26, -01-20, -01-16, -01-11, -01-06, -01-03, 2022-12-29, -12-26, -12-22, -12-19, -12-08, … CXR
    • There are linear and nodular opacities projecting at bilateral middle and lower lung that are c/w subpleural boneycombing feature after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Spondylosis of the T-spine
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (47 - 11) / 47 = 76.60%
      • M-mode (Teichholz) = 75
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild TR
  • 2023-07-17 CT - chest
    • Diagnosis
      • Malignant neoplasm of unspecified part of left bronchus or lung
      • Hypertensive heart disease without heart failure
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at left upper lobe with bony erosion measuring 4.57x1.45cm in largest dimension. In comparison with CT dated on 2023-01-17, the lesion is stationary or slightly regressed.
        • Diffuse interstitial change at both lungs with honey combing at bilatearl lower lungs are found. IPF is considered.
        • Ground glass patches at both lungs is found. In regression.
        • Calcified coronary arteries is found.
        • Hypertrophic left ventricle is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp:
      • left upper lobe lung cancer with bony erosion, in regression.
      • Diffuse intertitial change at both lungs with lower lobes predominance. IPF is suspected.
      • Hypertrophic left heart with Calcified coronary arteries is found.
  • 2023-01-17 CT - chest
    • Indication: Lung cancer with dyspnea
    • Comparison was made with previous CT dated on 2022/12/16
      • Chest
        • interval significant decrease in size of a large tumor at left upper anterior chest wall and heterogeneous consolidation at LUL as compared with CT on 2022/12/16.
        • there is subpleural and basal predominant pulmonary fibrosis charaterized by reticulation, traction bronchiectasis, traction bronchioectasis, archiectural distortion, and subpleural honeycombing.
        • extensive centrilobular emphysema and subpleural paraseptal emphysema at both upper lobes too.
        • Mediastinum and hila: interval regression of extensive lymphadenopathy the visceral space and both hila,as compared with CT on 2022/12/16
        • mild calcified plaques of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: mild dilated right main artery.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace Lt-sided effusion
      • Visible abdominal-pelvic contents:
        • normal appearance of gall bladder.
        • several bilateral renal cysts measuring up to 1.5cm (longest axial diameter)
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16.
      • combined emphysema and IPF.
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (43 - 19) / 43 = 55.81%
      • M-mode (Teichholz) = 55
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Mild MR, trivial TR
      • Preserved RV systolic function
  • 2022-12-22 MRI - brain
    • Clinical information: Lung cancer with lymph nodes and bone metastases, cT4N3M1b, stage IVA, R/O brain metastasis
    • Findings:
      • Known a case of lung cancer. No evidence of brain metastasis.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • An outpouch (8.5 mm) projecting anteriorly from ACom artery, indicating an aneurysm. Suggest endovascular treatment.
  • 2022-12-16 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) C3D15 Visit >
      • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Mass like lesion occupying left anterior chest about 7.9cm in largest dimension is found. Stable.
        • S/p port-A placement with its tip at Superior vena cava.
        • Centrilobular Emphysematous change over both lungs and honey combing at peripheral lungs is found. IPF like change is considered. In comparison with CT dated on 2022-10-07, the lesion progressed rapidly.
        • Tortous aorta with calcification is noted.
        • Enlarged, enhanced lymph nodes are found at both sides of the mediastinum, in enlargement.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp: Left anterior chest wall lung cancer s/p treatment with immune related pulmonary fibrosis. The primary tumor is stationary in size but the mediastinal lymph nodes enlarged. Pseudoprogression? Suggest close observation.
  • 2022-12-08 CXR
    • Patchy opacity projecting at left upper lateral lung was noted that is c/w lung cancer after correlate with CT.
    • There are several nodular opacities projecting at both lung. Please correlate with CT to R/O lung to lung metastases?
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-11-17, -10-27 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-12 CXR
    • Patch densities at bil. lungs.
    • Atherosclerosis of the aorta.
  • 2022-10-07 CT - chest
    • < BGB-A317-A1217-302 (iIRB No: 10-FS-043) Screening ICF Process >
      • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family via both on-site and remote on 2022.09.15, and on site disscussion on 2022.09.28.
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass attaching left anterior chest about 6.28cm in largest dimension is found. In comparison with CT dated on 2022-08-04, the lesion enlarged.
        • Centrilobular Emphysematous change over both lungs is found.
        • Cystic fibrotic change and cystic Bronchiectatic change at both peripheral lungs is found. Stationary.
        • Patent airway is found.
        • Enlarged lymph nodes are found at both sides of the mediastinum. Stationary.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left upper lobe lung cancer with mediastinal lymphadenopathy, The primary tumor enlarged.
      • COPD.
  • 2022-10-06 MRI - brain
    • ACom aneurysm (8.5 mm).
    • No interval change as compared with MRI on 20220822.
    • Please close follow up and consult neurosurgeon.
    • No evidence of brain metastases.
  • 2022-10-04 Tc-99m MDP whole body bone scan
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion.
    • Increased activity lower T- to upper L-spines and lower L-spines. Either bone metastases or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the sternum and bilateral rib cages. Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-04 Pulmonary Function Test, Spirometer
    • preexam spo2:98%; postexam spo2:94%
    • mild obstructive ventilatory impairment with partial reversibility, FEV1/FVC 65%, FVC 81->92%, FEV1 68->77%
    • normal slow vital capacity, SVC 89%
    • airway trapping, RV/TLC 131%
    • normal diffusing capacity, DLCO/VA 73% (low DLCO 58% favor due to low VA)
    • suggest to use bronchodilator such as spiriva for mild obstructive ventilatory impairment
  • 2022-08-31 ROS1 FISH
    • ROS1 fluorescent-in-situ hybridization report
    • Rearrangement of ROS1 gene is NOT detected.
    • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-08-31 ALK IHC
    • Result: Negative
    • The immunostaining of the section slide labeled S2022-13261, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-08-23 Tc-99m MDP whole body bone scan with SPECT
    • Increased activity in the antelateral aspect of left 3rd rib, compatible with malignancy with local bone invasion. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the lower T- to upper L-spines and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-08-22 MRI - brain
    • History and Indication
      • hemoptysis and severe chest pain
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications: aspirin 1# QD, inderal 1# BID, atozet 1# QD, gaster 1# BID, erispan 1# BID, stilnox 1# prnHS, uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
    • Without- and with-contrast multiplanar cerebral MRI (including axial and coronal T1WI, axial and sagittal T2WI, axial T2W FLAIR, and axial DW images; using 4 mm thickness for sagittal section and 5 mm thickness for the others) reveal:
      • Mild degree of general enlargement of ventricles, cistern spaces and cortical sulci, indicating general brain atrophy.
      • No evidence of intracranial hemorrhage, nor acute/subacute infarct.
      • No midline shift, nor space-occupying lesion.
      • No remarkable finding of skull base and bony structures.
      • No remarkable finding of nasopharynx visible in these images.
      • An outpouch (8 mm) projecting anterolaterally from ACom artery, indicaitng an aneurysm.
    • IMP: ACom aneurysm (8 mm). Mild general brain atrophy.
  • 2022-08-19 EGFR gene mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen S22-13261
  • 2022-08-19 PD-L1 (22C3)
    • PD-L1 Immunostaining Result
      • Tumor Proportion Score (TPS) assessment: 95%
      • Combined Positive Score (CPS) assessment: 95
  • 2022-08-12 Patho - bronchus biopsy
    • Labeled as “left chest wall tumor”, needle biopsy — non-small cell carcinoma.
    • IHC stains:
      • TTF-1 (-), Napsin-A (-), p40 (focal +), calretinin (-), CK7 (+), CK20 (-).
      • GATA-3 (-), CK5/6 (+), p63 (+). The pattern is in favor of squamous cell carcinoma.
    • Section shows fibrotic soft tissue with infiltration of irregular nests of non-small cell carcinoma.
  • 2022-08-11 Myocardial perfusion SPECT with persantin
    • Probably mild myocardial ischemia at the inferolateral wall, basal lateral wall and posterior wall.
  • 2022-08-11 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 31) / 79 = 60.76%
      • M-mode (Teichholz) = 60
    • Adequate LV systolic function with normal resting wall motion
    • Dilated LA, concentric LVH; LV diastolic dysfunction, Gr 1
    • Trivial MR, trivial AR and trivial TR
    • Preserved RV systolic function
  • 2022-08-04 CT - chest
    • Findings
      • Chest:
        • Severe centrilobular Emphysematous change over both lungs is found.
        • Pleural based fibrotic change at both lungs more on peripheral lung is found.
        • Soft tissue mass encasing left atnerior chest wall with bony invasion is found up to 4.5cm. suggest tissue proof.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • IMp:
      • Severe COPD.
      • Soft tissue mass encasing left atnerior chest wall with bony invasion is found. suggest tissue proof.
  • 2022-08-03 CXR
    • Patchy opacity projecting at left upper lateral lung or pleura was suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-08-03 ECG
    • Sinus rhythm with 1st degree A-V block
    • Nonspecific ST abnormality

[MedRec]

  • 2023-04-26 SOAP MER
    • S
      • SOB and desaturation during OPD
      • He developed decreased O2 Sat 5 days (90-95% initially), S/S exacerbated recent 2 days (<90%, about 84%)
        • no fever
        • no chest pain
      • A case of lung ca received clinical trial Tx, got PCP, CMV infection Hx
      • CXR showed pneumonitis
    • A/P
      • Respiratory failure, hypoxia, Critical, CRP15, bil PN
      • Hx: left lung CA, HTN, COPD; Patent CAD many years ago, PCP, CMV infection
      • CRP 15.4, WBC 7k, Medason, Tapimycin; OA Hema
      • 20230421 lung CT: Interstitial change of both lungs. In progression.
  • 2023-04-26 SOAP Dermatology
    • S: itchy and sweating sensation over trunk for weeks.
    • O
      • Diffuse annular lesions with spreading tendernecy and mild pruritus over trunk and gerion for weeks.
      • Past history: denied major systemic disease
      • Impression: tinea cruris et intertrigo eczema.
    • P
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) BID TOPI 7D
      • Zalain (sertaconazole nitrate) BID TOPI 7D
  • 2023-04-19 SOAP Hemato-Oncology
    • P
      • Due to purpura over arms and legs, the subject uses Hirudoid Gel, which is over the counter medicine, from 2023-04-19.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-04-19 to 2023-04-21.
  • 2023-04-12 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for 4 more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-05-10
  • 2023-03-29 SOAP Hemato-Oncology
    • P: For creatinine increased, hydration is given to the subject from 2023-03-29 to 2023-03-31.
  • 2023-03-29 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-04-12
  • 2023-03-22 SOAP Hemato-Oncology
    • P: Due to improvement of appetite, the dose of megestrol was adjusted from 160 mg PO QD to 80 mg PO QD since 2023-03-16.
  • 2023-03-16 SOAP Hemato-Oncology
    • AE:
      • Fever Gr 1 on 2022-10-20, related to IP.
      • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
      • Mucositis oral Gr 2 from 2023-01-26 to now, not related to IP. (Related to removable denture)
      • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
      • Diarrhea Gr 1 from 2022-12-05 to 2022-12-18, not related to IP.
      • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
      • Lung infection Gr 2 from 2023-01-21 to 2023-01-26, not related to IP.
      • Cytomegalovirus infection reactivation Gr 1 from 2023-01-16 to 2023-01-30, Gr 2 from 2023-01-31 to 2023-03-14, not related to IP.
      • Alanine aminotransferase increased Gr 1 from 2023-02-22 to 2023-03-14, not related to IP.
      • Aspartate aminotransferase increased Gr 1 from 2023-02-08 to 2023-02-21, not related to IP.
      • Anemia Gr 2 from 2023-01-09 to 2023-01-12, not related to IP.
      • Creatinine increased Gr 1 from 2023-03-01 to 2023-03-07, not related to IP.
      • Blood bilirubin increased Gr 1 from 2023-03-08 to now, not related to IP.
  • 2023-03-15 SOAP Infectious Disease
    • A: refill Valcyte dose to 2# qd for two more weeks, has received 3-week full dose Valcyte till 2023-02-22.
    • P: FU on 2023-03-29
  • 2023-03-15 SOAP Hemato-Oncology
    • O
      • 2023/03/13 CMV viral load assay = Target not deteceted IU/mL;
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: For prevention of creatinine increased, hydration is given to the subject from 2023-03-15 to 2023-03-16.
  • 2023-03-01 SOAP Hemato-Oncology
    • P: For Gr 1 creatinine increased, hydration is given to the subject from 2023-03-01 to 2023-03-03.
  • 2023-02-22 SOAP Infectious Disease
    • A: reduce Valcyte dose to 2# qd for two weeks, has received 3-week full dose Valcyte till 2023-02-22
    • P: FU on 2023-03-08
  • 2023-02-22 SOAP Hemato-Oncology
    • O
      • 2023/02/20 CMV viral load assay = <35 IU/mL;
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
  • 2023-02-15 SOAP Hemato-Oncology
    • P: For prevention of contrast-induced nephropathy, hydration is given to the subject from 2023-02-15 to 2023-02-17.
  • 2023-02-08 SOAP Hemato-Oncology
    • O
      • 2023/02/06 CMV viral load assay = 181 IU/mL;
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, follow up CMV viral load after 2 weeks of using Valcyte and adjust Prednisolone from 4 tab QD to 2 tab QD.
  • 2023-02-08 SOAP Infectious Disease
    • S: CMV related hepatitis follow up, easy fatigue, exertional dyspnea, intake still acceptable, loss of weight 1kg.
    • O
      • BT no fever, BW 65.2kg
      • 20230208 AST/ALT 80/335,
      • 20230206 CMV viral load 181
    • A
      • refill Valcyte for the 2nd and 3rd week therapy
      • reduction of steroid use indicated
    • P: FU on 2023-02-22
  • 2023-02-01 SOAP Infectious Disease
    • S
      • 2023/02/01 Referred from Onco OPD for CMV related hepatitis
      • no cough, exertional dyspnea and easy fatigue still noted,
      • PJP and interstitial lung discharged from Onco on 2023-01-20, with prednisolone and Baktar use
      • Underlying lung cancer, cT4N3M1b stage IVA SCC, cachexia.
    • O
      • BT no fever
      • 20230131 WBC 23290, AST/ALT 131/252
      • 20230127 CMV viral load assay = 62 IU/mL;
      • 20230117 CT chest: LUL cancer with chest invasion and mediastinal-hilar LAP, signficant as compared with CT on 2022/12/16. combined emphysema and IPF.
      • 20221224 CMV viral load not deteceted;
    • A
      • refill Valcyte for one week first, under CMV-related hepatitis impression.
    • P
      • FU on 20230208
  • 2023-01-31 SOAP Hemato-Oncology
    • O
      • 2023/01/27 CMV viral load assay = 62 IU/mL;
      • 2022/12/24 CMV viral load assay = Target not deteceted IU/mL;
    • P: Highly suspect CMV reactivation complicated with hepatitis -> After discussion with infection expertise, prescribe Valcyte and refer to Infection expertise for futher evaluation and management.
    • Prescription
      • Valcyte (valganciclovir 450mg) 2# BID 1D
  • 2023-01-26 SOAP Hemato-Oncology
    • P:
      • Due to impaired renal function which might be related dehydration, IV fluid support will be given.
      • In addition, potassium-binding agent will be used for hyperkalemia.
    • Presciption
      • Kalimate (calcium polystyrene sulfonate 5mg) 1# QD 5D
  • 2022-12-15 SOAP Hemato-Oncology
    • P: Because new main ICF (Version 2.0, 12-Oct-2022) and Optional Future Research ICF (Version 1.0, 12-Oct-2022) are proven, I give the new version ICF to the subject and let the subject have adequate time to read it, subsequently ask question and discuss with us. Then the subject sign the version ICF on 2022-12-15. A copy of the signed main ICF and Optional Future Research ICF were provided to the subject.
      • For prevention of contrast-induced nephropathy, hydration is given to the subject from 2022-12-15 to 2022-12-17.
      • The subject discontinued Cyproheptadine from 2022-12-15, and switched to Megestrol Acetate 160 mg PO QD for anorexia from 2022-12-15.
      • Due to relatively lower BP and occasionally dizziness, the subject hold Bisoprolol Fumarate from 2022-12-08.
      • The subject discontinued Lorazepam from 2022-12-08, and switched to Quetiapine from 2022-12-08.
      • Due to Morphine induced dry mouth, the subject discontinued Morphine and switched to Tramacet from 2022-12-08.
      • On 2022-12-16, the CT revealed the possibility of lung infection or pneumonitis. Therefore, oral empirical antibiotics with cephalexin 500 mg Q6H is given since 2022-12-16. If not working, admission for lung infection would be done.
    • Prescription
      • cephalexin 500mg 1# Q6H 7D
  • 2022-12-07 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-12-05 to now, not related to IP.
        • Anorexia Gr 2 from 2022-12-05 to now, not related to IP.
    • P
      • Due to sweating a lot, hydration is given to the subject from 2022-12-07 to 2022-12-09.
      • Cyproheptadine 4 mg PO TID for anorexia from 2022-12-07.
      • The subject discontinued Orolisin from 2022-11-30.
  • 2022-11-30 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to 2022-11-29, not related to IP.
        • Diarrhea Gr 1 from 2022-11-28 to 2022-11-29, not related to IP.
    • P
      • Due to suspect the sweating coming from taking Tramacet (tramadol/acetaminophen), discontinued Tramacet from 2022-11-17.
      • Because the subject mentions the eczema over bilateral upper limbs which is actually existed before being enrolled onto this trial, Levocetirizine, Fluocinonide and Urea are prescribed by dermatologist on 2022-11-30.
      • Due to sweating a lot, hydration is given to him on 2022-11-30.
  • 2022-11-30 SOAP Dermatology
    • S: itchy over exposesite of upper limbs
    • O: Widespread multiple reddish to brownish maucles, papules and confluent plaques with excoriations and scales over the upper limbs for months. No fever
      • Past history: denied major systemic disease
      • Impression: eczema, less likely drug-related. r/o pityriasis disorder.
    • P:
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Prescription
      • Xyzal (levocetirizine 5mg) 1# QN
      • Topsum Cream (fluocinonide 0.05%) BID EXT
      • Sinpharderm Cream (urea) BID TOPI
  • 2022-11-24 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-24 to now, not related to IP.
    • P
      • Sodium Chloride for hyperkalemia (K: 5.9 mmol/L)
      • Triamcinolone 1 qs TOPI PRNBID for prevention of mucositis.
  • 2022-11-09 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to 2022-11-08, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to 2022-11-08, not related to IP.
    • P: Due to sweating after taking Tramacet (tramadol/acetaminophen), hydration is given to him on 2022-11-09.
  • 2022-11-03 SOAP Hemato-Oncology
    • O
      • AE:
        • Fever Gr 1 on 2022-10-20, related to IP.
        • Fatigue Gr 1 from 2022-10-30 to now, not related to IP.
        • Mucositis oral Gr 1 from 2022-10-31 to 2022-11-02, Gr 2 from 2022-11-03 to now, not related to IP. (Related to removable denture)
        • Hyperkalemia Gr 2 from 2022-11-03 to now, not related to IP.
    • P
      • Triamcinolone for mucositis oral from 2022-11-03.
      • Sodium Chloride for hyperkalemia (K: 5.7 mmol/L)
  • 2022-10-27 SOAP Hemato-Oncology
    • S
      • BGB-A317-A1217-302 (iIRB No: 10-FS-043) C1D8 Visit
        • IP: Tislelizumab or Pembrolizumab 200 mg (D1) + BGB-A1217 900 mg or Placebo (D1) Q3W
        • C1D1 on 2022-10-20
    • O
      • PE (Body system: vision, general, HEENT, cardiovascular, chest and respiratory, abdomen, extremities/musculoskeletal, neurological) –> Yes & maculopapular rash and plaques
      • Examinations and Tests
        • Sample collection:
          • Lab tests:
            • Blood collection at 08:57 AM on 2022-10-27
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo; ADA of Tislelizumab or Pembrolizumab & A1217 or Placebo (pre-dose): Nil
            • PK of Tislelizumab or Pembrolizumab & A1217 or Placebo (post dose within 30mins): Nil
      • AE: Fever Gr 1 on 2022-10-20, related to IP.
    • P
      • Monitor adverse event
  • 2022-10-18 SOAP Hemato-Oncology
    • P
      • Acetylcysteine 600 mg PRBBID PO for productive cough.
      • Piroxicam 1 QS PRNBID TOPI for tumor pain.
  • 2022-10-12 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • The subject has still Aspirin, Bisoprolol, Atozet, Candesartan, Famotidine, Sennoside, Morphine, MgO, Acetylcysteine, Fluocinonide, Orolisin, Exelderm Cream, Urea at home, no priscription on 2022-10-12.
  • 2022-10-04 SOAP Hemato-Oncology
    • P
      • Refil the medicine
      • Actein for prevention of contrast-induced nephropathy.
      • Preliminarily discuss the content of trial on 2022-09-15 and 2022-09-26.
  • 2022-09-20 SOAP Hemato-Oncology
    • S
      • << BGB-A317-A1217-302 (iIRB No: 10-FS-043) Pre-screening ICF Process >>
        • I myself have already discussed the whole details concerning the investigational product, A1217, an anti TIGIT antibody, in combination with Tislelizumab compared to Pembrolizumab, and the trial, BGB-A317-A1217-302 (iIRB No: 10-FS-043), with subject and family on 2022.09.15, using the virtual discussion via web.
        • Before the Pre-screening informed consent form (V1.1_TC_20May2021) is signed, the Pre-screening ICF was read by patient and family with adequate time.
        • They had enough time to ask questions and I answered their questions thoroughly as well.
        • The subject agreed to provide the tumor slides to central lab for determination of PD-L1 expression, and had signed Pre-screening informed consent form on 2022.09.20.
        • A copy of the signed Pre-screening informed consent form was provided to the subject.
    • O
      • Study Title: BGB-A317-A1217-302
      • A Phase 3, Randomized, Double-Blind Study of BGB A1217, an Anti TIGIT Antibody, in Combination With Tislelizumab Compared to Pembrolizumab in Patients With Previously Untreated, PD L1 Selected, and Locally Advanced, Unresectable, or Metastatic Non Small Cell Lung Cancer
      • Pre-screening No.: SCR-886019-001
      • Initial: SJC
      • Date of birth: 1940.11.23
      • Gender: Male
      • ALK IHC: Negative
      • EGFR: Negative
    • A
      • Anticipate to arrange the freshly cut unstained FFPE slides on 2022-09-20.
  • 2022-09-15 SOAP Hemato-Oncology
    • O
      • 2022/08/31 Anti-HBc = Reactive;
      • 2022/08/31 Anti-HBc-Value = 7.15 S/CO;
      • 2022/08/31 ROS1 FISH: Negative
      • 2022/08/31 ALK IHC: Negative
      • 2022/08/19 EGFR: Negative
  • 2022-08-30 SOAP Hemato-Oncology
    • A
      • ALK, ROS1 and lab
      • T3N0M1a stage M1a SCC
  • 2022-08-17 SOAP Cardiology
    • Prescription
      • Bokey (aspirin 100mg) 1# QD 14 days
      • Concor (bisoprolol 5mg) 0.5# QD 14 days
      • Atozet (ezetimibe 10mg + atorvastatin 20mg) 1# QD 14 days
      • Blopress (candesartan 8mg) 1# QD 14 days
      • Ulstop (famotidine 20mg) 1# QD 14 days
  • 2022-08-03 SOAP Chest Medicine
    • S
      • hemoptysis
      • A case of HTN and 2-V CADs/p POBA for trifurcation lesion in ShinKong hospital got medical treatment
      • Active smoking 1/2+ PPD for 30+ years
      • Denied past history of DM
      • Complained of migratory localized chest pain in the recent 2~3 days, duration lasted for seconds, but denied effort related angina
      • 20220803 EKG: sinus rhythm, 1st AV block
      • 20220803 Current medications:
        • aspirin 1# QD,
        • inderal 1# BID,
        • atozet 1# QD,
        • gaster 1# BID,
        • erispan 1# BID,
        • stilnox 1# prnHS,
        • uricin 1# QD
      • CXR yesterday at LMD revealed left lung tumor, refer to chest clinic
      • Arrange echocardiography and Tl-201 myocardial perfusion scan for further evaluation

[chemoimmunotherapy]

  • 2023-04-07 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-03-16 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2023-02-23 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-12-01 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-11-10 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)
  • 2022-10-20 - BGB-A317 (tislelizumab) or Keytruda (pembrolizumab) 200mg NS 80mL 30min (with pump and filter) + BGB-A1217 (ociperlimab) or Placebo 900mg NS 55mL 30min (with pump and filter)

==========

2022-12-29

[Trimethoprim/Sulfamethoxazole (TMP/SMX) dosing]

  • Trimethoprim/sulfamethoxazole(TMP/SMX) for patients with moderate to severe Pneumocystis pneumonia infection: IV 15 to 20 mg/kg/day (TMP component) in 3 or 4 divided doses; may switch to oral therapy after clinical improvement.

    • In-hospital Baktar spec: sulfamethoxazole 400mg + trimethoprim 80mg in 5mL/amp. The patient’s body weight is 70kg.
    • 70kg * 15 = 1050mg ~ 13.125 amp ~ 4amp TID or 3amp QID
    • 70kg * 20 = 1400mg ~ 17.5 amp ~ 6amp TID or 4amp QID
  • As recent lab results revealed no abnormalities in the liver and kidney functions, it is less likely that dosage adjustments will be needed.

  • Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient >= 35 mm Hg) should receive adjunctive glucocorticoids.

700691239

230427

{not completed}

[exam findings] (not completed)

  • 2023-04-25 MRI - pelvis
    • Indication: posterior iliac crest tender mass, r/o abscess formation
    • With and without-contrast multiplannar and multisequences MRI of pelvis revealed:
      • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
      • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
      • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
    • Impression
      • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
      • c/w bone metastasis in spine, right sacral ala, and left acetabulum
  • 2023-04-13 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
  • 2023-04-06 SONO - abdomen
    • Right renal cyst (0.90x1.38cm).
  • 2023-03-23 MTBC PCR
    • S2023-04099 — Positive
  • 2023-03-07 Patho - bone exostosis
    • Soft tissue, labeled as “bone, right sacral”, CT-guide biopsy — Necrosis
      • NOTE: Correlation of micro-organism culture, image study and clinical findings is recommended.
    • Microscopically, it shows necrotic debris, mixed inflammatory infiltrate of lymphocytes and leukocytes and focal stromal fibrosis.
    • Immunohistochemical stain reveals CK(-) and GATA3(-) for tumor.
    • Acid-fast stain — Positive for mycobacterial bacilli, PAS stain — Negative; Suggest of mycobacterial infection
  • 2023-03-06 CXR
    • Old fracture of right clavicle S/P compression plate and screws fixation shows good alignment and good union.
    • There is soft tissue density in paraspinal area in T11-T12 level. Please correlate with CT.
    • Osteolytic lesion in T12 vertebral body is highly suspected.
  • 2023-03-01 PET scan
    • Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases. .
    • Increased FDG uptake in soft tissue in the RLQ and LUQ of abdomen, the nature is to be determined (another primary malignancy or others ?), suggesting biopsy for further investigation.
    • Right breast cancer s/p treatment, highly suspected tumor (breast or others ?) with multiple bone metastases, by this F-18 FDG PET scan.
  • 2023-02-16 Tc-99m MDP bone scan
    • In comparison with the previous study on 2022/02/16, the lesions in the lower T-spines, manubrium of the sternum, right aspect of sacrum, adjacent right iliac bone and inferior aspect of left acetabulum are new.
    • Multiple bone metastases should be watched out.
  • 2023-02-10 CT - abdomen
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
    • Findings:
      • There are osteoblastic change from T11 to L1.
        • In addition, There is osteolytic lesion in T12 vertebral body and soft tissue tumor extension from T12 vertebral body into anterior and left lateral aspect of the vertebral body and left psoas muscle.
        • Metastases are highly suspected. Please correlate with tumor marker and PET scan.
      • There is an ill-defined osteoblastic change and osteolytic lesion in right 1st sacrum that also may be bony metastasis.
      • Two low density lesion in the upper pole of both kidney are noted. Please correlate with sonography to R/O cyst?
      • There is no hyper-or hypodense lesion in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
    • IMP:
      • Bony metastases are highly suspected.
      • Please correlate with tumor marker and PET scan.
  • 2023-02-06 SONO - nephrology
    • Bilateral renal cysts
  • 2022-12-26 SONO - abdomen
    • Right renal cyst and stone.

[consultation]

  • 2023-04-26 Anesthesiology
    • Q
      • This 53-year-old female patient has past history of
        • Left breast tumor s/p left tumor excision in 2003
        • Right clavicle fracture s/p ORIF
        • Right breast tumor s/p tumor excision after needle localization on 2022/01/28
      • Right breast ductal carcinoma in situ status post right axillary sentinel lymph node biopsy on 2022-03-11. She denied any TOCC histories in recent 3 months.
      • This time she was admitted due to right iliac crest biopsy site severe pain with tenderness for 2 days. The pain was accompanied with fever up to 39.5 degC and chillness.
      • Under the impression of right iliac crest cellulitis, she was admitted for antibiotics treatment.
      • 2023/03/01 bone scan: Increased FDG uptake in the T10-L1 spines, right aspect of sacrum, and inferior aspect of the left acetabulum, highly suspected tumor (breast or others ?) with multiple bone metastases.
      • However, on 2023/03/02 Bone marrow biopsy showed no metastatic carcinoma
      • 2023/03/07 CT-guided biopsy of right sacrum showed positive AFS, and subsequently at 2023/03/23 tissue report showed TB positive
      • Lab data (20230424): CRP 12.68, WBC 15010; blood culture result pending
      • Currently the patient has been taking AKuriT-4 for 5 weeks.
      • MRI pelvis done on 20230425 showed c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • ID man suggested needle aspiration by radiologist; and Radiologists warned us about the risk of cutaneous fistula formation and skin TB after drainage procedure.
      • This morning, the patient started to notice right leg numbness radiating from hip downward from the side of thigh all the way down to right sole, but resolved after 2 hours
      • PE showed pain on right hip flexion, and restricted AROM on right hip extension.
      • Therefore, we also consulted neurosurgeon and replied no apparent invasion of spine.
      • GS was also consulted, and due to the lesions were deeply located, therefore, surgical debridement was not feasible
      • ORTHO will arrange debridement for her right sacral abscess on 20230427.
      • This time we would really need your expertise in providing preoperative anesthetic evaluation for this patient.
      • Thanks a lot in advance!
    • A
      • I’ve visited the patient and reviewed her data
      • CC: right iliac crest severe pain with tenderness, fever and chillness
      • DX: c/w tuberculous infection with cold abscess in right pelvis (invading erector spinae muscle, iliopsoas muscles, and sacroiliac joint.), in progression; c/w bone metastasis in spine, right sacral ala, and left acetabulum
      • OP: right sacral abscess debridement on 20230427
      • Anes plan:
        • ASA III
        • We will arrange ETGA for this patient
        • The patient has been informed on the anesthesia- and surgery-associated risks
  • 2023-04-25 Neurosurgery
    • Q
      • This time we would really need your expertise in evaluating the feasibility of incisional drainage with biopsy, and the possible cause of right sciatica.
    • A
      • A case of 53 y/o female, Hx have been reviewed; Extrapulmonary TB(+) under Tx.
      • NS is consulted for right LBP and wraist mass with tenderness; Fever(+);
      • O
        • Current status: Cons: clear
        • Walk ok; MP: bil 5-; sensation: symmetric; gait: fair; sphincter: continence
        • A pelvis MRI:
          • Fluid accumulation in right pelvis, involving erector spinae muscle, iliopsoas muscles, and sacroiliac joint. Marginal enhancement after contrast adminstration. Another fluid collection in left L1-2 paravertebral region.
          • An intramudullar lesion in right sacral ala, adjacent to right sacroiliac joint. Enhancement after contrast administration.
          • T2 hyperintense lesions in spine and left acetabulum. Enhancement after contrast administration.
      • A
        • c/w tuberculous infection with cold abscess in right pelvis and left paravertebral regions, in progression
        • c/w bone metastasis in spine, right sacral ala, and left acetabulum; breast cancer
      • P
        • May arrange CT guide or echo guide pigtail drainage and biopsy; pain control; Tx TB as usual;
  • 2023-04-22 Infectious Disease
    • A
      • 81-year-old breasst cancer female patient has right sacroiliac crest TB and has received 5 more week anti-TB treatment till now.
      • O
        • Painful growing mass is noted over right posterior lower back, where previous biopsy site.
        • Lab data revealed no drop of ESR and CRP levels.
      • A
        • Either hematoma or abscess formation is the first consideration.
        • No need for change the anti-TB regimen, but MRI or CT study necessary for the mass lesion nature.
      • Suggestion
        • Continue the present AkuriT-4 medication to complete the first 60-day medication.
        • Continue Tramacet and add Celebrex for pain relief.
        • Arrange MRI of T-L-S spine for evaluation of spine and iliac mass lesion.
  • 2023-03-10 Infectious Disease
    • A
      • 52-year-old breast cancer with suspect multiple bony metastases female patient, received right sacrum bone biopsy on 2023-03-07.
      • Patholgoy report revealed positive AFB smear and no cancer cell, that bone TB is the first consideration.
      • Review the PET report, there are multiple bone lesions, including sternum, T-spine, right sacrum and left acetabulum.
      • TB bone rarely presents so many sites.
      • TB bone culture was not done, that bone tissue TB-PCR study is necessary.
      • Please contact the TB practioner.
      • TB disease notification is necessary first, that anti-TB therapy can be started, even without PCR report.

[assessment]

  • AKuriT-4 (RIF 150mg + INH 75mg + PZA 400mg + EMB 275mg) 3# PO QDAC is administered according to the patient’s bone tuberculosis.

  • It is important to note that the patient is currently taking multiple NSAIDs (Laston (ketorolac) ST, Celebrex (celecoxib) QD, naproxen PRNQ8H). Concomitant use of multiple NSAIDs is not recommended due to the increased risk of side effects such as bleeding and kidney damage. Please monitor the patient closely for signs of bleeding or changes in kidney function and consider adjusting her medication regimen if necessary.

701048984

230427

[diagnosis] - 2023-03-29 admission note

  • gastric cancer with liver invasion, cT4bN1M0, stage IV s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection
  • constipation

[past history] - 2023-03-06 admission note

  • The patient had no systemic diseases
  • history of operation:
    • gastric cancer with liver metastasis, cTT4bN2M1, stage IVB, s/p liver S3 partial resection, cholecystectomy, choledochoduodenal bypass and gastrojejunal bypass on 2023/01/09
  • Regular medications or herb:
    • Tramacet 1tab PO HS
    • Sketa 1tab PO TID
    • Pariet 1tab PO QDAC
    • Mosapride 1tab PO TID         

[allergy]

  • NKDA         

[family history]

  • His father has hypertension.
  • Denied of any families have cancer history.

[exam findings]

  • 2023-04-18 Patho - stomach biopsy
    • Stomach, proximal to the anastomosis site, biopsy — Adenocarcinoma, moderately differentiated
    • Section shows fragments of gastric tissue with chronic inflammation, intestinal metaplasia and focal invasive cribriform glands.
    • The immunohistochemical stain of CK is positive.
  • 2023-04-18 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Gastric ulcer, LC site, proximal to the anastomosis, s/p biopsy
      • Remnant gastritis
      • Post subtotal gastrectomy with Billroth II anastomosis
    • Suggestion
      • Keep PPI therapy
      • Pursue pathology report
  • 2023-04-02, -02-06, -02-04 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-02-04 CXR
    • Atherosclerosis of the aorta.
    • Presence of ileus.
  • 2023-01-09 Patho - liver partial resection
    • Gallbladder, cholecystectomy — Chronic cholecystitis and cholelithiasis
    • The sections show a picture of chronic cholecystitis and cholelithiasis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
  • 2023-01-09 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S3, partial S3 resection — Adenocarcinoma, moderately differentiated, compatible with gastric origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial S3 resection
      • Specimen Size: 4.5 x 3.2 x 2.5 cm
      • Tumor Focality: Solitary
      • Tumor Site: S3
      • Tumor Size: 0.8 x 0.6 x 0.4 cm
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A2 = tumor, A3 = non-neoplastic liver
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Adenocarcinoma, compatible with gastric origin
      • Histologic grade: Moderately differentiated
      • Tumor growth pattern: Pushing
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Moderate (40%)
      • Parenchymal margin: Uninvolved by carcinoma
      • Distance of invasive carcinoma from closest margins: 1.2 cm
      • Vascular invasion: Not identified
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal inflammation, no interphase hepatitis, no lobular inflammation, and regenerative hepatocytes
      • Fatty Change: Present (3%)
  • 2023-01-05 CT - abdomen gastric filling with water
    • History and indication: gastric cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A large ulcerative lesion at gastric antrum with regional LAP.
      • Normal appearance of liver, spleen, pancreas, adrenals and kidneys.
      • Gallbladder stone (6mm).
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • No abnormal density at bilateral basal lungs.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE:III(Stage_value)
  • 2023-01-04 Flow Volume Chart
    • normal screening
  • 2023-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (94 - 34) / 94 = 63.83%
      • M-mode (Teichholz) = 64
    • Adequate LV systolic function with normal resting wall motion
    • Trivlal MR and trivial TR
    • LV diastolic dysfunction, Gr 1
    • Preserved RV systolic function
  • 2022-12-28 Patho - stomach biopsy
    • Stomach, antrum LC, biopsy — Adenocarcinoma.
    • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+).
    • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands and isolated neoplastic cells.
  • 2022-12-27 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Superficial gastritis, s/p CLO test
      • Suspected gastric cancer, antrum, LC site, s/p biopsy
    • Suggestion
      • Pursue pathology report
  • 2021-02-23 Auditory Brainstem Response, ABR
    • Absence of ABR wave I was noticed in L’t ear.
    • Prolonged ABR wave I latency in R’t ear.
    • ILD-V 0.08
    • no evidence of retrocochlear lesion
  • 2021-02-16 ENT Hearing Test
    • PTA:
      • Reliability FAIR
      • Average R’t 30 dB HL; L’t 44 dB HL
      • R’t normal to profound SNHL.
      • L’t normal to severe SNHL.
    • Tymp: Bil type A.
    • ART:
      • R’t ipsi 4k Hz and contra absent.
      • L’t absent.

[consultation]

  • 2023-04-17 Anesthesiology
    • Q
      • for anesthesia assessment
      • Arrange painless of EGD on 4/18 8AM
      • This 80-year-old male, who has a histiry of gastric cancer with liver invasion, cT4bN1M1 s/p gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09 s/p palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin. He suffered from initial presentation of RUQ of abd pain in Jan 2023, s/p sent to ER of ShuangHe Hospital and weight loss (+) (5kg in 12 months). Surgical pathology with liver, S3, partial S3 resection (20230109) proved Adenocarcinoma, MD. c/w gastric origin. Gallbladder, cholecystectomy: Chronic cholecystitis and cholelithiasis. Ascites (20230109) showed negative. Stomach, antrum LC, biopsy (20221227) proved adenocarcinoma.IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=1+). He received gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09, and received palliative chemotherapy with mFOLFOX IV, and IP chemotherapy Taxotere/Cisplatin Q2W x 12 , #1 on 20230216, #2 on 20230306, #3 on 20230330 - Acording to the patient describe, he suferred from vomiting dark red once and tarry stool noted on 2023/04/15, so he was brought to ChangGung Hospital for help first, then due to personal reason, so he went to our ER for help. At ER, the vital signs: BT 36.3 degC; HR: 99bpm; RR: 18bpm; SpO2 98% under room air, conscious: E4V5M6. The lab of CBC/DC showed anemia (Hb: 8.8g/dL), so gave blood tranfusion with LPRBC, hydration, Transamine, and PPI with Pantoloctreatment. After treatment, the Hb level go up to 10.1g/dL. Under the impression of Gastrointestinal hemorrhage, so he is admitted for future evaluation.
    • A
      • 80 y/o man has
        • Hx: gastric cancer stage VI
        • gastrojejunostomy, choledochoduodenostomy and liver S3 partial resection on 2023/01/09
      • Dx: GI Bleeing
      • Op: PES
      • Condition: Cons. clear, previous walking ok but now weakness and tired unable to sit on wheelchair, no dyspnea, chest tightness or leg edema
      • Lab: Hb10
      • ASA3
      • Plan:
        • High risk of aspiration, sepsis, shock
        • Anes. plan and risk was told to him at bedside
        • Resucitation, ETT will be procedured if emergence condition.
        • We will arrange IVGA, GI man will injection local anesthsia at GI tract.
        • Correct underly dx such as anemia, hypovulemia as your expertise.
        • Follow onetouch q6h or even q4h when nil per os if DM or high risk of hypoglycemia

[surgical operation]

  • 2023-01-09
    • Surgery
      • Laparoscopy
      • Liver S3 partial resection
      • Cholecystectomy
      • Choledochoduodenal bypass
      • Gastrojejunal bypass
    • Finding
      • A whitish hard tumor was protruding from the anterior wall of gastric antrum near lesser curvature.
      • A whitish tumomr was noted at the posterior wall of S3 segment, r/o direct invasion from the gastric tumor.
      • Hard tumors were noted at the pancreatic head and retroperitoneum.
      • After discussion with his family, tumors could not excised entirely. His son agreed with performing bypass surgery only.
      • No gallbladder stone was found.
      • At least cT4bN1

[chemotherapy]

  • 2023-04-27 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 100mL 2hr + fluorouracil 2000mg/m2 2900mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-29 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 550mg NS 100mL 2hr + fluorouracil 2000mg/m2 2800mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-06 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-16 - [oxaliplatin 40mg/m2 60mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 100mL 2hr + fluorouracil 2000mg/m2 3000mg NS 500mL 46hr] IVD + [docetaxel 30mg/m2 40mg + cisplatin 30mg/m2 40mg + NS 800mL + gentamycin 40mg + NaHCO3 2800mg] 1hr IP (FOLFOX NIPS)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

==========

2023-04-27

  • 2023-04-26 lab results showed low serum Na (133 mmol/L), K (3.4 mmol/L), Mg (1.4 mg/dL), and albumin (3.3 g/dL). These electrolyte imbalances are currently being addressed with appropriate supplementation. With the exception of mild anemia, the patient’s blood cell counts are within normal limits and do not represent a contraindication to the planned chemotherapy.

  • The PharmaCloud database shows that all of the patient’s most recent medications were prescribed at our hospital, and no medication reconciliation issues were identified.

2023-03-30

  • Laboratory data on 2023-03-29 showed normal liver/kidney function, however, cation electrolytes and HGB were slightly decreased, which would not contraindicate the planned chemotherapy.

  • Ascites cytology on 2023-03-08, 2023-03-07, 2023-02-20, 2023-02-17 showed no evidence of positive results.

  • No medication reconciliation issue identified.

2023-03-07

  • The patient is undergoing FOLFOX NIPS treatment for the second time during this hospital stay. There are no apparent complaints of adverse reactions following the patient’s last treatment.
  • Potassium supplementation is currently administered appropriately to manage low serum K level (2023-03-06 3.0mmol/L) in this patient.

2023-02-17

  • The patient undergos palliative chemotherapy with a combination of mFOLFOX IV/IP C/T every two weeks for a total of 12 cycles since this hospital stay. After the first 6 cycles the patient will undergo an abdominal CT scan to evaluate the response to treatment.
  • Lab data 2023-02-16 showed grossly normal readings, and the patient’s TPR and blood pressure vital signs have remained stable throughout his hospitalization as of now.
  • Megestrol is appropriately used as an appetite stimulant in this patient with poor appetite and unintended weight loss.

701173522

230427

{not completed}

[exam findings]

[surgical operation]

  • 2019-08-26
    • Diagnosis: Malignant ovary neoplasm with peritoneal carcinomatosis
    • PCS code: 73043B
    • Finding
      • ascite (-)
      • small bowel adhesion (++)
      • tumor (-)
  • 2019-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 73014B
    • Finding: mutiple tumor seeding over s7, right diaphragm, left paracolic gutter, pelvis, surface of urinary bladder, ascending colon, and sigmoid colon
  • 2019-07-15
    • Diagnosis: Ovarian cancer
    • PCS code: 80418B
    • Finding:
      • Supraumbilical midline vertical skin incision.
      • Uterus: 6x3 cm, tense contact with bladder, no obvious tumor noted
      • Adnexa:
        • Lt: 3x2 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
        • Rt: 4x3 cm, capsule intact, papillary surface, severe adhesion to uterus, pelvic wall and rectum due to tumor seeding
      • CDS: invisible due to tumor mass occupied
      • Ascites: little
      • Bilateral paraaortic and pelvic lymph nodes: normal(-), enlarged(+), indurated(-)
      • Omentum: with multiple hard, variablesized millitary nodules
      • Liver: with rough surface
      • Subdiaphragmatic surface: miliary tumor seeding(+), bean sized
      • After the operation, HIPEC was performed.
      • Residue tumor: multiple millitary tumors, diameter about 0.1 cm, over peritoneal wall, small intestine and colon
      • Estimated blood loss: 850ml (include ascites)
      • Blood transfusion: nil
      • Complication: nil
  • 2019-04-11
    • Diagnosis: Maliganat cervix uteri neoplas
    • PCS code: 47080B
    • Finding:
      • peritoneal carcinomatosis, PCI: 17/39, small bowel PCI: 4
      • malignant ascites(+), about 2600ml
      • omentum cake(+)
  • 2017-07-15
    • Diagnosis: Malignant ovary neoplasm
    • PCS code: 50010C
    • Finding: bilateral ureter was indwelled with 4Fr. catheter under direct vision

[chemotherapy]

  • 2023-04-19 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-04-12 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-29 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-22 - topotecan 1.75mg/m2 2.5mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-03-08 - topotecan 3.75mg/m2 5.0mg NS 100mL 30min + bevacizumab 10mg/kg 600mg NS 100mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + metoclopramide 10mg + NS 250mL
  • 2023-01-18 - bevacizumab 7.5mg/kg 450mg NS 250mL 90min + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-26 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-05 - bevacizumab 7.5mg/kg 450mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-14 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-24 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-04 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-12 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-01 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-25 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-07-11 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-05-03 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 300mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-04-20 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-21 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-03-15 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-02-22 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-24 - gemcitabine 1000mg/m2 1500mg NS 100mL 30min + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-18 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-12-28 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-11-09 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-10-19 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-09-06 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-08-16 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2021-07-26 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-30 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-06-07 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-05-17 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-04-27 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 75mg/m2 110mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-03-29 - bevacizumab 7.5mg/kg 400mg NS 250mL 1.5hr + docetaxel 60mg/m2 90mg NS 250mL 1hr + carboplatin AUC 2 600mg NS 250mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-02-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2021-01-04 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-12-07 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-26 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-10-05 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2020-09-01 - liposome doxorubicin 30mg/m2 40mg D5W 100mL 1hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

Medication

  • Lynparza (olaparib 150mg) 2# BIDCC PO
    • 2023-04-12 ~ undergoing (OPD)

[assessment]

  • The patient experienced severe neutropenia after their last chemotherapy session on 2023-04-19, with the low WBC count observed on 2023-04-24. G-CSF (filgrastim) 300ug QD for 14 days has been prescribed since 2023-04-24 to address this issue. To date, the WBC count has improved slightly, increasing from a low of 260/uL to 420/uL.
    • 2023-04-27 WBC 0.42 x10^3/uL
    • 2023-04-26 WBC 0.30 x10^3/uL
    • 2023-04-25 WBC 0.26 x10^3/uL
    • 2023-04-24 WBC 0.33 x10^3/uL
    • 2023-04-19 WBC 12.02 x10^3/uL
    • 2023-04-12 WBC 3.56 x10^3/uL
  • The patient has received blood transfusions for their anemia, with 2 units of L-PRBC administered on 2023-04-24 at around 20:00, 1 unit at around 23:00, and an additional 2 units on 2023-04-27 at around 13:00.
    • 2023-04-27 HGB 7.6 g/dL
    • 2023-04-26 HGB 8.1 g/dL
    • 2023-04-25 HGB 8.6 g/dL
    • 2023-04-24 HGB 7.6 g/dL
    • 2023-04-19 HGB 8.8 g/dL
    • 2023-04-12 HGB 10.2 g/dL
  • The patient’s platelet count has shown a steep drop and, as of now, there is no obvious sign of recovery. If the risk of bleeding is high, platelet transfusion may be necessary.
    • 2023-04-27 PLT 18 x10^3/uL
    • 2023-04-26 PLT 28 x10^3/uL
    • 2023-04-25 PLT 47 x10^3/uL
    • 2023-04-24 PLT 7 x10^3/uL
    • 2023-04-19 PLT 91 x10^3/uL
    • 2023-04-12 PLT 184 x10^3/uL

700618096

230426

[past history] - 2023-04-20 admission note

  • Hypertension for 10 years with regular medication control.

  • DM with triopathy for 10+ years with regular OHA, insulin control.

  • Asthma: Asthma since young with regular OPD f/u.

  • Operation history: Appendectomy 10 yrs ago.

  • Denied history of Hypertension, DM, asthma

  • Denied any operation, accident and other medical Hx.        

[allergy]

  • Primperan (metoclopramide): other

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-24 Tc-99m MDP bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, mandible, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2023-04-21 ECG
    • Normal sinus rhythm
    • Low voltage QRS
    • Borderline ECG
  • 2023-04-21 Nasopharyngoscopy
    • Findings: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
    • Diagnosis: suspect functional dysphonia, or medication-related dysphonia.
  • 2023-04-20 CXR
    • There are few nodular opacities projecting in right lung that may be metastases. Please correlate with CT.
  • 2022-10-21 CT - abdomen (at other hospital)
    • Findings
      • Fatty liver
      • post-operative change of colon
      • no definite lesion in pancreas, spleen, bilateral adrenal glands, kidneys
      • soft tissue lesions within pelvic cavity, peritoneal, metastases are considered
      • no definite lymphadenopathy
      • no ascites
    • Impression:
      • Peritoneal metastases
      • Fatty liver

[consultation]

  • 2023-04-21 Ear Nose Throat
    • Q
      • The 37 y/o woman has Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX. Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum. Then she received Avastin plus FOLFIRI * 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver. This time, admitted for chemotherapy with FOLFOXIRI.
      • For hoarse was noted for 3 weeks, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • Scope: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord movement without finding of vocal cord lesion.
      • Impression: suspect functional dysphonia, or medication-related dysphonia.
      • Plan: Please give Broen-C 2# TID and arrange ENT OPD follow-up after discharge.

[lab data]

  • 2023-04-12 Anti-HBc Nonreactive
  • 2023-04-12 Anti-HBc-Value 0.08 S/CO
  • 2023-04-12 HBsAg Nonreactive
  • 2023-04-12 HBsAg (Value) 0.49 S/CO
  • 2023-04-12 Anti-HCV Nonreactive
  • 2023-04-12 Anti-HCV Value 0.06 S/CO

[MedRec]

  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • s/p sigmoidectomy with LND on 2020-03-20
      • s/p Port-A on 2020-04-10
      • s/p adjuvant chemtoehrapy with FOLFOX from 2020-04-20 to 2020-10-28 -> PD over RML of lung and LN of left iliac chain, Stage IVA, rcT0N1bM1a
      • s/p Laparoscopic plevic LND on 2022-03-11
      • s/p A-FOLFIRI
      • s/p Laparoscopic intran-abdominla excision of peritoneal carcinomatosis on 2023-01-09 -> PD over lung, liver, bilateral iliac LNs and peritoneal carcinomosis by 2023-03-16 PET-CT, M1c, Stage IVB
    • P
      • Admission for FOLFOXIRI
  • 2023-04-06 SOAP Hemato-Oncology
    • S
      • Rectosigmoid cancer diagnosed 3 years ago s/p left hemicolectomy and then adjuvant chemotehrapy with 12 doses of FOLFOX.
      • Due to elevated tumor markers in 2022-02, PET was done and showed disease in progression over lung and peritoneum.
      • Then she received A-FOLFIRI 10 doses. Then the PET was arranged and disclosed bilateral lungs, peritoneum and liver.
    • P
      • Request medical records and report
  • 2017-12-14 SOAP Hemato-Oncology
    • O
      • 2017/12/07 Ferritin:5.2 ng/mL
      • Start iron therapy (20171214)
    • A
      • Iron deficiency anemia, unspecified [D50.9]
      • Thrombocytopenia [D69.6]
    • Prescription
      • Foliromin (sodium ferrous citrate 50mg) 1# QN 14 days
  • 2017-12-07 SOAP Hemato-Oncology
    • S
      • Referred from clinic on account of microcytic anemia
      • suspected thalassemia in her sister
      • Unexplained purpura
    • O
      • BH 168 BW 66
      • slight pale skin
    • Diagnosis
      • Anemia, unspecified [D64.9]
      • Thrombocytopenia [D69.6]

[assessment]

  • The patient was diagnosed with rectosigmoid cancer and underwent sigmoidectomy followed by treatment with the FOLFOX regimen in 2020. However, the patient experienced progressive disease. Laparoscopic plevic LND was performed in March 2022, and the patient was subsequently treated with the A-FOLFIRI regimen, but again experienced PD. This time, the patient was admitted to receive the planned FOLFOXIRI regimen.

  • Flumarin (flomoxef sodium) has been administered since 2023-04-23 to address the elevated sediment WBC and leukocyte esterase in the patient’s urine without issues.

  • The patient’s platelet count (PLT) has been decreasing over the past three years, with levels not exceeding 100K/uL in 2023. This should be carefully monitored, as it may suggest the presence of undiagnosed underlying conditions that require further evaluation and management.

    • 2023-04-25 PLT 83 *10^3/uL
    • 2023-04-24 PLT 95 *10^3/uL
    • 2023-04-11 PLT 100 *10^3/uL
    • 2022-12-24 PLT 143 *10^3/uL
    • 2020-12-28 PLT 160 *10^3/uL

701137983

230426

[diagnosis] - 2023-04-25 admission note

  • pancreatic head carcinoma,cT4N0M0, stage III, Dx in June 2022 , obstructive jaundice s/p PTGBD on 20220613
  • Type 2 diabetes mellitus without complications
  • Chronic obstructive pulmonary disease, unspecified
  • Obstruction of bile duct

[past history] - 2023-04-25 admission note

DM, HTN, CHF, COPD, Hyperlipidemia, Asthma                                                    

[allergy]

  • penicillin: rash;

[family history]

no hypertension, diabetes mellitus, cancer history

[exam finding]

  • 2023-04-03 KUB
    • Fecal material store in the colon.
    • S/P PTGBD with pigtail catheter implantation
  • 2023-03-13 CXR
    • Port-A catheter inserted into RA via left subclavian vein.
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Nodular opacitiy projecting over Rt lower lung zone due to nipple shadow
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad/ supine position
    • S/p PTGB drainage
  • 2023-03-13 ECG
    • Sinus tachycardia with Premature supraventricular complexes
    • ST & T wave abnormality, consider inferior ischemia
  • 2023-03-13 Endoscopic Retrograde Cholangiopancreatography, ERCP
    • Diagnosis
      • Failed Cholangiography
      • Pancreatic cancer s/p PTGBD
    • Suggestion
      • EUS/CDS or Rendevous ERCP
  • 2023-03-09 Cholangiography
    • Cholangiography via PTCD catheter administration revealed:
      • Patency of the catheter.
      • Obstruction of CBD.
  • 2023-03-08 SONO - abdomen
    • Post PTGBD with dilated IHD and CBD
    • Dilated main pancreatic duct
    • Pancreatic head tumor
  • 2023-03-08 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade D
      • Esophageal ulcers and erosions, lower to middle esophagus
      • Superficial gastritis, s/p CLO test
      • Gastric subepithelial lesion, anterior wall of upper body
    • Suggestion
      • PPI Q12H IV
      • EUS
  • 2023-03-06 ECG
    • Sinus tachycardia
    • Premature atrial complexes
    • Premature ventricular complexes
    • Marked ST abnormality, possible inferior subendocardial injury
    • Abnormal ECG
  • 2023-02-18, 2022-11-24 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • S/P pigtail catheter implantation at the gallbladder .
  • 2023-02-01 CT - abdomen
    • History:
      • 20220610 US: R/O pancreatic head tumor with obstructive jaundice.
      • 20220624 CT:Pancreatic head cancer, cT4N0M0, stage:III
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings: Comparison prior CT dated 2022/11/24.
      • Prior CT identified an ill-defined poor enhancing mass measuring 3.5 cm in the pancreatic head, causing marked dilatation of the bile duct and pancreatic duct, is noted again, mild increasing in size to 4 cm.
        • It is c/w adenocarcinoma of the pancreatic head S/P C/T with stable disease.
        • Prior CT identified tumor direct invasion the celiac trunk, superior mesenteric artery, and the trifurcation of superior mesenteric vein, splenic vein, and portal vein is noted again, stationary.
      • Prior CT identified liver metastasis 1.4 cm in S5 of the liver is noted again, mild decreasing in size and poor margination that is c/w liver metastasis S/P C/T with partial response. Follow up is indicated.
      • There are two cyst 1.7 cm and 0.5 cm in S6 liver.
        • Please correlate with sonography.
      • S/P PTGBD with pigtail catheter implantation
    • Impression:
      • Pancreatic head cancer S/P C/T show stable disease.
      • Liver metastasis in S5 S/P C/T show partial response.
  • 2023-01-31 SONO - abdomen
    • Post PTGBD
    • Dilated main pancreatic duct
    • Rule out pancreatic head tumor
  • 2022-11-24 CT - abdomen
    • History and indication: 71 y/o female, a pt of pancreatic head carcinoma, cT4N0M0, stage III
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of pancreatic head cancer.
      • S/P PTGBD. Right liver cyst (2.0cm).
  • 2022-09-08 Ocular fundus photography
    • fundus c/d 50% ou
    • moderate NPDR ou
      • ChatGPT: NPDR in the context of ocular fundus photography stands for Non-Proliferative Diabetic Retinopathy. There are two main stages of diabetic retinopathy:
        • Non-Proliferative Diabetic Retinopathy (NPDR): This is the early stage of diabetic retinopathy and is characterized by changes in the retinal blood vessels, including microaneurysms (small outpouchings), retinal hemorrhages (bleeding), and retinal edema (swelling). In some cases, NPDR may progress to a more advanced form called diabetic macular edema (DME), which is characterized by swelling in the central part of the retina (macula) and can lead to vision loss.
        • Proliferative Diabetic Retinopathy (PDR): This is the more advanced stage of the disease and is characterized by the formation of abnormal new blood vessels on the surface of the retina or the optic disc. These new vessels are fragile and prone to bleeding, which can lead to further complications like vitreous hemorrhage, retinal detachment, or severe vision loss.
  • 2022-06-30 Patho - pancreas biopsy
    • Pancreatic head, EUS-FNB — Ductal adenocarcinoma, moderately differentiated
    • The sections show a picture of ductal adenocarcinoma, composed of nests and cords of columnar to cuboidal neoplastic cells with abundant clear cytoplasm, embedded in fibrous stroma. Glandular differentiation and mucin secretion are present. Tumor necrosis can be identified also.
  • 2022-06-30 Cell Block Cytology
    • pancreas, SMEAR and CELL : adenocarcinoma;
    • SMEAR and CELL: show clusters of adenocarcinoma
  • 2022-06-30 Needle Aspiration Cytology - pancreas
    • pancreas, FNA: adenocarcinoma;
    • Smears show clusters of adenocarcinoma
  • 2022-06-30 Endoscopic Ultrasonography, EUS
    • suspected pancreatic head cancer, T4N1Mx, s/p EUS/FNB
    • reflux esophagitis, LA-A
  • 2022-06-29 CXR
    • Atherosclerosis of the aorta.
  • 2022-06-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (79 - 20) / 79 = 74.68%
      • M-mode (Teichholz) = 74.7 ~ 61.2
    • Conclusion
      • Normal AV with no AR
      • Normal MV with mild MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • Normal LV wall motion
      • No PR, trivial TR, normal IVC size
  • 2022-06-27 Flow-volume loops
    • Mild obstructive ventilatory impairment
  • 2022-06-24 CT - liver, spleen, biliary duct, pancreas
    • Imaging Report Form for Pancreatic Carcinoma
    • Impression (Imaging stage): T4N0M0, stage III
  • 2022-06-10 ECG
    • Sinus rhythm with 1st degree A-V block
    • Cannot rule out Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-06-10 CXR
    • Presence of ileus.
  • 2022-06-10 SONO - abdomen
    • diagnosis
      • suspicious, pancreatic head tumor with obstructive jaundice
      • fatty liver, mild
    • suggestion
      • correlate with other image study and tumor markers
  • 2022-03-17 Optical Coherence Tomography
    • fundus c/d 50% ou
    • moderate NPDR ou
  • 2022-02-14 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • mild enlarged cardiac silhoutte
  • 2021-03-15 CXR
    • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • moderate enlarged cardiac silhoutte
    • ……

[consultation]

  • 2022-06-24 General and Gastrointestinal Surgery
    • Q
      • For operation evaluation
      • This 71 y/o female has hitory of DM, HTN, CHF, COPD, Hyperlipidemia, Asthma under regular follow up at our CV, Meta, and CM’s OPD and this time she came our GI’s OPD for epigastric dullness pain for several weeks and jaundice, where PE and Lab data were surveyed and abdomen echo was also done and pancreatic head tumor with obstructive jaundice was suspected, so referal to ER for Covid-19 PCR checking and admission to GI’s ward for further management was done. However, the PCR result at ER showed positive result with CT value 17, the patient was admitted to our quarantine ward for Covid-19 infection. She transfer to GI ward on 2022/06/24. Abdominal CT was arranged on 2022/06/24. So we need you evaluation and suggestion of this patient. Thank you very much ~
    • A
      • S:
        • The patient was suspected pancreatic head tumor with obstructive jaundice. Surgical evaluation is consulted.
      • O:
        • vital signs: stable, no fever
        • abdomen: a PTGBD over R’t abdomen with bile content, soft, ovoid, decrease bowel sound, no tenderness, no Murphy’s sign
        • lab data: see chart
      • A:
        • Pancreatic head Ca, cT2N0M0, stage IB
      • P:
        • Please arrange echocardiogram & test
        • If heart function & PFT is OK, pylorus preserving pancreaticoduodenectomy is suggested next week.
  • 2022-06-13 Radiation Oncology
    • Q
      • For pancreat cancer with on PTGBD. (PTGBD: percutaneous transhepatic gallbladder drainage)
    • A
      • According to the clinical condition and imaging findings, PTGBD is indicated.

[MedRec]

  • 2022-07-05 SOAP Hemato-Oncology
    • S
      • PH:
        • COVID-19, virus identified
        • Chronic systolic (congestive) heart failure
        • Type 2 diabetes mellitus without complications
        • Chronic obstructive pulmonary disease
      • weight loss (+) (10kg in 2~3 Mo )
      • suffered from initial presentation of genealized jaundice in June 2022
      • referred to our clinic on 7/5 22 for pre-Op neoadjuvant C/T
      • ancreatic head carcinoma, cT4N0M0, stage III, Dx in June 2022
      • obstructive jaundice s/p PTGBD on 6/13 22.
      • explain to pt about the indication & risk / benefit of pre-Op neoadjuvant C/T wt FOLFIRINOX IV Q2W x 6 or more then do abd CT for response / Op evaluation (7/5 22).
      • HBsAg, anti-HBc (6/11 22): negative.
      • will give pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6 (7/5 22).
      • Adm 1 wk later on 7/15 22 for #1 pre-Op neoadjuvant C/T wt FOLFIRINOX ( self-paid ) IV Q2W x 6.
  • 2017-05-22 SOAP Cardiology
    • Diagnosis
      • Chronic systolic (congestive) heart failure [I50.22]
      • Essential (primary) hypertension [I10]
    • Prescription
      • Hexal (carvedilol 25mg) 1# QD 28 days
      • Blopress (candesartan 8mg) 0.5# BID 28 days
      • Aldactin (spironolactone 25mg) 1# QD 28 days
  • 2017-05-22 SOAP Chest Medicine
    • Diagnosis
      • Pulmonary TB, unspecified, by culture (+) [A15.0]
      • Acute respiratory failure [J96.00]
      • Pneumonia, unspecified organism [J18.9]
      • Congestive heart failure [I50.22]
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
      • hyperuricemia [E79.0]
    • Prescription
      • NovoNorm (repaglinide 1mg) 1# TIDAC 7 days
      • colchicine 0.5mg 1# QD 14 days
      • Vit B6 (pyridoxine 50mg) 1# QD 14 days
      • Euricon (benzbromarone 50mg) 1# QD 14 days
      • Through (sennosides) 12mg 1# HS 14 days
      • Rifinah (RIF 300mg + INH 150mg) 2# QD 14 days
      • pyrazinamide 500mg 2.5# QD 8 days
      • Welizen (famotidine 20mg) 1# BID 14 days
      • Epbutol (ethambutol 400mg) 2# QD 8 days
  • 2017-03-25 SOAP Metabolism
    • Diagnosis
      • DM w/o mention of complication, NIDDM Type, adult-onset or unspecified type, not stated as un [E11.9]
      • Essential hypertension, benign [I10]
      • Mixed hyperlipidemia [E78.2]
    • Prescription
      • Trajenta (linagliptin 5mg) 1# QD 4 days
      • Glucobay (acarbose 100mg) 1# TIDAC 4 days
      • Uformin (metformin 500mg) 1# TIDCC 4 days
      • Kludone (gliclazide 60mg) 1# BID 4 days
      • Uretropic (furosemide 40mg) 1# QD 4 days

[chemoimmunotherapy]

  • 2023-04-25 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-04-03 - oxaliplatin 80mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 190mg NS 500mL 2hr + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3000mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-03-03 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2023-02-13 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 205mg NS 500mL 2hr + leucovorin 400mg/m2 545mg NS 250mL 2hr + fluorouracil 2400mg/m2 3285mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-29 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-12-08 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-11-11 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2400mg/m2 3380mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-10-20 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 215mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-09-12 - oxaliplatin 80mg/m2 110mg D5W 250mL 2hr + irinotecan 150mg/m2 210mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3440mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-26 - oxaliplatin 80mg/m2 115mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3450mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-08-10 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • 2022-07-18 - oxaliplatin 60mg/m2 80mg D5W 250mL 2hr + irinotecan 150mg/m2 200mg NS 500mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRINOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL

[note]

  • Pancreatic Adenocarcinoma NCCN Evidence Blocks Version 1.2022 - May 3, 2022, p39,41
    • neoadjuvant therapy
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
      • Only for known BRCA1/2 or PALB2 mutations
        • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
        • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
    • adjuvant therapy
      • preferred regimens
        • Modified FOLFIRINOX (category 1)
        • Gemcitabine + capecitabine (category 1)
      • other recommended regimens
        • Gemcitabine (category 1)
        • 5-FU + leucovorin (category 1)
        • Continuous infusion 5-FU
        • Capecitabine (category 2B)
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU
  • Modified FOLFIRINOX chemotherapy for pancreatic cancer (UpToDate 20220719)
    • Cycle length: 14 days.
    • Regimen
      • Oxaliplatin
        • 85 mg/m2 IV
        • Dilute in 500 mL D5W and administer over two hours (prior to leucovorin). Shorter oxaliplatin administration schedules (eg, 1 mg/m2 per minute) appear to be safe.
        • Day 1
      • Leucovorin
        • 400 mg/m2 IV
        • Dilute in 250 mL NS or D5W and administer over two hours (after oxaliplatin).
        • Day 1
      • Irinotecan
        • 150 mg/m2 IV
        • Dilute in 500 mL NS or D5W and administer over 90 minutes. Administer concurrent with the last 90 minutes of leucovorin infusion, in separate bags, using a Y-line connection.
        • Day 1
      • Fluorouracil (FU)
        • 2400 mg/m2 IV
        • Dilute in 500 to 1000 mL 0.9% NS or D5W and administer as a continuous IV infusion over 46 hours. To accommodate an ambulatory pump for outpatient treatment, can be administered undiluted (50 mg/mL) or the total dose diluted in 100 to 150 mL NS.
        • Day 1
    • Pretreatment considerations:
      • Emesis risk
        • HIGH (greater than 90% frequency of emesis).
      • Prophylaxis for infusion reactions
        • Although infusion reactions have been reported with oxaliplatin, there is no recommended standard premedication for this regimen.
      • Vesicant/irritant properties
        • Oxaliplatin and FU are irritants, but oxaliplatin can cause significant tissue damage; avoid extravasation.
      • Infection prophylaxis
        • Primary prophylaxis with G-CSF is not warranted. However, given the risk of grade 3 or 4 neutropenia (46%), primary prophylaxis with G-CSF is used at many institutions, especially when this regimen is used in the adjuvant setting.
      • Dose adjustment for baseline liver or renal dysfunction
        • A lower starting dose of oxaliplatin and irinotecan may be needed for severe renal insufficiency. A lower starting dose of irinotecan and FU may be needed for patients with hepatic impairment.
        • NOTE: We do not recommend administration of FOLFIRINOX unless serum bilirubin is normal.
      • Maneuvers to prevent neurotoxicity
        • Pharmacologic methods to prevent/delay the onset of oxaliplatin-related neuropathy are controversial due to the absence of large clinical trials proving benefit. Counsel patients to avoid exposure to cold during and for approximately 48 hours after each infusion. Prolongation of the oxaliplatin infusion time from two to six hours may mitigate acute neurotoxicity.
      • Cardiac issues
        • QT prolongation and ventricular arrhythmias have been reported after oxaliplatin. ECG monitoring is recommended if therapy is initiated in patients with heart failure, bradyarrhythmias, coadministration of drugs known to prolong the QT interval, and electrolyte abnormalities. Avoid oxaliplatin in patients with congenital long QT syndrome. Correct hypokalemia and hypomagnesemia prior to initiating oxaliplatin.
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, electrocardiographic changes, and cardiomyopathy.
    • Monitoring parameters:
      • CBC with differential and platelet count prior to each treatment.
      • Electrolytes (especially potassium and magnesium) and liver and renal function prior to each treatment.
      • Irinotecan is associated with early and late diarrhea, both of which may be severe. For patients who develop abdominal cramping and/or diarrhea within 24 hours of receiving irinotecan, administer atropine (0.3 to 0.6 mg IV) and premedicate with atropine during later cycles. Patients must be instructed in the early use of loperamide for late diarrhea. Patients who develop diarrhea should be closely monitored and supportive care measures (eg, fluid and electrolyte replacement, loperamide, antibiotics, etc) should be provided as needed.
      • Assess changes in neurologic function prior to each treatment.
    • Suggested dose modifications for toxicity:
      • Myelotoxicity
        • Do not retreat unless neutrophil count is >=1500/microL and platelets are >=75,000/microL. The following dose reduction guidelines for hematologic toxicity are recommended; several of these are based upon recommendations in the original FOLFIRINOX protocol.
        • Neutropenia
          • If day 1 treatment delayed for granulocytes is <1500/microL or febrile neutropenia or grade 4 neutropenia >7 days: Reduce irinotecan dose to 120 mg/m2. For second occurrence: Reduce oxaliplatin dose to 60 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of granulocytes <1500/microL on day 1, discontinue treatment. For grade 4 neutropenia >7 days during treatment or febrile neutropenia, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
        • Thrombocytopenia
          • If day 1 treatment delayed for platelet count <75,000/microL, reduce oxaliplatin dose to 60 mg/m2 and reduce the continuous infusion FU to 75% of original doses. For second occurrence, reduce irinotecan dose to 120 mg/m2. If nonrecovery after a two-week delay, or if there is a third occurrence of platelets <75,000/microL, discontinue treatment. For grade 3 or 4 thrombocytopenia during treatment, reduce oxaliplatin dose to 60 mg/m2 and the infusional FU dose to 75% of the original dose. For the second occurrence, reduce dose of irinotecan to 120 mg/m2 and the dose of infusional FU an additional 25%. Discontinue treatment for third occurrence.
      • Diarrhea
        • Do not retreat with FOLFIRINOX until resolution of diarrhea for at least 24 hours without antidiarrheal medication. For diarrhea grade 3 or 4, or diarrhea with fever and/or grade 3 or 4 neutropenia, reduce irinotecan dose to 120 mg/m2. For second occurrence, reduce the oxaliplatin dose to 60 mg/m2 and the continuous FU dose to 75% of original dose. Discontinue treatment for third occurrence.
        • NOTE: Severe diarrhea, mucositis, and myelosuppression after FU should prompt evaluation for DPD deficiency.
      • Mucositis or hand-foot syndrome
        • For grade 3 to 4 toxicity, reduce dose of infusional FU by 25%.
      • Pulmonary toxicity
        • Oxaliplatin has rarely been associated with pulmonary toxicity. Withhold oxaliplatin for unexplained pulmonary symptoms until interstitial lung disease or pulmonary fibrosis is excluded.
      • Neurologic toxicity
        • For persistent grade 3 paresthesias/dysesthesias or transient grade 2 symptoms lasting >7 days, decrease oxaliplatin dose by 25%. Discontinue oxaliplatin for grade 4 or persistent grade 3 paresthesia/dysesthesia.
        • There is no recommended dose for resumption of FU administration following development of hyperammonemic encephalopathy, acute cerebellar syndrome, confusion, disorientation, ataxia, or visual disturbances; the drug should be permanently discontinued.
      • Cardiotoxicity
        • Cardiotoxicity observed with FU includes myocardial infarction/ischemia, angina, dysrhythmias, cardiac arrest, cardiac failure, sudden death, ECG changes, and cardiomyopathy. There is no recommended dose for resumption of FU administration following development of cardiac toxicity, and the drug should be discontinued.
      • Other toxicity
        • Any other toxicity >=grade 2, except anemia and alopecia, can justify dose reduction if medically indicated.
        • For other nonhematologic toxicities, if grade 2, hold treatment until <=grade 1; if grade 3 or 4, hold treatment until <=grade 2.
      • If there is a change in body weight of at least 10%, doses should be recalculated.

==========

2023-04-26

  • There is no medication reconciliation issue for the current active formulary, which includes medications prescribed by our cardiologist, pulmonologist, and metabolic specialist.

  • The patient’s underlying conditions of hypertension (HTN) and type 2 diabetes mellitus (T2DM) are not well controlled during this hospitalization. Blood pressure readings show systolic values between 170 and 184 mmHg, and HbA1c levels have been consistently above 8% for the past 4 months. Serum glucose was recorded as 231mg/dL on the evening of 2023-04-25 and as 158mg/dL on the morning of 2023-04-26. Addition of antihypertensive and/or hypoglycemic agents may be considered if symptoms persist.

    • 2023-04-08 HbA1c 8.3 %
    • 2023-01-14 HbA1c 8.6 %
    • 2022-10-20 HbA1c 7.4 %
    • 2022-07-25 HbA1c 7.0 %
    • 2022-04-30 HbA1c 8.3 %

2022-07-17

  • UGT1A1 genotyping result is not found in HIS5, please monitor if early and/or late (irinotecan caused) diarrhea occurs
  • There has been an upward trend in HbA1c levels over the past 12 months, a follow-up update might be considered.
    • 2022-04-30 HbA1c 8.3 %
    • 2022-02-05 HbA1c 8.2 %
    • 2021-11-13 HbA1c 7.4 %
    • 2021-08-21 HbA1c 7.0 %
  • Since this hospitalization, the level of blood sugar remains high
    • 2022-07-19 06:06 215 mg/dL
    • 2022-07-18 16:18 191 mg/dL
  • As for this patient has been taking metformin (DC for now), vildagliptin (DPP4i), glimepiride (sulfonylurea), and acarbose (alpha-glucosidase inhibitors) for a considerable period of time. Basal insulin might be an optional add-on if HbA1c rises above 8.5% and AC glucose rises above 250 mg/dL for most of the days.
  • A c-peptide test is also recommended for her.

700074348

230424

[exam findings] (not completed)

  • 2023-04-03 PET scan
    • In comparison with the previous study on 2022-02-22, some glucose hypermetabolism lesions in the retroperitoneum and in the left lower pelvic region come to less evident or disappear; several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen, however, are noted. The nature is to be determined (metastatic disease in progression or even another primary malignancy), suggesting biopsy (the soft tissue in RLQ of abdomen) for further investigation,.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar and mediastinal lymph nodes and in bilateral axillary lymph nodes, probably reactive nodes, suggesting follow-up.
    • Increased FDG uptake in the right lobe of the liver and in two right ribs, highly suspected malignancy with distant metastases.
    • Glucose hypermetabolism in the left shoulder, compatible with arthritis.
    • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases, by this F-18-FDG PET/CT scan.
  • 2022-10-31 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet, in whole body survey.
    • IMPRESSION:
      • No strong evidnece of bone metastasis.
      • Suspected benign lesions in the maxilla, mandible, L3-5 spines, both shoulders, sternoclavicular junctions, elbows, S-I joints, hips, knees, and feet.
  • 2022-09-17 MRI - L-spine
    • Past Hx: gouty arthritis; steroid(+); oral cancer. Right tonsillar cancer with right neck lymph node metastasis, T1N2cM0, stage IVA s/p concurrent chemoradiotheraphy in 2006. 20220819: LBP and right sciatica for 6 months; ongoing C/T;
    • Findings
      • General bulging disc, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral mild neuroforaminal narrowing at L2-3.
      • Decreased vertebral body height, end-plate degeneration, disc collapse with severe general bulging, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L3-4, much more severe on left side.
      • End-plate degeneration, disc collapse with general bulging and right lateral focal protrusion, hypertrophic yellow ligaments and enlarged facets causing mild spinal canal stenosis and bilateral neuroforaminal narrowing at L4-5, much more severe on right side.
      • Mild general bulging disc at L5-S1.
      • No intramedullary lesion.
      • Mild scoliosis of L-spine.
      • A 17-mm T2-hyperintense cyst at left kidney.
    • IMP: Lumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp L3-4 and L4-5 (with right HIVD).
  • 2022-06-28 CT - abdomen
    • Left renal cyst (1.4cm).
    • A cyst (9mm) at LLL.

[consultation]

  • 2023-04-24 Diagnostic Radiation
    • Q
      • This is a 58-year-old male with underlying history of:
        • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
        • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
        • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
        • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
        • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
      • On follow-up PET on 2023/04/03, report showed:
        • several glucose hypermetabolism lesions in the right supra-renal region, in the right para-aortic space, in bilateral common iliac chains, and in soft tissue in RLQ of abdomen
        • Seconary malignancy of lymph nodes of head and neck s/p treatment with suspected tumor progression in the abdomen as well as liver and bone metastases was impressed
      • Therefore, this time we would really need your expertise in performing CT-guided biopsy at RLQ abdomen soft tissue mass for this patient. Thanks a lot in advance!
    • A
      • According to the clinical condition and imaging findings, biopsy is indicated.
  • 2021-09-29 Radiation Oncology
    • Q
      • For RT evaluation
      • This is a 56-year-old male patient with a history of
        • right tonsillar cancer, T1N2cM0, stage IVA, status post concurrent chemoradiotheraphy in 2006,
        • right anterior mouth floor squamous cell carcinoma in situ, status post excision and revisional wide excision in 2010,
        • right mouth floor cancer, pT1N0cM0, status post wide excision and right selective neck dissection over level 1~3 in 2013,
        • left mouth floor cancer cT4aN0M0, status post induction chemotherapy and surgical excision in 2016, ypT1N1,
        • right lower neck tumor recurrence s/p right radical neck dissection on 2020-9-16, post-op CCRT completed on 2020-11-06, s/p oral ufur,
        • Left pelvic lesion s/p CT guided biopsy on 2021-03-12 (pathology: Metastatic squamous cell carcinoma, poorly differentiated), PET also revealed a new nodular lesion in RUQ of abdomen s/p CCRT for pelvic lesion (completed on 2021-05-17).
      • This time, he came to our hospital due to left lower gingiva lesion noted for weeks. Therefore, he came to our OPD for help. Abnormal painful leukoplakia-erythroplakia lesion at the left mandible was noted at OPD. Biopsy was done for left lower gingival lesion, and the pathology report was SCC. He received operation of oral tumor wide excision + marginal mandibulectomy +- local flap reconstruction on 2021-09-24, and the pathology was pending.
      • Also, pelvic and abdomen CT f/u on 2021-09-06 revealed A soft tissue lesion (2.4cm) at right perirenal region r/o tumor seeding and Enlarged LNs (up to 2.6cm) at retroperitoneum r/o metastases. Urologist was consulted and suggested CCRT.
      • Therefore, we need your expertised for further RT management for the patient.
    • A
      • Metastatic squamous cell carcinoma of the neck with unknown primary site, s/p CCRT (2006).
      • Squamous cell carcinoma of the right mouth floor, s/p operation (right mouth floor cancer wide excision. Right selective neck dissection, level 1~3, 2013-10-07), stage pT1N0(cM0).
      • Squamous cell carcinoma of the left mouth floor, s/p induction chemotherapy and operation (wide excision of left side mouth floor cancer with left side; tongue flap; tooth extraction, 2016-05-04), stage ypStage III, ypT1N1(cM0).
      • Metastatic squamous cell carcinoma of the right low neck to SCF, s/p operation (right neck dissection, level III, IV, V, 2020-09-02), and s/p CCRT, with left pelvic metastasis, s/p CCRT, with progression.
      • Squamous cell carcinoma of the anterior mouth floor, s/p wide excision and partial mandibulectomy.
    • P: Radiotherapy is indicated for this patient with the following indicators: metastatic lesions over the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Goal: palliation
      • Treatment target and volume: the soft tissue lesion at right perirenal region and enlarged LNs at retroperitoneum.
      • Technique: VMAT/IGRT
      • Preliminary planning dose: 4500cGy/25 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter. They understand and would like to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-10-01.
  • 2020-09-01 Colorectal Surgery
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • S: Consult for left pelvic nodule.
      • O: CT > A LN (0.8cm) at left pelvic cavity.
        • with suspect adhesion to vessel and sacal bone
        • Also nodule lesion over right inguinal region.
      • A: Multiple PET lesion
      • P:
        • please arrange colonoscopy to check colon tumor
        • high risk for surgical remove this nodule. and PET also show multiple lesion.
        • If no colonic lesion is seen, suggest medical treatment first (by neck etilogy)
  • 2020-09-01 Urology
    • Q
      • This time, PET scan showed left pelvic lesion, and pelvis CT showed a lymph node (0.8cm) at left pelvic cavity. Owing to his clinical condition mentioned above, we sincerely need your expertise regarding further management for this patient. Thank you very much!
    • A
      • 55M with left pelic LNs
      • S: oral cancer, s/p op,
      • O: PET and CT: showed one 1cm LN near left internal ileac artery
      • A: oral cancer, stage IVa
      • P:
        • oral cancer with LNs mets is highly suspected
        • difficult position for CT-guided biopsy
        • please check PSA, U/A, and urine cytology to r/o prostate cancer and bladder cancer

[chemotherapy]

  • 2022-09-27 - doxorubicin 60mg/m2 85mg NS 100mL 10min

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-08-30

  • 2022-08-01

  • 2022-07-01

  • 2022-05-31

  • 2022-01-03 - cisplatin 100mg/m2 150mg NS 500mL 4hr + fluorouracil 1000mg/m2 1550mg NS 500mL 21hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2021-11-12 - NS 500mL (before cisplatin) + cisplatin 30mg/m2 40mg NS 500mL 2hr + NS 500mL (after cisplatin) (CCRT)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + 1S 250mL
  • 2021-11-05

  • 2021-10-29

  • 2021-05-11

  • 2021-05-04

  • 2021-04-28

  • 2020-11-03

  • 2020-10-27

  • 2020-10-20

[assessment]

  • On 2023-04-03, a PET scan revealed multiple glucose hypermetabolic lesions in the right supra-renal region, right paraaortic space, bilateral common iliac chains, and soft tissue in the right lower quadrant (RLQ) of the abdomen. These lesions could indicate metastatic disease progression or even another primary malignancy. A CT-guided biopsy of the soft tissue mass in the right lower quadrant of the abdomen is scheduled for 2023-04-25 at 11:00 AM to determine the nature of these lesions.

  • 2023-04-24 eGFR 46. OxyNorm (oxycodone) - CrCl 30 to <60 mL/minute: Immediate release, Oral: Initial: Administer 50% to 75% of usual dose no more frequently than every 6 hours. Use with caution; titrate gradually based on patient response and adverse effects.

700267861

230424

[exam findings]

  • 2023-04-11 Patho - kidney biopsy
    • Kidney, left, CT-guided biopsy — Invasive urothelial carcinoma, high-grade
    • The sections show following features:
      • Histologic type: Urothelial carcinoma, invasive
      • Histologic grade: High-grade
      • Tumor configuration: Nodular
      • Muscularis propria: Absent
      • Lymphovascular invasion: Not identified
    • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
  • 2023-04-10 CT - abdomen
    • History and indication: Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma, suspected renal cell carcinoma
    • With and without-contrast CT of abdomen-pelvis revealed:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
      • Some LNs at retroperitoneum.
      • Liver cysts (up to 1.5cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
  • 2023-04-01 CXR
    • Blunting of left CP angle
    • Borderline enlarged cardiac sihoutte
  • 2023-04-01 EXG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
    • Abnormal ECG
  • 2023-03-27 SONO - neurology
    • Chronic renal parenchymal disease, mild degree
    • Suspected left renal pelvic mass lesion with hydronephrosis
  • 2023-03-23 CT - abdomen
    • Indication: nausea without vomiting and abdominal pain for half a monthalso, mild dyspnea was notedwent to Feng Rong Hospital, ileus and mild pneumonia was told
    • Without contrast enhancement CT of abdomen shows:
      • Infiltrating mass lesion in retroperitoneum, possibly derived from left ureter. Imperceptible margin with adjacent kidney and aorta. Regional enlarged lymph nodes noted.
      • Left hydronephrosis.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No bony destructive lesion on these images.
    • Impression
      • Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma; DDx: renal cell carcinoma
      • Suspect regional lymph node metastsis
  • 2023-03-23 KUB
    • Degenerative change of the lumbar spine
  • 2023-03-23 ECG
    • ST & T wave abnormality, consider anterolateral ischemia

[consultation]

  • 2023-03-24 Urology
    • Q
      • nausea without vomiting and abdominal pain for half a month
      • also, mild dyspnea was noted
      • went to Feng Rong Hospital today, ileus and mild pneumonia was told
      • PH: DM, HF
      • OP: hysterectomy 50 yrs ago, left inguinal hernia, s/p op 10 yrs ago
      • NKA
    • A
      • please treat her ileus and pneumonia first, due to advanced age and poor condition, she may not fit for further diagnostic or therapeutic intervention for cancer currrently.

[MedRec]

  • 2023-04-21 SOAP Hemato-Oncology
    • Con’s:E4V5M6
    • 2023/04/11 PATHO - kidney biopsy
      • Invasive urothelial carcinoma, high-grade
        • Histologic type: Urothelial carcinoma, invasive
        • Histologic grade: High-grade
        • Tumor configuration: Nodular
        • Muscularis propria: Absent
        • Lymphovascular invasion: Not identified
      • IHC: CK7(+), CK5/6(+), GATA3(+), CA 9(-), and CD117(-)
    • 2023/04/10 CT: ABD
      • An infiltrative tumor (4.0x7.8x4.2cm) at left retroperitoneal with adjacent structures (aorta, left renal artery/ vein, left kidney, spine and adjacent vessels) invasion. Left hydronephrosis.
    • 2023/03/23 CT: ABD
      • Retroperitoneal tumor with aorta and left kidney involvement, r/o left urothelial carcinoma
      • Suspect regional lymph node metastsis
    • Lab
      • 2023/04/10
        • HBsAg = Nonreactive;
        • Anti-HBc = Reactive;
        • Anti-HCV = Nonreactive;
  • 2023-04-07 SOAP Hemato-Oncology
    • Past hx : hypertension, hyperlipidemia, T2DM, renal tumor
    • Allergy : NKDA
    • She was treated at Cathay hospital for her CV problem.
    • preliminary impression: R10.9 Unspecified abdominal pain
    • Discussion about tissue proof
    • Inform the patients son and sons wife about the risk and benfit of biopsy
  • 2023-03-23 SOAP Emergency
    • preliminary impression: Retroperitoneal tumor with aorta and left kidney involvement, suspected left urothelial carcinoma
    • lab data
      • 2023/03/23 21:22 BUN = 31 mg/dL;
      • 2023/03/23 21:22 Creatinine = 1.51 mg/dL;

==========

2023-04-01

  • On 2023-03-23, a CT scan revealed a retroperitoneal tumor involving the aorta and left kidney, with a differential diagnosis of left urothelial carcinoma or renal cell carcinoma. Regional lymph node metastasis is also suspected.
  • Further work on staging is pending. Family members requested not to inform the patient about the diagnosis until the pathology report is confirmed.
  • There are no medication reconciliation issues after checking the PharmaCloud database.

700287641

230424

[diagnosis] - 2023-04-22 discharge note

  • Left breast cancer, rpT4bN1M0, stage IIIB,ER (+): +, PR (+): +, HER-2/Neu +:  Negative (1+), Ki-67: 10-20 %. ECOG:1.
  • Right breast invasive carcinoma, pT2N3aM0, stage IIIB. ER (+), PR(-), Her2/neu: negative(score=0), Ki-67:30 %. ECOG:1.
  • For adjuvant chemotherapy with Taxotere
  • Nasopharyngeal carcinoma, cT1N0M0, stage I
  • Essential (primary) hypertension

[exam findings]

  • 2023-03-11 Anoscopy

    • mild mixed hemorrhoids, perianal dermatitis
  • 2023-02-09 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95 - 20) / 95 = 78.95%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Gr II LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; mild MR; mild TR; mild PR.
  • 2022-12-22 Nasopharyngoscopy

    • Findings
      • bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
      • a few watery discharge at left posterior nasal cavity floor
    • Diagnosis/Conclusion
      • NPC s/p treatment, no evidence of recurrence
  • 2022-11-24 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (95.9 - 20.0) / 95.9 = 79.14%
      • M-mode (Teichholz) = 79
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2022-11-17 SONO - abdomen

    • Right renal cyst (0.87x0.98cm).
  • 2022-10-26 PET scan

    • Glucose hypermetabolic lesions in the right axillary lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in the right mediastinal lymph nodes, the nature is to be determined (metastatic or reactive nodes ?), suggesting biopsy for further investigation.
    • Increased FDG uptake in the left pulmonary hilar region, probably reactive nodes.
    • Left breast cancer s/p treatment with tumor recurrence and right axillary lymph nodes metastases, by this F-18 FDG PET/CT scan.
  • 2022-10-18 Patho - breast mastectomy with regional lymph nodes

    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right, modified radical mastectomy —- Invasive carcinoma of no special type
      • Resection margins, ditto — Free of tumor invasion
      • Skin and nipple, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN, MRM — Tumor metastasis (10/10) with extracapsular extension (8/10)
      • AJCC Pathologic Anatomic Stage — pT2N3a, if cM0, stage IIIC; Prognostic Stage — Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast: 21 x 13.3 x 3.7 cm
      • Skin: 18 x 5.1 cm, normal appearance
      • Nipple: 1.2 x 1.2 cm, mild retraction
      • Tumor: 3 x 2.2 x 2.1 cm
      • Resection margins: Free, 0.7 cm away from closest base
      • Lymph node: R’t axillary sentinel and non-sentinel lymph node
      • Representatively embedded for sections as: A1-A2: Nipple + skin + tumor, A3-A8: Tumor, X1: tumor + base and X2: four peripheral margins and B1-B2: R’t axillary LNs [Reference F2022-00487, FSA1-FSA2 and A: R’t axillary sentinel LN]
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3 x 2.2 x 2.1 cm
      • Histologic grade (Nottingham histologic score): Grade II (score 6) including (A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]
      • Margins: Free, 0.7 cm from closest base margin
      • Lymph node, R’t axillary SLN: Tumor metastasis (3/3) with extracapsular extension (3/3)
      • Lymph node, R’t axillary non-SLN: Tumor metastasis (10/10) with extracapsular extension (8/10)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present, multiple
      • Perienural invasion: present
      • Immunohistochemistry: E-cadherin(+)
  • 2022-10-18 Frozen Section

    • R’t axillar sentinel lymph nodes, frozen section — Tumor metastasis (3/3)
  • 2022-10-17 Flow Volume Loop

    • mild obstructive impairment
  • 2022-10-07 Patho - breast biopsy (no need margin)

    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0), Ki-67(30 %), E-cadherin (+).
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-07 SONO - breast

    • S/P left mastectomy.
    • Right subareolar irregular tumor with regional skin edema/thickening. Suggest biopsy.
    • BI-RADS: Category 4: suspicious abnormality-biopsy should be considered.
  • 2022-10-07 Mammography

    • Impression:
      • S/P left mastectomy.
      • Right periareolar skin thickening, suggest further study.
    • BI-RADS: Category 0 (incomplete. Need additional imaging evaluation.)
  • 2022-08-25 SONO - abdomen

    • Right renal cyst (1.08x1.14cm).
  • 2022-08-11 Nasopharyngoscopy

    • Findings: bi NP smooth, no tumor found; bi MM clear, larynx and hypopharynx np
    • Diagnosis/Conclusion: NPC s/p treatment, no evidence of recurrence
  • 2022-06-30 ENT Hearing Test

    • Tymp RE type C, LE type B
    • PTA:
      • Reliability FAIR
      • Average RE 74 dB HL, LE 81 dB HL
      • RE moderately severe to profound HL
      • LE severe to profound MHL
  • 2022-06-08 Neurosonology

    • Moderate to severe atheromatous lesion in R CCA bifurcation; mild (to moderate) atheromatous lesions in R middle CCA and L CCA bifurcation; mild atheromatous lesion in L distal CCA.
    • Elevated flow velocities in bilateral MCAs (PS/ED: R = 234/80, L= 182/55 cm/s), suggesting bilateral MCA stenosis; relatively reduced flow in R cervical VA as compared to L VA.
    • Normal extracranial carotid, L vertebral, and intracranial vertebral, basilar arterial flows.
    • Normal bilateral ophthalmic arterial flows
  • 2022-06-02 SONO - abdomen

    • Right renal cyst (0.85x1.12cm).
  • ……

  • ……

  • 2017-05-26 Surgical pathology Level VI

    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy —- Invasive carcinoma of no special type, grade 3
      • Resection margins, ditto — Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Skin, ditto — Tumor invasion
      • Nipple, ditto — Tumor invasion
      • Lymph nodes, left axillary, dissection — Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • AJCC Pathologic Stage — pT4N1Mx, stage IIIB at least
    • MACROSCOPIC EXAMINATION
      • Breast: 18 x 12 x 3 cm
      • Skin: 15.5 x 7 cm
      • Nipple: 1.8 x 1.8 x 0.7 cm
      • Tumor: difficult to assess grossly. Only mild fibrosis of skin and few foci of fibrous nodules found. Microscopically, multiple foci of tumor measures up to 2.3 x 2 cm is noted.
      • Resection Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Lymph node: left axillary LNs
      • Representative sections as follows: A1: nipple, A2-A6: tumor; B1-B6: LNs.
    • MICROSCOPIC EXAMINATION (FOR INVASIVE CARCINOMA)
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: Multiple foci, up to 2.3 x 2 cm
      • Histologic grade (Nottingham histologic score): Grade III (score 8)
        • [(A) Tubule formation: score 3; (B) Nuclear pleomorphism: score 3 and (C) Mitotic count: score 2]
      • Margins: Close, less than 0.1 cm away from base margin and 0.9 cm away from closest peripheral margin
      • Nodal status: Positive for tumor metastasis (1/20) with extracapsular extension (1/1)
      • Treatment Effect: N/A
      • Immunohistochemical study of CK highlights tumor is very close to base margin
  • 2017-05-25 PET scan

    • Glucose hypermetabolism in the left breast, compatible with breast malignancy.
    • Mild glucose hypermetabolism in some mediastinal and bilateral pulmonary hilar lymph nodes. Inflammatory process is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Mild glucose hypermetabolism in the L3 spine. Degenerative spine disease may show this picture.
  • 2017-05-22 Gynecologic ultrasonography

    • Endometrial thickening
  • 2017-05-16 Surgical pathology Level IV

    • Breast, left, sono-guide biopsy — Invasive carcinoma of no special type
    • Immunohistochemical stains:
      • CK14: loss of myoepithelial cells
      • E-cadherin: positive for tumor cells
      • ER: 90%, intensity 2+
      • PR: 10%, intensity 3+
      • Her2/neu: negative; DAKO score 1+
      • P53: positive, 100%
      • Ki67: 60-70% activity
    • Microscopically, the sections show a picture of invasive carcinoma of no special type of the breast tissue characterized by pleomorphic tumor cells show linear or nested pattern, infiltrate in the desmoplastic stroma.
  • 2017-05-16 SONO - breast

    • CC/Indication:
      • Lt breast mass and CNB performed 2012-11-06, 2012-11-19 (CNB = Core Needle Biopsy)
      • DCIS was told. (Chat GPT: DCIS stands for ductal carcinoma in situ. It is a non-invasive form of breast cancer where abnormal cells are found in the lining of the breast ducts but have not spread beyond the ducts into surrounding breast tissue. Although DCIS is not an invasive cancer, it is considered a pre-cancerous condition and has the potential to develop into invasive breast cancer if left untreated. Treatment options for DCIS typically include surgery, radiation therapy, and hormonal therapy.)
    • Suggestion and Plan
      • Bilateral breast cysts and fibroadenomas.
      • Left breast 9’region irregular hypoechoic tumor with prominent vascularity, suggest biosy.
    • BIRADS4

[consultation]

  • 2022-10-17 Rehabilitation
    • Q
      • This 70 year-old women, she has right breast cancer with right simple mastectomy + SLNB on 2022/10/18. We need your help for rehabilitation after surgery, thank you!!
    • A
      • We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
      • Premorbid functional status
        • Walk ID, ADLs ID.
      • Physical examination
        • 2022/10/17 10:42 T/P/R: 36.0 / 61bpm / 18bpm BP:134/64mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Bilateral shoulders ROM: nearly full range of ative and passive ROM
      • Past hx: left forzen shoulder (improved)
      • Hand and arm circumference (R/L,cm):
        • Elbow joint above 5cm 25/27
        • Elbow joint below 5cm 22.5/24
      • Left arm lymph edema now:
        • ISL grade I, stage I
        • soft, intact skin, no fibrotic change in left arm
      • previous record:
        • 2021/09/15 rehab OPD
          • Skin test +
          • ISL stage: III: fibrotic changes over the forearm and arm
          • Other complications: Frozen shoulder at end-range
      • Imp
        • Rt breast ca ,cT2N0M0 stage 2A
        • OP: right simple mastectomy + SLNB on 2022/10/18.
        • Past hx:
          • Recurrent lt breast ca s/p MRM on 2017-05-26
          • adjuvant C/T with EC ->T since 2017-06-19
          • Lt upper limb lymphedema
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[MedRec]

  • 2022-11-23 SOAP General and Gastroenterological Surgery
    • The multidisciplinary cancer team meeting concluded on 2022-10-28. The treatment plan for the patient is as follows: TC chemotherapy every three weeks for a total of four cycles, followed by CDK4/6 inhibitor (self-paid), radiotherapy, and five years of hormone therapy.
  • 2022-11-08 SOAP Radiation Oncology
    • A:
      • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy (2004-05-25 ~ 2004-07-16).
      • Predominant ductal carcinoma in situ, intermediate grade, with focal microinvasive ductal carcinoma of the left breast, stage pStageIA, pT1aN0(0/2)(cMx); ER(weak positive, 30%), PR(weak positive, 30%), Her2/neu: (negative, 1+), s/p partial mastectomy, left axillar sentinel lymph node biopsy, radiotherapy in 2013/03, and status during hormone therapy (Tamoxifen) since 2012/12/10, with left breast recurrence, s/p MRM and ALND (2017-05-26), stage pT4N1(1/20)(cN0), stage IIIB, s/p chemotherapy and radiotherapy, and status during endocrine therapy.
      • Invasive carcinoma of no special type, of the right breast, ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: negative(score=0),AJCC Pathologic Anatomic Stage pT2N3a, cM0, stage IIIC; Prognostic Stage — Stage IIIB, s/p MRM (2022-10-18)
    • P: Radiotherapy is indicated for this patient with the following indicators: stage pT2N3a, cM0
      • Goal: curative
      • Treatment target and volume: right chest wall, axilla, to low SCF
      • Technique: IMRT
      • Preliminary planning dose: 5000cGy/25 fractions of the right chest wall, axilla, to low SCF
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her elder sister. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started after completion of chemotherapy. RTC: at the last cycle of chemotherapy.

[surgical operation]

  • 2022-10-18
    • Surgery: MRM        
      • ChatGPT: MRM stands for modified radical mastectomy, which is a surgical procedure to remove breast cancer. It involves the removal of the entire breast tissue, including the nipple, areola, and axillary lymph nodes. In addition, the lining over the chest muscles is also removed in this procedure. The goal of MRM is to remove the cancerous tissue and prevent the spread of cancer to nearby lymph nodes and tissues.
    • Finding
      • a 3x2x2 cm slight firm subareolar mass in rt breast
      • SLN 3/3(+)    
      • multiple axillary LNs up to 1.5 cm in size  
  • 2017-05-26
    • Diagnosis: left breast cancer
    • PCS code: 63007B: Radical mastectomy - unilateral
    • Finding
      • Three nodules up to 0.5 cmin size over lt breast
      • axillar LNs sl enlarged

[radiotherapy]

  • 2004-05-25 ~ 2004-07-16 - Past Hx (according to the Hua-Lien record): After admission, systemic work up was done and NPC cT1N0M0 was diagnosed.
    • Non keratinizing undifferentiated carcinoma of the nasopharynx, stage cT1N0M0, s/p radiotherapy. RT total dose was 7020 cGy.

[chemotherapy]

  • 2023-04-21 - docetaxel 75mg/m2 110mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-31 - docetaxel 75mg/m2 111mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-10 - docetaxel 75mg/m2 108mg NS 250mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-02 - docetaxel DC (due to WBC 1.57K/uL)

  • 2023-02-09 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 866mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2023-01-18 - liposome doxorubicin 30mg/m2 40mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 860mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-12-21 - liposome doxorubicin 35mg/m2 58mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 988mg NS 500mL 1hr (2023-01-11 WBC 1.67K/uL)

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL
  • 2022-11-29 - liposome doxorubicin 35mg/m2 50mg D5W 250mL 2hr + cyclophosphamide 600mg/m2 864mg NS 500mL 1hr

    • betamethasone 8mg + diphenhydramine 30mg + famotidine 20mg + granisetron 1mg + NS 250mL

Femara (letrozole) KFEMA01

  • 2017-12-04 ~ undergoing 2.5mg QD

Granocyte (lenograstim) CGRAN01

  • 2023-04-26 - 250ug 2 days (2023-04-21 IPD)
  • 2023-04-05 - 250ug 2 days (2023-03-31 IPD)
  • 2023-03-13 - 250ug 2 days (2023-03-13 OPD)

Foliromin (ferrous sodium citrate) KFOLIR01

  • 2023-01-18 IPD on and off

==========

2023-04-24

  • The patient’s HGB levels show a marked downward trend, even though there is no record of blood transfusion. With recent MCV and MCH levels both above the normal range, this macrocytic anemia is less likely to be caused by iron deficiency. The addition of oral Kentamine (vitamin B1, B6, B12) may be helpful.

  • The development of anemia during chemotherapy suggests that the patient’s HGB levels are not fully recovered at the current dosage, interval, and frequency of the treatment regimen. In cases of severe chemotherapy-induced anemia, blood transfusion is recommended. Another potential option could be to reduce docetaxel from 75mg/m2 to 65mg/m2.

  • If the patient refuses a blood transfusion, a less optimal alternative may be the use of erythropoiesis-stimulating agents (ESAs). However, it is important to note that ESAs have been associated with shorter overall survival and/or increased risk of tumor progression or recurrence in clinical trials involving patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To minimize these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid red blood cell transfusions. ESAs should only be used for anemia resulting from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the expected outcome is cure. It is also recommended that ESAs be discontinued after completion of chemotherapy.

2023-04-03

  • On 2022-10-28, the multidisciplinary cancer team held a meeting and decided on the following treatment plan for the patient: TC chemotherapy every three weeks for a total of 4 cycles, followed by a CDK4/6 inhibitor (patient self-paid), radiotherapy, and 5 years of hormone therapy.

  • The patient received 4 cycles of AC (liposome doxorubicin plus cyclophosphamide) on 2022-11-29, 2022-12-21, 2023-01-18, and 2023-02-09. On 2023-01-11, leukopenia occurred with a WBC count of 1.67K/uL, leading to a reduction in liposome doxorubicin dosage from 35mg/m2 to 30mg/m2 for the last two cycles. On 2023-03-02, another leukopenia episode was observed with a WBC count of 1.57K/uL, causing the scheduled docetaxel on that day to be postponed.

  • The patient’s HGB and PLT levels are showing a obvious decline trend, despite no record of blood transfusion being available. This suggests that under the current dose, interval, and frequency of administration, the patient’s HGB and PLT levels are not able to fully recover.

    • 2023-03-31 HGB 7.7 g/dL
    • 2023-03-13 HGB 8.4 g/dL
    • 2023-03-10 HGB 8.3 g/dL
    • 2023-03-02 HGB 8.6 g/dL
    • 2023-02-09 HGB 8.6 g/dL
    • 2023-01-18 HGB 8.4 g/dL
    • 2023-01-11 HGB 8.3 g/dL
    • 2022-12-21 HGB 11.4 g/dL
    • 2022-12-07 HGB 11.5 g/dL
    • 2022-11-28 HGB 11.9 g/dL
    • 2022-10-17 HGB 11.6 g/dL
    • 2022-06-08 HGB 12.6 g/dL
    • 2022-02-24 HGB 12.6 g/dL
    • 2021-04-29 HGB 12.7 g/dL
    • 2023-03-31 PLT 130 x10^3/uL
    • 2023-03-13 PLT 139 x10^3/uL
    • 2023-03-10 PLT 156 x10^3/uL
    • 2023-03-02 PLT 123 x10^3/uL
    • 2023-02-09 PLT 175 x10^3/uL
    • 2023-01-18 PLT 233 x10^3/uL
    • 2023-01-11 PLT 154 x10^3/uL
    • 2022-12-21 PLT 249 x10^3/uL
    • 2022-12-07 PLT 127 x10^3/uL
    • 2022-11-28 PLT 228 x10^3/uL
    • 2022-10-17 PLT 191 x10^3/uL
    • 2022-06-08 PLT 227 x10^3/uL
    • 2022-02-24 PLT 262 x10^3/uL
    • 2021-04-29 PLT 248 x10^3/uL
  • When severe anemia caused by chemotherapy is present, blood transfusion is recommended. However, if the patient refuses to receive transfusion, a suboptimal option could be to use erythropoiesis-stimulating agents (ESAs). It is important to note that ESAs have been associated with a shortened overall survival and/or an increased risk of tumor progression or recurrence in clinical studies of patients with breast, non-small cell lung, head and neck, lymphoid, and cervical cancers. To decrease these risks, as well as the risk of serious cardiovascular and thromboembolic reactions, the lowest effective dose should be used to avoid RBC transfusions. ESAs should only be used for anemia from myelosuppressive chemotherapy and are not indicated for patients receiving myelosuppressive chemotherapy when the anticipated outcome is cure. It is also suggested to discontinue ESAs following the completion of a chemotherapy course.

700835257

230421

[diagnosis] - 2023-03-22 admissiion note

  • Malignant neoplasm of unspecified site of right female breast
  • Unspecified lump in breast

[past history]

  • The patient had no systemic diseases

  • History of operation: NIL

  • Regular medications or herb: no

  • G2P2

  • menarche : 16y/o

  • menopause: 51y/o

  • Hormone therapy: (-)

  • Family history of breast cancar: NIL                        

[allergy]

  • NKDA         

[family history]

  • Her mother has type II diabetes mellitus and liver cirrhosis, father has pancreatic cancer.

[exam findings]

  • 2023-03-24 CT - chest
    • Indication: Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
    • Imp: s/p op. over right breast. Suggest follow up.
  • 2022-12-19 ECG
    • Right bundle branch block
  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 24) / 93 = 74.19%
      • M-mode (Teichholz) = 66
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; trivial MR; trivial TR.
  • 2022-11-18 Patho - breast mastectomy with regional lymph nodes
    • Diagnosis
      • Breast, right, partial mastectomy — Invasive lobular carcinoma
      • Resection margin: free
      • Lymph node, right, axilla, sentinel, lymphadenecomy —- Negative for malignancy (0/3)
      • AJCC 8 th edition, Pathology stage: Anatomic stage: pStage IA, pT1cN0(sn)(if cM0) Prognostic stage: IA
    • Gross Description
      • Procedure: partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen): Sentinel lymph node(s)
      • Specimen laterality: Right
      • Breast: Size: 5.7 x 5.5 x 2.0 cm
      • Skin: Size: 2.8 x 0.5 cm.
      • Nipple: Not Included
      • Tumor: Size: 1.1 x 1.0 x 1.0 cm.
      • Resection Margin: Free, 0.2 cm from the deep margin
      • Sections are taken and labeled as: FsA: deep margin; FsB1-2: sentinel lymph nodes (FsB1: a bisected lymph node), for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: skin; X2: breast, non-tumor; X3-5: tumor.
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive lobular carcinoma; The immunohistochemical stain of E-cadherin is negative.
        • Size of invasive carcinoma (mm): 11 x 10 x 10
        • Histologic grade (Nottingham histologic score): grade II (score 6)
          • Tubule formation: score 3
          • Nuclear pleomorphism: score 2
          • Mitotic count: score 1
        • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent
          • Chest wall invasion deeper than pectoralis muscle: not received
      • For Ductal Carcinoma In Situ: absent
      • Margins: Negative, Closest margin (2 mm from deep margin)
      • Nodal status: Negative, sentinel
        • No. examined: 3
        • No. macrometastases (>2 mm): 0
        • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
        • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: patient not received
      • Lymphovascular invasion: absent.
      • Perineural invasion: present
      • Immunohistochemical Study: S2022-16430
  • 2022-11-17 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-11-16 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-14 Bone Scan
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the mandible, middle C-spine, L4, bilateral shoulders, hips, knees and feet in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle C-spine and L4 spine. Degenerative change may show this picture.
      • Increased activity in the mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2022-10-14 CT - chest
    • Right breast cancer with non-specific lymph nodes are found at bilatral axillary region is found.
  • 2022-09-27 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Breast tumor, right 10.5/7 area, core needle biopsy — Invasive lobular carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of two strips of breast tissue measuring up to 0.8 x 0.1 x 0.1 cm in size, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in one cassette.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show a picture of invasive lobular carcinoma characterized by dyscohesive tumor cells arranged in linear or cord pattern with desmoplasia. Immunohistochemistry shows CK5/6 and P63: loss of myoepithelial cell, E-cadherin(-), ER(>90%, intensity 2~3+), PR(>90%, intensity 1~2+), Her2/neu(-, Dako score 1+) and Ki-67: 5-10% for tumor.
  • 2022-09-27 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan: Right breast tumor, suggest biopsy.
    • BI-RADS: Category 4c: suspicious abnormality-biopsy should be considered.
  • 2020-10-22 Gynecologic ultrasonography
    • RT adnexae: free I - EM:4.7mm

[consultation]

  • 2022-11-16 Rehabilitation
    • A
      • Imp
        • Invasive lobular carcinoma of right breast cT1bN0M0, stage IA status post right partial mastectomy and sentinel lymph node biopsy on 2022/11/17, ECOG:0, ER(+), PR(+), Her2/neu(-), Ki-67: 5-10%
      • OP: right partial mastectomy and SLND on 2022/11/17.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
          • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-17
    • Surgery
      • partial mastectomy and SLNB        
    • Finding
      • right 10/7 tumor, about 1cm in diameter
      • SLNB: negative of malignancy, 0/3

[chemotherapy]

  • 2023-04-20 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-03-22 - epirubicin 90mg/m2 145mg NS 100mL 30min + fluorouracil 500mg/m2 820mg NS 100mL 30min + cyclophosphamide 500mg/m2 820mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-27 - epirubicin 70mg/m2 100mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W) Epicin (decrease dosage from 90mg/m2 to 70mg/m2 due to WBC:3580, seg:37.6, ANC:1346)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-07 - epirubicin 90mg/m2 140mg NS 100mL 30min + fluorouracil 500mg/m2 800mg NS 100mL 30min + cyclophosphamide 500mg/m2 800mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-11 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - epirubicin 80mg/m2 120mg NS 100mL 30min + fluorouracil 500mg/m2 770mg NS 100mL 30min + cyclophosphamide 500mg/m2 770mg NS 500mL 1hr (CEF, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

[note]

in-hospital “Prescription Collection of Chemotherapy for Breast Cancer” protocol (dated 2022-03-11)

  • CE (Epirubicin or Lipodox) F (Lipodox is not strongly recommended in the adjuvant setting)
    • Cyclophosphamide 500 mg/m2 IV Days 1
    • Epirubicin 90 mg/m2 IV Day 1 or Lipodox 30 mg/m2 IV Day 1
    • 5-fluorouracil 500 mg/m2 IV Days 1
    • _ References
      • Citrom, ML, et al.J Clin Oncol 21:1431-, 2003.1439
      • Martin M, et al. J Natl Cancer Inst 2008; 100:805-814.
      • O’brien, et al. Annals of oncology, 15(3). 440-449.
      • Rau KM, et al. BMC Cancer, 2015; 15: 423

==========

2023-04-21

  • Except for a slightly elevated ALT 52U/L, all other labs were normal on 2023-04-20. No problem with the active prescription.

2023-03-23

  • After the episode of neutropenia on 2023-02-27, the decision to reduce the dose of epirubicin in the CEF regimen was made. Subsequently, no further episodes of neutropenia were observed, even when the dose was increased to the standard recommended level.

700392038

230419

{not completed}

[diagnosis] - 2023-04-21 discharge note

  • Right lower lobe lung cancer, adenocarcinoma, T4N3M1c, stage IVB, with brain and lung to lung metastases s/p Target therapy with Afatinib from 2021/09/08~  
  • Secondary malignant neoplasm of brain
  • Chronic obstructive pulmonary disease, unspecified
  • Type 2 diabetes mellitus without complications
  • Diarrhea, unspecified

[exam findings]

  • 2023-04-10 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
    • Atherosclerotic change of aortic arch
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, sternum, some ribs, sacrum, left S-I joint and possible left sternoclavicular junction.
    • IMPRESSION: In comparison with the previous study on 2022/08/08, more new bone lesions are noted. The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-21 CXR
    • Patchy opacity projecting at right lower lung zone was noted that is c/w lung cancer after correlate with CT.
    • There are multiple small nodular opacities on both lung that are c/w lung to lung metastases.
  • 2023-02-08 EGFR mutation
    • Cell block No: S2023-01756
    • Result: Two mutations were detected at exon 20 (T790M) and exon 21 (L858R) of EGFR gene in this specimen.
  • 2023-02-06 CXR
    • A poorly defined large tumor with reticular opacities over Rt lower lobe
    • Enlargement of Rt hilum due to lymphadenopathy
    • Thoracic aortic calcified atheriosclerotic plaque
  • 2023-02-03 Patho - bronchus biopsy
    • Lung, RLL, bronchioscopic biopsy — adenocarcinoma, poorly differentiated
    • Sections show bronchial mucosa with infiltration of large pleomorphic solid tumor cells and acinar galndular cells.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), CD56(-), and p40(-). The results are supportive for the diagnosis.
  • 2023-02-01 CT - chest
    • Indication: Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis
    • Comparison was made with previous CT dated on 2022/08/03
      • Lungs: interval significant increase in size of RLL tumor with newly developed extensive interlobular septal thickening and peribronchoscular bundle thickeninng and new RML nodule as compared with CT on 2022/8/3. the tumor involves Rt inferior pulmonary artery and hilum.
      • Mediastinum and hila: enlarged LN in Rt hilum.
      • Vessels:
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura:small Rt effusion with parietal thickening.
      • Chest wall: metastatic LAP at Lt supraclavilar fossa
      • Visible abdominal contents: several small hepatic cysts and a Lt renal cyst 28mm
        • unremarkable of the adrenal glands, spleen, pancreas, adrenal glands
      • Visualized bones: no lytic or blastic lesion.
        • axial brain images: no evidence of brain metastasis based on noncontrast images. diffuse cerebral atrophy.
    • Impression:
      • RLL tumor, T4N3, in progression as compared with previous CT on 2022/08/03
  • 2023-01-30 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-08 Tc-99m MDP bone scan
    • A hot area at the L4-5 spines, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in both rib cages, some C- and L-spine, bilateral shoulders, and S-I joints.
  • 2022-08-03 CT - chest
    • RLL tumor, inccrease in size of the tumor T4 as compared with previous CT on 2022/03/02. no mediastinal LAP.
  • 2022-03-02 CT - chest
    • RLL tumor, slightly decrease in size of the tumor as compared with previous CT on 2021/11/24. no mediastinal LAP.
  • 2021-11-24 MRI - brain
    • Findings
      • Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
      • Only two small dark noudles were seen in right cerebellum and left anterior temporal lobe.
      • Poor or equivocal abnormal enhancement after contrast administration of those two nodules seen.
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
    • Imp: Markedly regression of the nodules seen on Scan MRI, 2021/08/19.
  • 2021-11-24 CT - chest
    • RLL tumor, significant decrease in size of the tumor (21 mm on this exam) as compared with previous CT on 2021/08/10
  • 2021-08-31 Patho - bronchus biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.

[lab data]

2021-09-23 EGFR Sample No S21-11584
2021-09-23 EGFR G719X not detected
2021-09-23 EGFR Exon19 del not detected
2021-09-23 EGFR S768I not detected
2021-09-23 EGFR T790M not detected
2021-09-23 EGFR Exon20 ins not detected
2021-09-23 EGFR L858R detected
2021-09-23 EGFR L861Q not detected

[MedRec]

  • 2021-09-23 SOAP Chest Medicine
    • S
      • just discharged on 20210917 due to hemoptysis
      • EGFR mutation: L858R (+), exon 19 (-), ALK(-)
    • O
      • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date: 20210914
      • Dr Huang JunYao: check EGFR mutation status, apply TKIs for this case if indicated
      • Conclusion: palliation C/T, RT, best supportive care, EGFR TKIs if definite mutation
  • 2021-09-08 SOAP Chest Medicine
    • S
      • admission on 20210916 for Cyramza 600mg
      • A case of Lung cancer, adenocarcinoma, T4N3M1c with brain, lung to lung metastasis, ECOG 1,
        • T4: RLL mass with RLL, RML
        • N3: bilateral mediastinal LAPs
        • M1c: multiple brain metasatsis
      • EGFR mutation: L858R (), exon 19 (), ALK(),
      • PD-L1:
      • Right hilum tumor, nature?
  • 2021-08-30 POMR Chest Medicine
    • Discharge Diagnosis
      • Chronic obstructive pulmonary disease, unspecified
      • Right hilum tumor, nature?
      • Right lower lung mass.
    • CC: Cough intermittent with hemoptysis for months
    • Present Illness
      • He suffered from hemoptysis to Zhongxiao Hospital for help in early August, Chest CT on 2021/08/10 showed RLL carcinoma with lung to lung metastasts and mediastinal LAP is considered first. Multiple small hypodense nodules in liver. Brain MRI on 2021/08/19 showed Multiple brain metastatic tumors should be considered. Whole body bone scan on 2021/08/20 showed likely DJD or certain entity in the L4.
  • 2021-08-23 SOAP Chest Medicine
    • S
      • Right hilum tumor, nature?
      • cough intermittent without scanty sputum for months, sorethroat(-), chest tightness for weeks, dyspnea, rhinorrhea(-), nasal congestion(-), post nasal dripping(-), acid regurgitation, DOE(+), exercise limitation(+)
      • Past history: Allergic rhinitis, asthma
      • Family history of asthma
      • Smoking(-)
      • Allergic history(-)
      • Traveling history(-)
    • O
      • BP:120/70, HR:70
      • Throat: hyperemia
      • Tonsil: enlargement
      • Neck LAP(-)
      • Breathing sound: course(+), wheezing(+), crackle(+), decreased(+)
      • HS: RHB
      • Abdomen: soft and flat
      • Pitting edema(-)
  • 2021-05-19 SOAP Dermatology
    • S
      • Multiple painful erythematous papule-nodules on face, trunk and 4 limbs
      • Multiple erythematous scars and keloids on face for months, progressive enlarged recently. Itching(+), keloid(+)
    • O
      • Imp: acne on face and trunk for months, multiple pustule (+), inflammation(+), painful(+)
      • NSAID for pain release
    • Plan
      • education about drug side effec and explain
      • strongly suggested OPD f/u
    • Diagnosis
      • L70.2 Acne varioliformis
      • L73.0 Acne keloid
    • Prescription
      • doxycycline 100mg/cap 1# BID PO 7 days
      • fusidic acid 1 tube BID EXT 7 days
      • Shincort (triamcinolone acetonide) 50mg ST IS (intrasynovial)

[medication]

  • 2023-03-07 ~ undergoing - Giotrif (afatinib 30mg) tab 1# QDAC
  • 2021-09-08 ~ 2022-10-05 - Giotrif (afatinib 30mg) tab 1# QDAC

700181400

230418

[diagnosis] - 2023-04-13 admission note

  • Rectosigmoid colon cancer with lymph node metastases s/p da Vinci robotic assisted radical low anterior resection on 2023/03/17, pT4aN2aM0, pStage IIIC
  • Insomnia, unspecified

[present illness] - 2023-04-13 admission note

  • This 45 year old woman suffered from diarrhea and loose stool passage since 2022/12. She also developed nausea notede, epigastric dull pain, fullness belching, acid regurgitation. Also bloody stool passage was noted on 2023/02/20 evening. Stool was collected and shoed occult blood 3+.
  • Colonoscopy was performed on 2023/03/02 and found one tumor occupied almost intralumenal circumference of colon at 15 cm from anal verge, pathology reported adenocarcinoma. Pelvis MRI on 2023/03/14 showed: 1. Rectosigmoid colon cancer about 3.5cm in length with regional lymphadenopathy about 3 in number. 2. A prominent soft tissue mass at left inguinal canal. 3. Small uterine myoma. 4. A nabothian cyst about 0.7cm. T3N1bMX. Due to above reasons, she was admitted for colon cancer staging. She received da Vinci robotic assisted LAR on 2023/03/17 and pathology showed adenocarcinoma, moderately to poorly-differentiated with lymph node metastatic (6/22), pStage IIIC, pT4aN2aMX, immunohistochemistry (IHC) Testing for Mismatch Repair (MMR) Proteins, no loss of nuclear expression of MMR proteins: low probability of microsatellite instability-high (MSI-H). Now, she was admitted to ward for Port-A catheter insertion and chemotherapy with FOLFOX(C1D1).
    • ChatGPT:
      • The term “no loss of MMR protein” refers to the absence of any detectable decrease or loss in the expression or function of proteins involved in the DNA mismatch repair (MMR) system. The MMR system is a crucial mechanism in cells that helps maintain genomic stability by correcting errors that may occur during DNA replication.
      • The primary MMR proteins include:
        • MLH1 (MutL homolog 1)
        • MSH2 (MutS homolog 2)
        • MSH6 (MutS homolog 6)
        • PMS2 (postmeiotic segregation increased 2)
      • Loss or dysfunction of any of these MMR proteins can lead to a condition called microsatellite instability (MSI), which is characterized by a higher rate of mutations in the DNA. MSI is associated with certain types of cancer, such as colorectal cancer and endometrial cancer, particularly in the context of Lynch syndrome (also known as hereditary nonpolyposis colorectal cancer or HNPCC).
      • When there is “no loss of MMR protein,” it means that the MMR system is functioning properly in the cells, and the risk of developing cancers due to microsatellite instability is reduced. However, it is important to note that the presence of functional MMR proteins does not guarantee the complete absence of cancer risk, as there may be other factors or mechanisms contributing to cancer development.

[past history]

  • DM(-), HTN(-)
  • Uterine myoma uteri status post myomectomy on 2018/08/09
  • GERD, LA grade A history of Hp infection before noted at LMD.
  • da Vinci robotic assisted radical low anterior resection on 2023/03/17

[allergy]

  • NKDA

[family history]

1.There is no family history of cancer, hypertension, mental diseases or asthma. 2.No members of the family with diabetes.

[lab data]

2023-04-17 Anti-HCV Nonreactive
2023-04-17 Anti-HCV Value 0.10 S/CO
2023-04-17 Anti-HBc Reactive
2023-04-17 Anti-HBc-Value 4.11 S/CO
2023-04-17 Anti-HBs 774.10 mIU/mL
2023-04-17 HBsAg Nonreactive
2023-04-17 HBsAg (Value) 0.40 S/CO

[chemotherapy]

[assessment]

  • Lab data for hepatitis B virus is provided. It is recommended to initiate treatment with either Baraclude (entecavir) or Vemlidy (tenofovir alafenamide) before starting chemotherapy to minimize the risk of reactivation.
    • 2023-04-17 Anti-HBc Reactive
    • 2023-04-17 Anti-HBc-Value 4.11 S/CO
    • 2023-04-17 Anti-HBs 774.10 mIU/mL
    • 2023-04-17 HBsAg Nonreactive
    • 2023-04-17 HBsAg (Value) 0.40 S/CO

700534651

230418

[exam findings]

  • 2023-04-06 SONO - chest
    • Special Procedure:
      • echo-assisted
      • Pleural tapping 16 #-needle Left side 550 ml bloody
    • Echo diagnosis:
      • pleural effusion
        • Chest echography was performed first. The suitable intercostal space was selected and located.
        • Catheter was inserted with negative pressure smoothly.
        • Left side pleural effusion was drawn smoothly.
        • Watch out BP after tapping.
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block),
      • biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-04-03 CT - chest
    • Findings
      • moderate Lt pleural effusion.
      • Lungs: a subsegmental consolidation at LLL-laterobasal segment.
        • mosaic attenuation changes in Rt lung, LUL, and aerated Lt lower lobe. there is subpleural reticulation and ground-glass opacity at both lower lobes too.
      • Mediastinum and hila: a 15mm calcification in posterior Rt hilum.
        • extensive mild calcified plaques of the LAD, and LCX, and right coronary arteries.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: dilated trunk (3.3cm in caliber) and right main artery.
      • Heart: normal in size of cardiac chambers. mild calcified aortic valves.
      • Chest wall and visible lower neck: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or suspected tumor.
      • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
      • extensive 3V-CAD.
  • 2023-03-29 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
    • small Lt pleural effusion
    • volume reduce over Lt lower lung zone
    • a short linear high density over Rt infrahilar shadow, foreign body?
    • S/P posterolateral bony fusion at L-spine
  • 2020-06-29 Right knee standing
    • Osteoarthritis change of right knee with joint space narrowing and marginal spur formation. Loose bodies in the right knee joint.
  • 2020-06-29 KUB and Lumbar spine lateral:
    • Bilateral clear psoas shadows. Unremarkable bowel gas pattern. Grade 1 degenerative spondylolisthesis at L4-5 level. Degenerative change of the spine with marginal spur formation. Osteopenia of visible bones. L5-S1 disc space narrowing.

[SOAP]

  • 2023-04-06 Chest Medicine
    • past history: alzheimzer disease under licodin, HTN
    • chest tapping for exam.
  • 2023-04-06 Hemato-Oncology
    • S
      • This 77 year old woman with dementia, HTN and insomnia came to our OPD due to hemptosis for 10+ days, shortness of breath on excertion, body weight loss (4-5kg in 10 months)
      • Smoking history for 20+ years, quit for 20+ years
      • Lives in Nanshijiao, has five children (lives with the eldest daughter, one passed away from throat cancer, one lives in Tainan, one was given to another family to raise, and the youngest daughter lives in Nangang).
    • O
      • 2023/04/03 CT: Lung/Mediastinum/Pleura
        • moderate transudative pleural effusion. LLL subsegmental consolidation, infection or r/o tumor.
        • obstructive chronic airway diease in lungs and suspect mild fibrosis in lower lobes of lungs.
        • extensive 3V-CAD.
    • A
      • Arrange admisson for CT-guided biopsy
      • Suspected lung cancer
      • Suggestion: admitted for further evaluation
    • P
      • Chest contrast CT
      • CT gudide biopsy
      • check tumor marker
  • 2023-04-03 Chest Medicine
    • chest sono on 2023/04/06 PM0230
    • hold Licodin (ticlopidine) since 2023/04/04
    • refer to oncologist for suspected Left lower lung pleural based tumor
  • 2023-03-29 Chest Medicine
    • S: hemoptysis (blood in phlegm) for 10 days, mld short of breath
      • consciousness: clear
      • breath sound: clear
      • abdomen: soft, no tenderness
      • extremities: freely movable; no pitting edema
      • smoking:quit for 20 years
      • past history: alzheimzer disease, HTN
    • O: CXR: bilateral increased infiltrate
    • P:
      • suggest ER for admission, but the patient and family hesitate (unable to be hospitalized these days)
      • suggest if hemoptysis progressed -> ER admission
      • check lab
      • arrange chest CT on 2023/04/03
      • sputum TB x3
    • Diagnosis
      • R04.2 Hemoptysis
      • J15.9 Unspecified bacterial pneumonia
    • Medication
      • Romicon-A (dextromethorphan 20mg, cresolsulfonate 20mg, lysozyme 90mg) cap 1# TID 5 days
      • Cravit (levofloxacin 500mg) tab 1.5# QDAC 5 days
      • Transamin (tranexamic acid 250mg) cap 1# BID 5 days
  • 2023-02-22 Oral and Maxillofacial Surgery
    • S
      • current medication
        • antihypertensive drug
        • peripheral vasodilators for dementia
    • O
      • Panoramic findings:
        • Missing: nil
        • Impaction: nil
        • Crown and Bridge: 11,15,16,25,26,34-35X,43-44-45XX
        • Caries: nil
        • Periodontal condition: chronic periodontitis
      • vascular spot on the lower alveolar mucosa and tongue was noticed, might be drug-related
  • 2023-02-16 Family Medicine
    • CC
      • HTN loss f/u
      • headache
      • mild petechiae over lips and gum -> ginko related?
    • Past history HTN, dementia
    • Allergy history (-)
    • previous medication: Ginkgo, Stilnox, Xyzal

[assessment]

  • The patient should have been diagnosed with dyslipidemia and hypertension with heart failure, as he has regularly refilled prescriptions for rosuvastatin, valsartan, and spironolactone within the past 3 months, according to PharmaCloud. Additionally, a CT scan on 2023-04-03 revealed extensive 3-vessel coronary artery disease (3V-CAD), indicating significant atherosclerotic plaque in the LAD, LCX, and RCA.

  • If there are no contraindications, it is recommended to reintroduce these medications and consult a cardiologist to assess whether the patient requires aggressive medical management or revascularization procedures, such as coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI angioplasty with stent placement).

700555767

230418

[chief complaint] - 2023-04-17 admission note

  • Vertigo since 2023/01/07, progress for 2 weeks

[present illness] - 2023-04-17 admission note

The 57 y/o woman has history of hypertension. She had fall down in bus on 2022/11 and then fatigue, vertigo and right hip pain since 2023/01/07, so she bedridden for 3 months. Right breast tumor noted also 3 months. This time, she has dizziness and severe vertigo, so she was brought to our ED for help on 2023/04/17. Her right lower limbs MP down to 3 for 3 months. She denied fever, chills, vomit, SOB or hematuria. At ED, the brain CT showed 1. Mild cortical brain atrophy. 2. Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation? 3. Chronic left mastoiditis. UTI noted from urinalysis. Under the impression of right breast tumor, vertigo, suspect spinal stenosis, so she was admitted on 2023/04/17.

[past history]

  • hypertension under CV OPD follow up
  • constipation

[allergy]

  • NKDA

[family history]

  • No cancer, CVA, CAD or DM in her family

[exam findings]

  • 2023-04-17 CT - brain
    • CC
      • bedridden for 3 months after falling down
      • dizziness, vertigo, nausea, no tinnitus
      • right hip pain
    • phx: HTN, dyslipidemia, HBV carrier
      • NKDA
      • pregnancy: denied
    • Cranial CT scans without IV contrast medium enhancement was performed smoothly and show:
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • The basal ganglia, internal capsule, corpus callosum, and thalamus appear normal.
      • Sella and pituitary are normal, parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • Left parietal skull osteolytic destruction, nature?
    • Imp:
      • Mild cortical brain atrophy.
      • Left parietal skull osteolytic destruction, metastasis or less likely arachnoid granulation?
      • Chronic left mastoiditis.
  • 2023-04-17 Hip joints Rt
    • Permeative osteolysis over Rt acetabulum and superior pubic ramus and body, metastatic lesion d/d diffuse osteoporosis
  • 2023-04-17 CXR
    • marginal spurs of multiple vertebral bodies of T-spine due to spondylosis.

[SOAP]

  • 2023-04-17 Emergency
    • Diagnosis
      • N63 - Unspecified lump in breast
      • M89.59 - Osteolysis, multiple sites
      • R42 - Dizziness and giddiness
      • Z74.01 - Bed confinement status
  • 2021-08-03 Cardiology
    • Objective
      • 2021/08 123/75; 70;
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 0.5# QD
      • Norvasc (amlodipine 5mg) 1# QD
  • 2019-11-21 Cardiology
    • Objective
      • 2019/11 128/80; 65
    • Medication
      • Concor (bisoprolol 5mg) 0.5# QD <- 1# QD
  • 2019-08-02 Cardiology
    • Assessment
      • Essential hypertention, unspecified [I10]
      • Obesity, unspecified [E66.9]
      • Hepatitis B carrier [Z22.51]
      • Gout, unspecified [M10.9]
    • Medication
      • Olmetec (olmesartan medoxomil 20mg) 1# QD
      • Concor (bisoprolol 5mg) 1# QD
      • Natrilix SR (indapamide 1.5mg) 1# QD

[assessment]

  • An unspecified breast lump and multiple-site osteolysis are under investigation.
  • The patient’s underlying hypertension and obesity are well controlled with Olmetec (olmesartan), Norvasc (amlodipine) and Concor (bisoprolol) prescribed by our cardiologist without any medication reconciliation issues.
  • To date, there is no evidence of hyperuricemia (although this diagnosis remains in the cardiology OPD records). On 2023-04-17, the patient’s serum uric acid level was 5.4 mg/dL.
  • The most recent data for total cholesterol, triglycerides, LDL, and HbA1c were obtained on 2022-09-20 and may need to be updated.

700891439

230418

[diagnosis] - 2023-04-12 admission note

  • Malignant neoplasm of rectum
  • Malignant neoplasm of bladder, unspecified
  • Iron deficiency anemia, unspecified
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection)

[past history]

  • Squamous cell cacinoma of the Lt buccal region, stage T4aN0M0 (IVA), s/p wide excision, segmental osteotomy, and supraomohyoid neck dissection, radiotherapy, and chemotherapy in 2008
  • Small bowel ileus post enterolysis with bowel decompression in 2018
  • Ileus s/p Explosive laparotomy in 2018
  • Adenocarcinoma of rectum, pT2N2a(cM0), stage IIIB, s/p EXP LAP with AR and enterolysis, and s/p CCRT
  • Invasive urothelial carcinoma s/p transurethral resection of bladder tumor on 2021/05/28
  • Adhesion ileus s/p operation on 2018/04/20

[family history]

  • elder brother: lung cancer
  • father: liver disease
  • No members of the family with colon cancer.

[lab data]

  • 2021-07-14 All-RAS not detected
  • 2021-07-14 BRAF not detected
  • 2021-07-07 PD-L1(22C3) CPS>=1 and <10
  • 2021-07-07 PD-L1(28-8) TC>=1% and <5%

[exam findings]

  • 2023-04-14 Patho - gingival/oral mucosa biopsy
    • Mass, right buccal mucosa, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by tumor nests with enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the stroma with keratin material.
    • Immunohistochemical stains show CK(+); P63(+) and P16(-) for tumor.
  • 2023-04-13 Nasopharyngoscopy
    • Finding: granular tumor over right buccal, retromolar, gingivobuccal
    • Conclusion: right buccal ca
  • 2023-03-28 CT - neck
    • Indication: right facial tumor bleeding noted on 1AM. he had similar episode 2 weeks ago. The mass was noted for 2-3 months, which is growing with bleeding and pus formation.
    • Past history: double ca (colon ca and bladder ca) folfox 6 R/T, Bladder cT2N0M0 stage II UC with squamous change
    • Protocols: Axial scans with 2 mm slice thickness with multiplanar image reformation using Aquilion Prime CT.
    • Neck CT without/with contrast enhancement shows:
      • large enhancing mass at right buccal region (maximal diameter about 8cm), with direct invasion to right mandibular bone and right masticator space muscles, including masseter and temporalis muscles and probably also pterygoid muscles. Advanced right buccal cancer is compatible. T4b disease is considered.
      • multiple enlarged lymphadenopathy at right level Ib, II, Va. Possible extranodal invasion cannot be well evaluated in CT. N2b disease is favored.
      • bilateral symmetric pharyngeal mucosa.
      • chronic right maxillary sinusitis with complete sinus opacity and sinus bone thickening.
    • Impression: Advanced right buccal cancer, image staging favor AJCC T4bN2b, stage IVB.
  • 2022-12-24 CT - abdomen
    • s/p LAR. No evidence of recurrent/residual tumor in the study.
  • 2022-07-30 CT - abdomen
    • S/P colon and bladder operation. No evidence of tumor recurrence.
  • 2022-02-15 CT - abdomen
    • Post-op at the colon. Suggest follow up.
    • Liver cysts.
    • Left lower lung nodule 0.4cm, stationary, suggest follow up.
  • 2021-06-24 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Rectum, EXP LAP with low anterior resection — Adenocarcinoma, moderately differentiated
      • Resection margins, EXP LAP low anterior resection — Free
      • Lymph nodes, mesocolorectal, dissection — Metastatic adenocarcinoma (6/22)
      • Pathology stage: pT3N2a(cM0); Stage IIIB
    • MACROSCOPIC EXAMINATION
      • Operation procedure: EXP LAP low anterior resection
      • Specimen site: Rectum + sigmoid colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 5.8 x 4.5 cm
      • Tumor location: 4.0 cm away from the distal resection margin
      • Depth of invasion grossly: Perirectal soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A5=tumor, A6-A10= regional LNs, B= proximal end, C= distal end.
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: Perirectal soft tissue
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Circumferential (radial) margin of rectum: Uninvolved, 5 mm from the margin
      • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (6/22) (No. Positive / No. Total)
      • Extranodal involvement: Present
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT3 (Tumor invades pericolorectal tissues)
        • Regional Lymph Nodes (pN): pN2a (4 to 6 regional lymph nodes are positive)
        • Distant Metastasis (pM): cM0
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: None identified
      • Tumor regression grading S/P CCRT: N/A
      • IHC (S2021-7997): EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2021-06-23 PD-L1 (SP142)
    • VENTANA PD-L1 (SP142) Assay for Urothelial Carcinoma (S2021-08015)
      • PD-L1 Expression: <5% IC
      • Scores – Immune cells (IC): 2%; Tumor cells (TC): 0%
  • 2021-06-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 47.8) / 126 = 62.06%
      • M-mode (Teichholz) = 62.1
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mitral valve prolapse (posterior leaflet) with trivial regurgitation
      • Trivial tricuspid regurgitation
      • Thick IVS and dilated aortic root
  • 2021-05-28 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, “tumor”, near neck at 11-1 o’clock, TURBT — Invasive urothelial carcinoma with marked squamous differentiation, high-grade
      • Urinary bladder, “base”, TURBT — Involved by carcinoma
    • MICROSCOPIC EXAMINATION
      • Histologic type: Urothelial carcinoma, invasive, with marked squamous differentiation
      • Histologic grade: High-grade
      • Tumor configuration: Papillary and nodular
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • Specimen labeled “base”: Involved by carcinoma
  • 2021-05-27 Patho - colon biopsy
    • Intestine, large, rectum, near R-S junction, biopsy — adenocarcinoma
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • IHC stain — EGFR(+), PMS2(+), MSH2(+), MSH6(+), MLH1(+)
  • 2021-05-27 Colonoscopy
    • Suspected colon cancer, rectum near R-S junction, 15cm from anal verge, s/p biopsy
    • Mixed hemorrhoid
  • 2021-05-24 CT - abdomen
    • History and indication: fever, L’t abd pain, cause?
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with regional LAP.
      • A tumor (3.3cm) in urinary bladder r/o malignancy.
      • A soft tissue nodule (2.5x5.8cm) in presacral region r/o GIST.
      • Small liver cysts (3-6mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T2(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIB(Stage_value)

[surgical operation]

  • 2021-06-23
    • Surgery
      • EXP LAP with AR and enterolysis     
    • Finding
      • Rectal tumora invasion to bladder, Adenocarcinoma of rectum, stage T2N2aM0, stage IIIB
      • Anastomosis by CDH 33#
      • Previous surgery, severe adhesion  
  • 2021-05-28
    • Surgery
      • Transurethral resection of bladder tumor
    • Finding
      • urethral trauma during urethral dilation
      • Bilateral U/O normal with clear efflux
      • A large round shape tumor with hypervascularity tumor beneath normal mucosa was noted at anterior wall or urinary bladder. The location is very near 11 o’clock bladder neck. Based on clinical finding, it is hard to tell whelther it came from urinary bladder or prostate
      • Risk evaluation:
        • Tumor size: >3cm
        • Multifocality: solitary
      • a wrinkle at left posterior wall, compatible with location of sigmoid colon with wall thickening

[chemotherapy]

  • 2022-01-24 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-01-10 - (FOLFOX Q2W)
  • 2021-12-27 - (FOLFOX Q2W)
  • 2021-12-13 - (FOLFOX Q2W)
  • 2021-11-29 - (FOLFOX Q2W)
  • 2021-11-15 - (FOLFOX Q2W)
  • 2021-10-25 - (FOLFOX Q2W)
  • 2021-10-11 - (FOLFOX Q2W)
  • 2021-09-27 - (FOLFOX Q2W)
  • 2021-09-13 - (FOLFOX Q2W)
  • 2021-08-30 - (FOLFOX Q2W)
  • 2021-08-02 - (FOLFOX Q2W)

700154637

230417

[past history] - 2023-04-13 admission note

  • s/p appendectomy at the age of 18
  • Brenner tumor and benign mucinous cystadenoma s/p left salpingo-oophorectomy on 2008-05-20 at our hospital
  • The recurrence of brenner tumor and benign mucinous cystadenoma s/p ATH and right oophorectomy on 2012-02 at CGMH
  • Brenner tumor and benign mucinous cystadenoma with pelvic seeding and partial intestinal obstruction, due to tumor involvement and adhesion s/p excision of pelvic tumor and enterolysis and segmental resection of ileum with anastomosis on 2014-01-20
  • Brenner tumor s/p chemotherapy x3 three years ago (from peripheral line)
  • Colon cancer s/p OP
  • GB stone
  • Hemmorhoids

OB/GYN history:

  • Menarche: 18 Y/O
  • Menopause: 52 y/O
  • G5P4AA1
  • No perimenopausal hormone therapy
  • No smoking
  • No family members had breast CA, endometrial CA, ovary CA and colon CA

[allergy]

  • Ulexin (cephalexin 500 mg/cap) local rash

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-14 Tc-99m MDP bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, middle and lower T-spines, L5-sacrum junction, bilateral shoulders, right sternoclavicular junction and bilateral elbows in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the middle and lower T-spines and L5-sacrum junction. Degenerative change is more likely.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, right sternoclavicular junction and bilateral elbows, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-04-12 CXR
    • Patch density at RUL.
  • 2023-04-12 CT - abdomen
    • CC: abdominal pain, Lower abdominal dull pain for 3 months, progressed in 2 days. No diarrhea, no N/V, No fever, No dysuria
    • Past history:
      • Right ovarian cancer s/p TAH + BSO
      • Metastatic carcinoma in left pelvic cavity with sigmoid colon and left distal ureteral involvement, T4N0Mx s/p sigmoid colon resection
      • GB stones
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple poor enhancing masses on both hepatic lobes, the largest one 3 cm in S2/3, that are c/w metastases.
      • Multiple gallstones are noted.
      • S/P hysterectomy
      • S/P LAR with autosuture retention over the sigmoid colon.
      • There are two small soft tissue nodules 5 mm in RML of the lung.
        • Please correlate with chest CT to R/O metastases or inflammatory process.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Multiple metastases on both hepatic lobes.
      • Two small soft tissue nodules 5 mm in RML of the lung, nature?
        • Please correlate with chest CT.
  • 2023-04-12 KUB
    • Degeneration of bony structures.
    • Stool retention in bowl.
  • 2023-03-21 KUB
    • Rim calcification in RUQ.
    • Mild lumbar spondylosis.
  • 2023-03-21 Renal ultrasound
    • Grossly normal, bilateral kidneys
  • 2020-06-19 Pap Smear
    • Atrophy with inflammation
  • 2020-03-10 KUB
    • Degenerative change of the lumbar spine
  • 2020-03-10 CT - abdomen
    • Indication: acute onset diffused abdominal pain, with radiation to the back, nausea.
    • PMH: ovarian and uterus cancer s/p OP
    • Protocols: Axial scans with 5 mm slice thickness with multiplanar image reformation using 64-slice MDCT.
    • Abdomen & Pelvis CT without/with contrast enhancement shows:
      • postoperative change with suture material in the pelvic cavity.
      • clustered dilated small bowel loops (mainly ileum) in the pelvic cavity, with abrupt tapering of lumen at transition zone. Adhesion ileus is first considered.
      • colon is not dilated.
      • no ascites; no intraperitoneal free air.
      • tiny simple hepatic cysts in left hepatic lobe.
      • no definite focal lesion in the spleen, pancreas, bilateral kidneys and adrenal glands.
      • multiple gallbladder stones.
    • Impression:
      • Postoperative change in the pelvic cavity. Focal small bowel ileus in the pelvis, favor adhesion ileus.
      • Multiple gallbladder stones.
      • Tiny simple hepatic cysts, left lobe.
  • 2018-11-30 CT - abdomen
    • Chief Complaints: abd pain, upper abodmen, Nausea (+), vomiting (-), Diarrhea (-) Radiation to back (-) constipatin (-)
      • Past History: Nil
      • Surgical history: Hysterectomy and oophorectomy
      • Drug allergy: Ulex
      • Stomach ache sudden onset since 4 pm
    • Indication: R/O intestinal obstruction.
    • Without and with contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys
      • post-OP change in the rectosigmoid colon.
    • Impression: post-OP change in the rectosigmoid colon.
  • 2018-11-30 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-11-30 KUB
    • Osteopenia of the bony structure is noted.
  • 2018-03-06 Surgical pathology Level V
    • Clinical diagnosis: Malignant ovary neoplasm
    • Pathological diagnosis
      • Labeled as “pelvic mass”, excision — Adenocarcinoma.
        • IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Labeled as “sigmoid colon”, resction — Free
      • Lymph node, epricolonic, sigmoid colon resection — Metastatic carcinoma (1/1) with extra-nodal extension.
    • MICROSCOPIC DESCRIPTION:
      • Sections of the pelvic tumor mass show adenocarcinoma with neoplastic glands lined by goblet cells and elongated nuclei.
        • IHC stains: CK7 (+), CK20 (focal +), the pattern the same as previos pattern (S2014-1036).
        • Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-).
      • Section of the sigmoid colon show bland colonic mucosa, submucosa, muscular layer and serosa. One lymph node at the resection margin shows tumor metastasis with extra-nodal extension.
  • 2018-01-30 Sigmoid fiberscopy
    • external compression and scopy can not pass through since 10 cm from AV
  • 2018-01-30 Upper GI panendoscopy
    • Hiatal hernia with reflux esophagitis, Gr A  - Superficial gastritis, antrum and body
  • 2018-01-29 CXR
    • Scoliotic alignment of the thoracolumbar spine is noted.
    • Osteopenia of the bony structure is noted.
  • 2018-01-29 CT - abdomen
    • A multiloculated cystic lesion (4.9x8.8cm) at left pelvic cavity.
    • Gall stones (0.3-1.4cm). A hypodense nodule (0.3cm) at left hepatic lobe.
    • S/P colon operation.
    • Focal wall edema of small bowel at pelvic cavity.
  • 2016-03-15 SONO - OBS
    • L’t adnexal mass: 62x51mm (RI:0.17, RI:0.78)
  • 2016-03-15 CT
    • S/P hysterectomy.
    • R/O recurrence malignancy in left pelvic cavity with sigmoid colon and left distal ureteral involvement.
    • GB stones with GB fundus wall thickening.
  • 2015-04-22 CT
    • In favor of S-colon cancer (T4N0Mx) (The gold standard of evaluation of lymph node metastases and detailed tumor status is microscopic examination).
    • cStage: T4N0Mx.

[consultation]

  • 2023-04-17 Family Medicine
    • Q
      • This 79 year old woman patient is a case of right ovairan cancer s/p TAH + BSO with pelvic cavity, sigmoid, ureteral involvement s/p OP with liver metastases. Laparotomy on 2008/05/21. OP with TAH+BSO in 2012/02 at CGMH. Debulking with pelvic lymph node enlargement, suspect recurrent ovarian tumor and pelvic tumor, r/o recurrent ovarian cancer with invasion to sigmoid colon on 2018/03/05 and pathology showed Adenocarcinoma. IHC stains: CK7 (+), CK20 (focal +), pattern the same as previos pattern (S2014-1036). Addtional IHC stains: CDX-2 (weak +), PAX-8 (-), WT-1 (-). Lymph node, epricolonic, sigmoid colon resection pathology showed metastatic carcinoma (1/1) with extra-nodal extension. Patient and family refuse further chemotherapy.
      • For pain control and hospice care, we need your further evaluation and management.

[surgical operation]

  • 2018-03-05 Debulking
  • 2012-02 (at CGMH) TAH + BSO
  • 2008-05-21 Laparotomy

[assessment]

  • This patient and her family refuse further chemotherapy, so family medicine is consulted for combined hospice care and pain management.
  • Palliative and supportive care is provided. There is no problem with the active prescription.

700824633

230417

[exam findings]

  • 2023-02-22 CT - abdomen
    • History:
      • 20230117 CT: Ileocecal mass lesion causing small bowel obstruction. Please correlate with colonoscopy.
      • 20230118 S/P ileostomy for decompression.
      • 20230216 S/P right hemicolectomy: A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy.
    • Indication: R/O IAI (Intra-Abdominal Infection)
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformatted isotropic images were obtained in non-contrast scan.
    • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ perfusion status cannot be determined without IV contrast.
    • Findings:
      • There is pneumoperitoneum that may be post-operative change.
        • The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
      • S/P right hepatectomy
      • S/P cholecystectomy.
      • S/P Jackson-Pratt drainage tube insertion from right flank area and the tip located over subhepatic space.
      • Others
        • There is no hyper-or hypodense lesion in the liver, biliary system, pancreas, spleen & both kidneys.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • IMP:
      • There is pneumoperitoneum that may be post-operative change. The differential diagnosis includes hollow organ perforation.
      • There are free gas bubbles in the gastrohepatic ligament and ligamentum teres. Please correlate with gastroscopy.
  • 2023-02-17 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, cecum, right hemicoloectomy — Mucinous adenocarcinoma, poorly differentiated
      • Margin, proximal and distal: Free
      • Omentum, right hemicoloectomy — Adenocarcinoma, seeding
      • Lymph node, regional, dissection — Meatastatic adenocarcinoma (2/17)
      • Ileostomy, closure — Confirmed
      • AJCC 8th edition pathology stage: pT4aN1bM1a; AJCC stage IVA
    • Gross Description:
      • Procedure: Right hemicolectomy
      • Tumor Site: Cecum
      • Tumor Size: 6.2x 4.2 cm
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:1:bil cut-ends, A2:stomy, A3-5:tumor, A6-8:LNs, X1-3:tumor, X4:omentum, X5:LNs
    • Microscopic Description:
      • Histologic Type: Mucinous adenocarcinoma
      • Histologic Grade: G3 - Poorly differentiated
      • Tumor Extension
        • Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
          • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
      • Tumor Deposits: Present
        • Specify number of deposits: Mesocolon
      • Regional Lymph Nodes
        • Number of Lymph Nodes Involved/Examined: Positive (2/17)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN)
            • pN1b: Two or three regional lymph nodes are positive
          • Distant Metastasis (pM)
            • pM1a: Metastasis to one site or organ is identified without peritoneal metastasis
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Pending
      • Comment(s): None
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (98 - 27) / 98 = 72.45%
      • M-mode (Teichholz) = 73
    • Conclusion:
      • Indeterminated LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; trivial TR; mild PR.
  • 2023-02-15 Flow Volume Chart
    • normal ventilation
  • 2023-02-14 CXR
    • A calcification at LUQ.
  • 2023-01-17 CT - abdomen
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N1(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2021-03-24 Treadmill Exercise Electrocardiogram
    • The patient exercised according to the BRUCE for 06:16 min:s, achieving a work level of max METS: 7.3. The resting heart rate of 67 bpm rose to a maximal heart rate of 115 bpm. This value represents 77 % of the maximal, age-predicted heart rate. The resting blood pressure of 139/57 mmHg, rose to a maximum blood pressure of 216/70 mmHg. The exercise test was stopped due to Dizziness, Leg discomfort.
    • Conclusion: Inadequate exercise load
  • 2018-11-14 Myocardial perfusion SPECT with persanti
    • The Tl-201 stress myocardial perfusion scan was performed after sequentially injecting 38.1 mg of dipyridamole and 2.3 mCi of the radiotracer to the patient. The images after stress revealed mildly decreased radiotracer perfusion to the apical lateral wall of the left ventricle. The images at rest revealed further decline radiotracer perfusion to aforementioned hypoperfused area of the left ventricle. No dilatation of the left ventricle was noted.
    • IMPRESSION:
      • Probably normal variant or mild myocardial ischemia in the apical lateral wall of the left ventricle.
      • No post-stress dilatation of the left ventricle.
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (78.2 - 25.6) / 78.2 = 67.26%
    • Report
      • AO(mm) = 32.8
      • LA(mm) = 36
      • IVS(mm) = 13.1
      • LVPW(mm) = 10.9
      • LVEDD(mm) = 41.9
      • LVESD(mm) = 26.4
      • LVEDV(ml) = 78.2
      • LVESV(ml) = 25.6
      • LV mass(gm) = 177.5
      • RVEDD(mm)(mid-cavity) =
      • TAPSE(mm) = 22.6
      • LVEF =
      • M-mode(Teichholz) = 67.3
      • 2D(M-Simpson) =
    • Diagnosis
      • Heart size: Normal
      • Thickening: IVS
      • Pericardial effusion: None
      • LV systolic function: Normal
      • RV systolic function: Normal
      • LV wall motion: Normal
      • Valve lesions:
        • MV prolapse: None
        • MS: None
        • MR: None
        • AS: None, Max.AV velocity = 1.3 m/s
        • AR: None
        • TR: Trivial, Max.pressure gradient = 22.8 mmHg
        • TS: None
        • PR: None
        • PS: None
      • Mitral E/A = 53.5 / 68.1 cm/s (E/A ratio= 0.79 )
      • Mitral E’/A’ = 6.9 / 12 cm/s (septal MA); E/E’ = 7.8
      • Intracardiac thrombus: None
      • Congenital lesion: None
    • Conclusion
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial tricuspid regurgitation
      • Mildly thicked IVS

[consultation]

  • 2023-01-17 Colorectal Surgery
    • Q
      • For small bowel illeus due to suspected cecum tumor obstruction
      • The 75 year old woman suffered from no stool and no gas release for 1 week and her abdomen became distended and gradually painful. She visited our ER today and KUB showed small bowel illeus, and CT was done that it was suspected a cecum tumor obstructed the bowel. As a result, we need your expertise to evaluate if she needed emergent operation, thanks!
    • A
      • O
        • CT:
          • Dilatation of small bowel and collapse of colon, r/o obstruction.
          • Wall thickening at ileocecal junction with perifocal fat stranding.
          • Several lymph nodes, at least 8, in right mesocolon.
          • Unremarkable chagne of the liver, spleen, pancreas, and kidneys.
          • No ascites or extraluminal free air.
          • No bony destructive lesion on these images.
        • No fever
        • Vital signs: stable
        • Abdomen: soft, no peritoneal signs or muscle guarding, mild tenderness and distended
      • A: R/O tumor of cecum with obstruction
      • P:
        • Diverting ileostomy for decompression first followed by staged right hemicolectomy 2-3 weeks later is recommeneded
        • The operation will be performed tomorrow on call
        • Please keep current treatment (NPO, NG, nutrition support, antibiotics, Albumin use, check tumor makers)
        • We’ll take over this patient tomorrow morning

[surgical operation]

  • 2023-02-16
    • Surgery
      • Exp. Lap with right hemicolectomy and closre of loop-ileostomy
    • Finding
      • A locally advanced tumor was found at cecum with adhesion to RLQ abdomen wall and invasion of great omentum, with obstruction s/p loop-ileostomy
      • Right hemicolectomy was carried out smoothly and anastomosis using endo-GIA for both ends and side-to-side hand-sewn sutures with 4/0 PDS+ silk.
      • Blood loss was about 30ml. A drain in right subhepatic region
  • 2023-01-18
    • Surgery: Loop-ileostomy    
    • Finding: Dilation of small bowel with wall edema and some ascites. Loop-ileostomy was created at RLQ abdomen. The whole procedure was smooth. 
  • 2017-11-20
    • Diagnosis: varicose vein
    • PCS code: 69014B
    • Finding: left varicose vein with posterior thigh varicose lake

[chemotherapy]

  • 2023-04-13 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4323mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-27 - oxaliplatin 85mg/m2 131mg D5W 250mL 2hr + leucovorin 400mg/m2 617mg NS 250mL 2hr + fluorouracil 2800mg/m2 4320mg NS 1000mL 46hr (FOLFOX Q2W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[assessment]

  • The modified FOLFOX6 regimen was administered on 2023-03-27 and 2023-04-13, and severe diarrhea with 10 bowel movements each day occurred on 2023-03-28 and 2023-04-14.
  • Treatment should be withheld for grade 2 or worse diarrhea and restarted at a 20% lower dose of all agents after complete resolution. A dose reduction of oxaliplatin is recommended (to 75 mg/m2 for patients in the adjuvant setting and 65 mg/m2 for patients with advanced disease). Since the bolus FU is skipped in the regimen used, consideration may be given to reducing the infusional FU from 2800mg/m2 to 2400mg/m2 after recovery from grade 3 or 4 diarrhea in the previous cycle.
  • Severe diarrhea, mucositis, and myelosuppression following FU should lead to evaluation for DPD deficiency.
  • Loperamide is recommended as initial therapy for chemotherapy-related diarrhea (CRD). For mild to moderate (grade 1 or 2) uncomplicated CRD, an initial dose of 4 mg should be administered, followed by 2 mg every 4 hours or 2 mg after each loose stool (maximum daily dose of 16 mg). For severe (grade 3 or 4) diarrhea, or mild to moderate diarrhea complicated by moderate to severe abdominal cramping, grade 2 or worse nausea/vomiting, decreased performance status, fever, sepsis, neutropenia, frank bleeding, or dehydration, or mild to moderate uncomplicated diarrhea that persists after 24 hours of loperamide, high-dose loperamide (4 mg initially followed by 2 mg every 2 hours; maximum daily dose 16 mg) should be used. Loperamide was prescribed on 2023-03-30 when the patient was discharged after her first dose of FOLFOX.

700841910

230417

{not completed}

[exam findings]

  • 2023-04-16 Nasopharyngoscopy
    • Findings
      • smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold
    • Diagnosis/Conclusion
      • hypopharynx ca
  • 2023-03-02 Nasopharyngoscopy
    • Findings: 3/2 fiber = RT since 3/1 + CT (3/2 3 courses left), dyspnea, R false cord bulging
  • 2023-02-13 MRI - larynx
    • Indication
      • Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets), s/p incomplete CCRT (2022-09-21 ~ 10-20).
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows (comparison: 2022/08/19 MRI)
      • No evident abnormal enlarged lymph node in the visible neck. Regressed LNs seen on prior MR study.
      • Markely Regressed hypopharygeal tumor.
      • After IV contrast administration shows well or heterogenous enhancement in right hypopharynx and around the esophagus inlet (around NG tube, edema?).
      • Presence of soft tissue swelling over bil. neck, post R/T change likely.
      • No evident bony destructive lesion.
    • IMP: Markedly regressed neck LAPs. Markely regressed right hypopharyngeal tumor, likely with minimal residual tumor mass or edematous change, suggest follow up.
  • 2023-02-02 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
  • 2023-01-30 CT - abdomen
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts measuring 4.3cm is found at right side.
      • Enlarged prostate measuring 6.3cm with calcification is found.
      • The GB is well distended without soft tissue lesion
      • S/P NG tube placement.
      • The spleen, pancreas and adrenals are intact.
      • Very small nodule at hepatic hilum measuring 0.8cm in largest dimension. In comparison with CT dated on 2022-10-12, the lesion regressed.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • No definite inguinal or pelvic sidewall LAP
      • Visible chest
        • Normal heart size.
        • Calcified coronary arteries is found.
        • The lung fields are clear.
    • Imp:
      • Hepatic hilar nodule. In regression.
      • Enlarged prostate. 6.3cm
  • 2023-01-05 Nasopharyngoscopy
    • Hypo ca undergoing CCRT
    • NG+
    • saliva stasis
  • 2022-11-03 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
  • 2022-10-27 ECG
    • Sinus tachycardia
    • T wave abnormality, consider anterior ischemia
  • 2022-10-12 CT - abdomen
    • Indication:
      • Poor intake after R/T, dysphagia, odynophagia
      • 68 y/o male, a pt of Hypo ca, R+ neck mets (R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT= suspect liver mets) Dx in Aug 2022
    • Findings
      • Regression of S1 liver lesion (or hepatic hilar lesion), from 1.9cm to 1.0cm.
      • Right kidney cyst, 5.2cm.
      • No ascites or extraluminal free air.
      • No evidence of bowel obstruction.
      • No enlarged lymph nodes in para-aortic and pelvic regions.
      • Enlargement of prostate gland.
      • No bony destructive lesion on these images.
    • Impression
      • Regression of S1 liver lesion (or hepatic hilar lesion)
      • Prostate enlargement
  • 2022-09-15 Nasopharyngoscopy
    • 202208 Hypo ca, R+ neck mets(R level Vb, II-III, possible L), cT4aN2bM1 (Abd CT = suspect liver mets) = wish
    • 20220915 fiber = new R vocal palsy + supraglottic smooth bulging progress + no glottis visible (no dyspnea) + mucopus
  • 2022-09-06 Patho - odontogenic/dental cyst
    • Labeled as “granulation tissue in the extraction socket of tooth 34”, removal — Granulation tissue
    • Section shows benign squamous mucosa lined granulation tissue composed of proliferative small blood vessels, fibrosis, and moderate diffuse acute and chronic inflammation.
  • 2022-08-29 CT - abdomen
    • Liver low density lesion at S1, liver meta is favored.
    • Enlarged prostate. Please correlate with PSA.
  • 2022-08-25 Esophagogastroduodenoscopy, EGD
    • Right hypopharynx mass
    • Gastric ulcers, antrum
    • Reflux esophagitis LA Classification grade A
    • Hiatal hernia
    • Superficial gastritis, s/p CLO test
  • 2022-08-25 SONO - abdomen
    • Prob. Parenchymal liver disease
    • Bil renal cysts
  • 2022-08-23 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, additional biopsy (S2022-13982) for formalin fixation — squamous cell carcinoma (SCC). IHC stains: p16 (-), Ki-67: 10-15%.
    • Labeled as “right hypopharyngeal tumor”, initial biopsy with frozen section examination (F2022-391) — squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-23 Frozen section
    • Preliminary diagnosis: right hypopharynx, squamous cell carcinoma in situ (CIS), at least.
  • 2022-08-22 Whole body PET scan
    • Glucose-hypermetabolic lesions in the right hypopharynx, highly suspected the primary hypopharyngeal cancer, suggesting biopsy for investigation.
    • Glucose hypermetabolic lesions in lymph nodes in bilateral cervical regions and in the right supraclavicular fossa, highly suspected cancer with regional lymph nodes metastases.
    • A glucose hypermetabolic lesion in the right lobe of the liver, highly suspected cancer with distant metastasis. However, another primary cancer (HCC) should be excluded.
    • Suspected benign lesions in the lesser curventure of the stomach, and physiological uptake of FDG in the colon.
    • Right hypopharyngeal cancer with bilateral cervical and right SCF lymph nodes and liver metastases, cTxN2cM1, stage IVC (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2022-08-19 MRI - larynx
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:4a(T_value) N:2b(N_value) M:0(M_value) STAGE:IVA(Stage_value)
  • 2022-08-18 CT - neck
    • IMP: Right hypopharynx CA with neck LAPs. T4aN2BMx. stage IVA
    • Imaging Report Form for Hypopharynx Carcinoma
    • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
  • 2022-08-18 Nasopharyngoscopy
    • Findings
      • 3x3 cm palpable non-tender mass over right neck Level I-II region
      • Scope: bilateral intact ear drums, smooth nasopharynx, oropharynx
        • mass lesion over right AE fold, with moderate airway patency
      • Diagnosis and conclusion
        • right hypopharynx mass, cause to be determined
  • 2021-04-09 KUB
    • The psoas shadow is clear.
    • There is no evidence of destructive bone lesion.
    • Calcified dot(s) is found at left paravertebral region, ureter stone(s) is most likely.
    • Increased intestinal gas is found.

[consultation]

  • 2023-04-16 Ear Nose Throat
    • Q
      • Chief Complaints: just done C/T 1 month ago.
      • progressive dyspnea, productive cough today.
      • Past History: hypophagreal ca cT4aN2bM1 sp CCRT. liver metastasis
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • Stridor for 20 days.
      • Scope: smooth NPx, OPx, supraglottic swelling, vocal cord edema, R vocal palsy, L vocal paresis, saliva pooling over hypopharynx aspirated to trachea, whitish lesion over left AE fold (compared to 202303)
      • Imp: Supraglottic sweillng, suspect C/T related or acute infection
    • Plan:
      • Failed NG insertion due to supraglottic swelling, may consult GI man for insertion
      • Monitor airway, informed the risk of tracheostomy, prescribed Bosmin (adrenalin) + steroid inhalation, IV steroid (if no contraindication)
  • 2022-10-27 Metabolism and Endocrinology
    • Q
      • The 64 y/o man has DM, HCVD and R hypopharyngeal CA wt bil cervical & R SCF LNs & liver mets, cTxN2cM1, stage IVC. He just did chemotherapy on 2022/10/18. Due to weakness and hyperglycemia noted, suspect DKA, so the RI pump use from ED. We need your help for management. Thanks!
    • A
      • We were consulted for blood sugar control.
      • O:
        • BH: 162 cm, BW: unknown
        • Diet: NPO except water and drugs
        • Medication in OPD: unknown
        • Medication during hospitalization: RI pump 30 ml/hr
        • Na: 123, K: 5.4, Ca: 2.75
        • ALT: 32
        • BUN/Cr: 71/1.95 (eGFR: 36.54)
        • F/S: 275
        • Blood glucose: 673 mg/dL
        • HbA1c: unavailable
        • Blood osm: 317, effective osm: 283
        • Urine ACR: unavailable
        • OPH OPD: nil
      • A: Type 2 DM, poor control
      • Suggestions:
        • Avoid all OADs. Keep NPO except water and drugs
        • RI pump 50U in 500ml N/S run as protocol
        • H/S 500ml Q12H, 0.298% KCl QD + STAT (STAT after serum K reading)
        • Check F/S Q2H. Check Na, K, vein gas Q8H until off RI pump
        • Switch to basal bolus therapy later. (contact us to adjust)
        • Check HbA1c, urine ACR
        • Consult OPH for DM retinopathy if his condition is stable.
        • Consider to consult nutritionist for DM diet education (self-paid approximate TWD 600)
        • Basic educations for Diet control, Hypoglycemic precautions, DM complications and Self-Monitoring of Blood Glucose were given at bedside
        • Contact us if needed. I’d like to follow up this patient. Meta-OPD F/U.
  • 2022-08-18 Ear Nose Throat
    • Q
      • Right neck pain for 1 month
      • Never seek medical help, only took pain-killers and then tarry stool noted. called at our GI OPD this morning. EGD was arranged for R/O UGI bleeding.
      • Right ear tingling pain, horseness also noted
      • Odynophagia (+)
      • No fever noted
      • Occupation: Taxi driver
      • Medication: Bokey for
      • Past hx: DU, DM
      • OP hx: renal stone s/p op
    • A
      • S
        • sore throat with FB sensation for a month
        • fair saturation under room air
        • odynophagia(+), dysphagia(-), dyspnea(-),stridor (-), mouth drooling(-), voice change (+), otalgia (+, right), fever(-), alcohol(+), smoking(+), betelnut(-)
      • O
        • 3x3 cm palpable non-tender mass over right neck Level I-II region
        • Scope:
          • bilateral intact ear drums, smooth nasopharynx, oropharynx
          • mass lesion over right AE fold, with moderate airway patency
      • A
        • Impression: Right hypopharynx or larynx tumor with neck mass, r/o metastasis
      • P
        • inhalation therapy with steroid + bosmin if no contraindication
        • keep monitor breathing pattern and saturation, intubation or cricothyrodectomy may be considered then if s/s worsen
        • we will f/u the patient

[chemotherapy]

  • 2023-03-15 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-08 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2023-03-01 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-18 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-11 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-10-04 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-09-26 - cisplatin 30mg/m2 50mg NS 500mL 1hr (cisplatin weekly, CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

UFT (tegafur 100mg + Uracil 224mg) KUFT01

  • 2023-02-02 ~ undergoing - 2# BID
  • 2022-08-29 ~ 2022-10-03 - 2# BID

[assessment]

  • For the patient’s shortness of breath (SOB), in addition to the currently prescribed Ipratran (ipratropium bromide), the addition of Butanyl (terbutaline) could be considered if there are no contraindications. Inhaled glucocorticoids such as beclomethasone, budesonide, ciclesonide, fluticasone, mometasone and triamcinolone may also be considered.

701010079

230417

[exam findings]

  • 2023-03-24 MRI - pelvis
    • CC: Stool passage from urine, hematuria, turbid urine
      • 20210111 CT: Rectal cancer,T4bN2aM0,STAGE:IIIC. Rectal-vesical fistula.
      • 20220413 CT: Soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • 20230218 CT: soft tissue mass at left lateral pelvis with left hydroureteronephrosis.
      • 20230223 TURBT of Bladder tumor: Adenocarcinoma c/w colorectal origin.
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • There is no evidence of left hydroureteronephrosis.
      • There is no focal abnormality in the prostate.
        • Non-visualization of the seminal vesicle is noted.
      • There is no evidence of ascites or lymphadenopathy.
      • The visible abdominal aorta and IVC are grossly unremarkable.
    • IMP:
      • There is an ill-defined soft tissue mass-like lesion in between the rectum and the urinary bladder, measuring 4.4 x 2.8 cm in size.
        • Rectal cancer with urinary bladder invasion is highly suspected. Please correlate with contrast enhanced CT or MRI.
        • In addition, rectal-vesical fistula is noted.
      • No evidence of left hydroureteronephrosis.
  • 2023-02-27 PD-L1 (SP142)
    • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
      • Tumor type: colorectal adenocarcinoma with bladder invasion
      • Tumor location: urinary bladder
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark ULTRA
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=50 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor cell (TC) staining assessment:
        • TC category: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): <1%
      • Tumor-infiltrating immune cell (IC) staining assessment:
        • IC category: IC >=1% and <5%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): 2%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-02-27 PD-L1 IHC
    • Tumor cell (TC) staining assessment:
      • TC: <1%
  • 2023-02-27 PD-L1 (22C3)
    • Combined Positive Score (CPS) assessment: CPS >= 10
    • Combined Positive Score (CPS): 15
  • 2023-02-23 Patho - urinary bladder TUR
    • Bladder tumor, TURBT — Adenocarcinoma, compatible with colorectal origin
    • Microscopic examination
      • Histologic type: Adenocarcinoma, compatible with colorectal cancer with bladder invasion
      • Histologic grade: moderately differentiated
      • Tumor configuration: tubular, cribriform or papillary tumor with focal necrosis and muscle invasion. Besides, normal colonic mucosa is also included in the submitted specimen
      • Immunohistochemistry: CK7(+, scatter), CK20(+), GATA-3(-), CDX2(+) and P63(-) for tumor
      • Clinical correlation is advised.
  • 2023-02-22 CXR
    • Fibrocalcified infiltrates in right upper lung.
    • Right lower lung nodule, 0.9cm, stationary.
  • 2023-02-18 CT - abdomen
    • Indication: new bladder cancer, colon cancer history
    • Abdominal CT without IV contrast ehnancement shows:
      • The urinary bladder is collapsed with thick wall and suspeced soft tissue infiltration to perirectal region measuring 5.65*3.03cm in largest dimension. In comparison with CT dated on 2022-04-13, the lesion enlarged. Suggest further treatment.
      • Left hydronephrosis and hydroureter obliterated by the tumor mass is found.
      • The spleen, liver, pancreas and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • Visible chest
        • Calcified coronary arteries is found.
        • Normal heart size.
        • One calcified dot at right lower lobe is found measuring 0.45cm in largest dimension. Old insult is considered.
        • No pleural effusion is found.
    • IMP: Soft tissue mass at bladder base with left hydronephrosis and hydroureter. Uroepithelial cancer is favored.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-09 Patho - urinary bladder TUR
    • Urinary bladder, TURBT — high-grade invasive urothelial carcinoma. Muscularis propria not present.
    • Microscopically, section showsinvasive urothelial carcinoma characterized by papillary architecture of the neoplasm lined by high-grade atypical urothelial cells. The tumor cells have irregular nuclear contours with hyperchromasia and pleomorphism, variably prominent nucleoli and mitotic activity. The tumor has invaded subepithelial connective layer. Muscularis propria is not present.
  • 2022-12-07 SONO - nephrology
    • left severe hydronephrosis
  • 2022-04-13 CT - abdomen
    • History: 20210111 CT:rectal cancer with rectal-vesical fistula, cT4bN2aM0, cStage: IIIC
    • Past History: Liver abscess S/P right hepatectomy, old TB
    • Findings:
      • S/P right hepatectomy and S/P cholecystectomy.
      • S/P right transverse colostomy
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
      • Fibro-calcified shadows of right upper lung are noted, which is c/w old TB.
    • Impression:
      • There is soft tissue mass in between the rectum and the urinary bladder that is c/w rectal cancer with urinary bladder invasion.
      • Prior CT identified a metastasis measuring 7.5 mm in RLL of the lung is noted again, stationary.
  • 2021-09-11 CT - abdomen
    • NO evidence of tumor invasion into urinary bladder is found.
    • The urinary bladder is collaped with thick wall. Although no tumor invasion is found in the current study. Cystoscopy is suggested if hematuria persisted.
    • Right lower lobe nodule, in regression.
  • 2021-01-26 CT - chest
    • Indication: rectal intramucosal adenocarcinoma, Chest x-ray showed right lung nodule
    • MDCT (256-detectors, GE Revolution, was performed with 0.625 mm collimation & 1.25 mm slice thickness) of the chest without contrast enhancement, coronal and sagittal reformatted images and axial MIP images obtained shows:
      • Lungs:
        • reticular and nodular opacities with architextural distortion in RUl. reticular opacities in anterior RLL.
        • two solid nodules in RLL (up to 9 mm in largest axial dimension) and snother smaller solid nodule in RML.
      • Mediastinum and hila: no enlarged LN or mass.
        • old calcified LNs in the mediastinum and hila, sequela of previous TB infection
      • Vessels: mild coronary arterial calcification
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: Rt apical pleural thickening.
      • Chest wall: unremarkable.
      • Visible abdominal contents: s/p Rt hepatic posterior segmentectomy.
      • Visualized bones: no lytic or blastic lesion.
    • Impression:
      • three solid nodules in Rt lung, firstly considered metastases.
      • post inflammatory fibrotic change in RUL and anterior RLL.
  • 2021-01-25 CXR
    • Interstitial pattern at RUL.
    • A nodule at right middle lung zone.
    • Blunted right costophrenic angle.
  • 2021-01-19 Patho - colorectal polyp
    • Rectal tumor, biopsy — Intramucosal adenocarcinoma at least
    • Microscopically, the sections show a picture of intramucosal adenocarcinoma at least characterized by tumor arranged in cribriform or villous pattern with subtle stromal reaction.
    • Immunohistochemistry shows CDX-2(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor.
  • 2021-01-19 Barium Enema (double contrast)
    • LGI series with water soluble contrast medium revealed:
      • Total occlusion of rectum, about 9cm from anal verge. No further passage of contrast medium even on a 10mins delayed image.
      • Plain pelvis CT was performed for comparison and prooved above description.
    • IMP:
      • c/w rectal mass with total occlusion
      • Suggest oral contrast study if a colo-vesical fistula is suspected clinically.
  • 2021-01-19 Colonoscopy
    • Suspected rectal cancer obstruction s/p biopsy
  • 2021-01-11 CT - abdomen
    • History and indication: rectal-vesical fistula
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent fat stranding and regional LAP. Presence of rectal-vesical fistula.
      • S/P right hepatic lobe operation.
      • Some small LNs at retroperitoneum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • No ascites.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
      • Degeneration and spondylosis of L-S spine.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N2a(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)

[chemotherapy]

  • 2023-04-14 - leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + NS 250mL
  • 2021-05-05 - irinotecan 120mg/m2 180mg D5W 250mL 90min
    • betamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg PO + NS 500mL
  • 2021-03-29 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-24 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-08 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2
  • 2021-03-04 - [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouacil 400mg/m2 650mg NS 100mL 10min] D1-2

[assessment]

  • The patient’s serum creatinine has been above 2 mg/dL since 2022Q4 and has not dropped below that level since. The eGFR has been consistently around 30 since 2023.

  • On 2023-04-13 the following lab results were obtained: HGB 5.1g/dL, Iron bound Fe 22ug/dL, UIBC 145ug/dL, TIBC 146ug/dL, AST 14U/L, and ALT 13U/L. On 2023-04-14, Ferritin was 545ng/mL and Transferrin was 124ng/mL. There is no evidence of iron deficiency or liver dysfunction. Anemia of chronic disease and/or anemia of inflammation might be possible, as well as nutritionally deficiency. The body weight of 36.5 kg recorded on the TPR panel on 2023-04-13 appears to be too low, which may be an erroneous entry.

701091164

230417

[diagnosis] - 2022-11-25 admission note

  • Rectal cancer s/p neoadjuvant concurrent chemoradiotherapy at TP-VGH in 2012, with response of CR, so no OP. Due to near total obstruction on 2018/06, receiving T-colostomy on 2018/06/11 followed by neoadjuvant radiotherapy for 17 doses, then neoadjuvant FOLFOX or CapOx for 3 cycles, subsequently receiving APR on 2018/10/11, and then FOLFOX or CapOx for 9 cycles (to 2019-05) at TSGH in 2018 with lung metastases.
  • Malignant neoplasm of colon, unspecified
  • Chronic viral hepatitis B without delta-agent
  • Chronic kidney disease, stage 5
  • Hyperuricemia
  • hypertension
  • Constipation
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Hypertension for years with drug control,
  • CKD stage 5,
  • colorectal cancer s/p operation on 2018 and 2019,
  • Right ureteral stricture with hydronephrosis s/p D-J since 2020.
    • 3-6 months to replace the DBJ regularly
    • Last changed right DBJ in June (at TSGH)

[allergy]

  • penicillin

[family history]

  • Mother had hypertension and diabetes.
  • There is no family history of cancer, mental diseases or asthma.

[exam findings]

  • 2023-03-21 CT - abdomen
    • WITHOUT contrast enhancement CT of abdomen - whole:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder.
      • S/P double J catheter drainage, right side.
      • S/P PCN catheter drainage, left side.
      • Presence of gallbladder stones.
      • R/O liver cysts, up to 4.7cm in left lobe.
      • Bilateral lung tumors, stationary.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • Impression:
      • S/P colostomy, presence of ventral herniation.
      • Soft tissue tumor in presacral region with urinary bladder wall involvement.
      • Hyperdensity in the urinary bladder, hematoma? or tumor.
      • S/P double J catheter drainage, right side. S/P PCN catheter drainage, left side.
      • GB stone.
      • R/O liver cysts.
      • Bilateral lung tumors, stationary. Suspected lung metastasis.
  • 2023-02-14 KUB
    • S/P double J catheter insertion in place, right side.
    • S/P PCN catheter drainage, left side.
    • Lumbar spondylosis.
    • Non-specific bowel gas pattern.
    • Calcifications in the pelvic cavity, could be due to phleboliths.
  • 2023-02-13 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-02-01 Nasopharyngoscopy
    • smooth nasopharynx,oropharynx, hypopharynx
    • pale and boggy inf. turbinate, with clear mucus, erosion wound over inferior turbinate and nasal septum
    • intact ear drum with cerumen, s/p removal
  • 2022-10-31, -10-06, -09-22 SONO - kidney
    • Bilateral hydronephrosis
  • 2022-10-24, -10-19 CXR
    • Atherosclerotic change of aortic arch
    • Few nodular opacity projecting in both lower lung are noted that are c/w metastases after correlate with CT.
  • 2022-10-19 CXR
    • Septal infarct, age undetermined
  • 2022-09-20 All-RAS + BRAF mutations assay
    • All-RAS mutations assay
      • Detection range
        • KRAS codon 12, 13, 59, 61, 117, 146
        • NRAS codon 12, 13, 59, 61, 117, 146
      • Results
        • There was no variant detected in the KRAS/NRAS gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • BRAF mutations assay
      • Detection range
        • BRAF codon 600
      • Results
        • There was no variant detected in the BRAF gene.
      • Interpretation
        • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
  • 2022-09-15 PET scan
    • Glucose hypermetabolism in the posterior lower pelvic region, compatible with a metastatic lesion.
    • A glucose hypermetabolic lesion in the lower lobe of left lung, compatible with lung metastasis.
    • Two mild glucose hypermetabolic lesions in the right lung. Metastatic lesions can not be ruled out. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the lower portion of the esophagus. The nature is to be determined (inflammation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2022-09-14 Tc-99m MDP bone scan
    • Faint hot spots in both rib cages, and increased activity in bilateral pubic bones, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
    • Suspected benign lesions in the mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, S-I joints, and hips.
  • 2022-09-14 Bladder Sonography
    • PVR (post-void residual volume) 16.79 ml
  • 2022-09-13 PD-L1 (22C3)
    • Combined Positive Score (CPS) category: CPS >= 1 and < 10
    • Combined Positive Score (CPS): 2
  • 2022-09-13 PD-L1 (SP142)
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absent (TC = 0%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: 10% Immune cells (IC= 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC):
        • The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC):
        • The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-09-13 PD-L1 (IHC)
    • Result:
      • Tumor cell (TC) staining assessment: 0%
      • Combined Positive Score (CPS) assessment: 0.1
  • 2022-09-12 CT - abdomen
    • S/P colostomy with incisional hernia and small bowel ileus.
    • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
    • Lung metastases.
  • 2022-09-09 Body fluid cytology - urine
    • DIAGNOSIS: atypia;
    • GROSS DESCRIPTION: 15 ml turbid clear
    • MICROSCOPIC DESCRIPTION: numerous neutrophils and many atypical urothelial cells present. Further work up, including biopsy or tumor excision, may be considered.
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Urianry bladder, posterior wall, left, TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of seven small pieces of gray-brown soft tissue, labeled “bladder tumor, left posterior wall”, measuring up to 0.4 x 0.3 x 0.1 cm. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arranged in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades subepithelial connective tissue
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin (extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma is most likely
  • 2022-09-08 Patho - urinary bladder TUR
    • PATHOLOGIC DIAGNOSIS
      • Prostatic urethra, TURBT — Adenocarcinoma, enteric type, favors metastatic colonic carcinoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of multiple small pieces of gray-brown soft tissue, labeled “prostatic urethra”, measuring 2.0 x 1.5 x 0.4 cm in aggregate. All for sections.
    • MICROSCOPIC EXAMINATION
      • Histologic type: Adenocarcinoma, enteric type, composed of columnar to cuboidal tumor cells, arragned in tubular, papillary and cribriform patterns. Tumor necrosis and neutrophil infiltration are present
      • Histologic grade: Moderately differentiated
      • Tumor configuration: Papillary
      • Muscularis propria: Present
      • Lymphovascular invasion: Not identified
      • Microscopic tumor extension: Tumor invades muscularis propria
      • IHC: CK7(-), CK20(+), GATA3(-), CDX2(+), and B-catenin(extensive membranous and cytoplasmic expression, only few tumor cells show nuclear staining)
      • Comment: According to histology and immunophenotypes, metastatic colonic adenocarcinoma most likely
  • 2022-09-01 SONO - nephrology
    • Bilateral hydronephrosis with hydroureter, mild to moderate degree. (right kidney is more prominent)
    • Right chronic parenchymal renal disease.
    • Double J catheter in situ, right kidney.
    • Urinary retention, suspected neurogenic bladder.
    • Gall bladder stones.
  • 2022-09-01 Bronchial Dilator Test
    • normal, FEV1/FVC = 81%, FVC = 93%, FEV1 = 95%
    • without significant reversibility
  • 2022-08-26 CT - lung/mediastinum/pleura
    • Findings
      • Chest:
        • Ground glass nodule at posterior segment of right upper lobe up to 0.47cm in largest dimension is found.
        • One spiculated nodule at subpleural space of right middle lobe up to 0.88cm in largest dimension is found. Another lobulated nodule at left lower lobe up to 1.9cm is found. Lung meta is favored.
        • No evidence of bilateral pleural effusion.
        • Calcified coronary arteries is found.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • Bulging renal tumor at left side up to 2.83cm in largest dimension. Nature?
        • The spleen, liver, pancreas and adrenals are intact.
    • Imp:
      • Right upper lobe ground glass nodule, suggest follow up.
      • Right middle lobe and left lower lobe nodules, lung meta is favored.
      • Left renal tumor.
  • 2022-08-25 CXR
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • Subtle nodular opacity over Lt retrocardiac lower lobe

[consultation]

  • 2022-09-13 Colorectal Surgery
    • Q
      • For Ventral hernia with intestines herniation and ileus
      • Colon cancer s/p operation on 2018 and 2019 at Tri-Service General Hospital (APR and hemicolectomy?)
      • Abdomen CT (20220912) showed parastomal hernia and lung metastases.
      • The patient is a case of bilateral hydronephrosis, was admitted for surgery of URS.
      • At admission, he accepted antibiotics with flumarin therapy due to urine culture (2022-09-01) showed Klebsiella pneumoniae. Preoperative evaluation and examination were done. Anemia (HGB: 7.9) was found and BT LPRBC 2U. The same day, PPI was given due to vomiting multiple times also found and the vomit showed coffee. Consultation Nephrology for renal function impairment (BUN 124 mg/dL, Cr 8.52->10.36mg/dL).
      • Post TURBT, Left PCN and right URS on 2022-09-08. After surgery, abdomrn fullness also found and KUB showed focal small bowel ileus. Due to no drainage from the left PCN, antegrade pyelography (2022-09-09) was done and which showed dislodgement of the pigtail over left side; Ventral hernia with intestines herniation is found. Ileus is also noted. Therefore, left PCN re-insertion was done on 20220909.
      • He complained small amount of vomiting per day. Abdomen distention still was noticed. Abdomen CT showed parastomal hernia and lung metastases.
      • We need your help for further evaluation and management. Thanks for you.
    • A
      • O:
        • Abdomen: soft, parastomal hernia(+), no tenderness, no distended or rigidity
        • Colostomy: pass flatus or stool(+)
        • TURBT — Adenocarcinoma, enteric type, in favor of colorectal origin
        • 20220912 CT
          • S/P colostomy with incisional hernia and small bowel ileus.
          • Increased soft tissue in pelvic cavity. S/P right side double J catheter insertion. S/P left PCN. Some hematoma in left perirenal region.
          • Lung metastases.
      • A:
        • Para-stomal hernia, without bowel incarceration or strangulation
        • Favor local recurrence of rectal adenocarcinoma in low pelvic region
      • P:
        • Please check CEA, and arrange PET scan for more cancer evaluation
        • We would like to follow this patient and make decision for further management
  • 2022-09-08 Nephrology
    • A
      • S
        • This 66 years old male patient had underlying history of hypertension, CKD stage 5 and colon cancer s/p op and right hydronephrosis s/p DJ since 2020.
        • Consult for renal function impairment
      • O
        • Lab data:
          • Na: 132, K:4.2, albumin: 4.5
          • WBC: 9.49, Hb: 7.9, Plt: 320
          • BUN: 124, cre: 8.52 -> 10.36
        • Renal echo (20220901): bilateral hydronephrosis with hydroureter (DJ in right kidney), distended urinary bladder with urine retention
        • U/O: 652ml under foley
      • Assessment
        • Acute kidney injury on CKD stage 5, suspect post renal with bilateral hydroneophrosis and hydroureter
      • Suggestion
        • Keep Foley patent, record U/O and BW qd.
        • DC exforge, if BP is high, you may add norvasc
        • Give Recormon 500U sc qW for renal anemia
        • Follow up BUN, cre, Na, K, Ca, P, CO2 or VBG
      • Consider HD if refractory hyperkalemia, metabolic acidosis or pulmonary edema is noted.

[chemotherapy]

  • 2023-04-17 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-22 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-03-03 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2023-01-16 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug + NS 250mL
  • 2022-12-28 - irinotecan 80mg/m2 100mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-30 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-11-08 - irinotecan 50mg/m2 80mg D5W 250mL 90min + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 0.5mg SC + palonosetron 250ug
  • 2022-10-21 - leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1750mg NS 500mL 24hr D1-2 (FOLFIRI without Iri)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-09 - mitomycin-c 30mg/m2 30mg 1hr BI (bladder irrigation)

==========

2023-04-17

  • The patient’s renal function appears to be declining recently, which should be noted.
    • 2023-04-17 Creatinine 2.59 mg/dL
    • 2023-04-06 Creatinine 2.50 mg/dL
    • 2023-03-16 Creatinine 2.07 mg/dL
    • 2023-04-17 eGFR 26.50
    • 2023-04-06 eGFR 27.60
    • 2023-03-16 eGFR 34.32
    • 2023-04-17 BUN 49 mg/dL
    • 2023-04-06 BUN 38 mg/dL
    • 2023-03-16 BUN 35 mg/dL
  • The patient has undergone 7 blood transfusions since September 2022, and elevated ferritin levels of 596 and 545 ng/mL were observed in the last quarter of 2022. Kentamin (B1, B6, B12) has been administered, and the patient’s MCV, MCH, and MCHC levels are normal as of 2023-04-17, making iron deficiency less likely. It is advised to reassess the patient’s iron storage before determining if iron supplements are necessary. Currently, Foliromin (ferrous sodium citrate) is prescribed.

2023-03-22

  • This patient has CKD stage IIIb-IV (eGFR 15-44) and has not undergone dialysis. The patient has received 5 blood transfusions since September of last year and 1 in March of this year. Updated lab results from 2023-03-16 show normal MCV, MCH, and MCHC, but a decreased HGB level of 9.7g/dL, suggesting that iron-deficiency anemia is less likely. The patient’s lab history indicates high ferritin levels of 596 and 545 ng/mL in the last quarter of 2022. The current prescription includes Foliromin (ferrous sodium citrate). It is recommended to assess the patient’s iron storage to determine if iron supplementation is necessary.
  • In accordance with the current National Health Insurance medication reimbursement regulations, EPO - hu-erythropoietin such as Eprex and Recormon) and darbepoetin alfa (such as Aranesp) can be used for chemotherapy-related anemia in cancer patients with solid tumors who have symptomatic anemia and Hb<8 gm/dL. And the regulation requires that EPO treatment should not be used for cancer patients who are expected to have reasonable and sufficient survival time, including curative and expected adjuvant chemotherapy.

2023-01-17

  • His blood lab data indicated that his ferritin level increased by over 30% in less than 20 days after taking iron supplements from time to time.

    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-11-22 Ferritin 454.2 ng/mL
  • High ferritin levels suggest an excess of iron or an acute inflammatory reaction in which ferritin is mobilized without excess iron. Ferritin can be used as an indicator of iron overload disorders, such as hemochromatosis or hemosiderosis. Ferritin can increase the liver proinflammatory mediators IL-1b, iNOS, RANTES, IkappaB alpha, and ICAM1. As ferritin is also an acute-phase reactant, it is often elevated in various diseases. A normal C-reactive protein (CRP) can be used to exclude elevated ferritin caused by acute phase reactions. However, our HIS5 does not contain simultaneous data on ferritin levels and CRP levels.

  • As the body content of iron (iron burden) increases beyond that needed for normal production of red blood cells, muscle cells, and iron-containing enzymes, the plasma iron-binding protein transferrin becomes saturated, eventually exceeding its capacity and resulting in binding of iron to other proteins and molecules, including albumin, citrate, acetate, and others. This iron is referred to as non-transferrin-bound iron (NTBI); it begins to appear once the transferrin saturation exceeds 35 percent and rises significantly with transferrin saturation above 70 percent. NTBI is taken up by cells that have active uptake mechanisms. This includes parenchymal cells of the liver, heart, and endocrine organs. In these affected organs, excess iron can chemically interact with hydrogen peroxide. These reactive oxygen species in turn can cause tissue damage, inflammation, and fibrosis. The liver, heart, joints, and endocrine organs appear to be especially susceptible.

  • By the time clinical findings have developed (hepatic fibrosis, heart failure, cardiac conduction defect), it is likely that significant iron deposition and tissue injury has occurred. Please ensure that the patient’s iron level is checked as needed and monitor any signs of iron overload if iron supplements are continued.

2022-12-29

  • The lab data indicated that MCV, MCH, MCHC, UIBC were normal; Ferritin was exceeded; Fe (iron bound) and TIBC was low.

    • 2022-12-28 MCV 89.7 fL
    • 2022-12-28 MCH 29.2 pg
    • 2022-12-28 MCHC 32.5 g/dL
    • 2022-12-13 Ferritin 596.5 ng/mL
    • 2022-12-13 Fe (Iron-bound) 32 ug/dL
    • 2022-12-13 TIBC 189 ug/dL
    • 2022-12-13 UIBC 157 ug/dL
    • 2022-11-22 Ferritin 454.2 ng/mL
    • 2022-11-22 Fe (Iron-bound) 42 ug/dL
    • 2022-11-22 TIBC 197 ug/dL
    • 2022-11-22 UIBC 155 ug/dL
  • Normal MCV, MCH, MCHC may suggest the anemia is less likely to be caused by iron insufficiency. High ferritin may suggest iron overload. Low TIBC can suggest that there is not enough transferrin available to bind to iron, i.e., the patient has high iron level, so most of the transferrin is bound to it, which leaves very little free in his blood. Frequent blood transfusions may cause iron overload.

  • It is recommended to hold the Foliromin (ferrous sodium citrate) until the cause of the anemia is confirmed to be iron deficiency.

2022-11-28

  • 2022-11-22 lab results showed a low serum iron concentration (42 mcg/dL, normal range 60 to 150 mcg/dL), as well as a low transferrin level (TIBC 197 mcg/dL, normal range 300 to 360 mcg/dL), which resulted in a transferrin saturation level of 21% at the lower end of the normal range (20%~45%). In the meantime, ferritin levels increased (545 ng/mL, normal ranges, 30 to 200 mcg/L for women and 30 to 300 mcg/L for men, prior to the planned transfusion).
  • Inflammatory conditions in which cytokine production might lead to altered iron trafficking and decreased production of RBCs. The underlying condition could be a chronic kidney disease or a malignancy.
  • Upon discovery of a serum ferritin level exceeding 1000 mcg/L, a daily dose of 14mg/kg of Jadenu (deferasirox, available at this hospital) with regular serum creatinine monitoring might also be an optional add-on.

2022-11-09

  • Insufficient renal function, 2022-11-02 serum Cre was 2.42mg/dL, BUN was 34mg/dL, and eGFR was 28.66. The active prescription has been well-adjusted to reflect the patient’s renal function.
  • The patient is being administered irinotecan (at a lower dose of 50mg/m2) for the first time. Irinotecan can cause early and late forms of diarrhea. Early diarrhea may be accompanied by cholinergic symptoms which has been dealed with prescribed subcutaneous premedication atropine. In the event of late diarrhea, loperamide should be administered as soon as possible. Please monitor the patient for signs of diarrhea.

2022-10-20

  • This is a patient with rectal cancer who underwent an abdominoperineal resection and a T-colostomy and treated with FOLFOX/CapeOx at Tri-Service General Hospital in 2018.
  • 2022-09-20 All-RAS and BRAF assay showed no detected variant in the KRAS/NRAS/BRAF gene. Treatment with anti-EGFR antibodies might be beneficial. The use of encorafenib would not be preferred.
  • The level of PD-L1 expression was low (outsourced lab results in late Sep 2022). This might limit the use of immunotherapy methods that involve PD-L1.
  • FOLFOX/CapeOx has previously been used, so FOLFIRI (+ bevacizumab or + cetuximab or panitumumab) might be considered as a possible treatment option.
  • Neither fluorouracil nor leucovorin nor irinotecan dosage adjustments are provided in the manufacturer’s labeling for the FOLFIRI regimen in patients with impaired kidney function (2022-10-20 Cre 2.54 mg/dL, eGFR 27.10).

701447197

230417

[diagnosis] - 2023-04-06 admission note

  • Infectious gastroenteritis and colitis, unspecified
  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Cardiomegaly
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Diffuse large B-cell lymphoma, spleen
  • Hypertensive heart disease without heart failure
  • Chronic viral hepatitis B without delta-agent

[past history] - 2023-04-06 admission note

  • Hypertension for 15 years with drug control
  • Hyperlipidemia for 15 years
  • Gout for 15 years        
  • COVID-19 positive on 2022/10    
  • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys) , Lugano stage IV, IPI score2 s/p chemotheraphy
  • Multiple myeloma, IgG kappa type, ISS stage II            

[allergy]

  • Mobic 7.5mg/tab (meloxicam): skin rash

[family history]

  • No known congenital or systemic disease.
  • Family history is unremarkable.
  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-04-06 CXR
    • Ground glass opacity in RLL.
    • Cardiomegaly.
  • 2023-03-28 PET
    • The FDG PET findings are compatible with lymphoma in bilateral pulmonary hilar and mediastinal lymph nodes, bilateral lungs, spleen and bone marrow (stage IV). However, in comparison with the previous study on 2022/08/17, the previous glucose hypermetabolic lesions are either less evident or disappeared, suggesting partial response to the therapy.
    • Increased FDG accumulation in bilateral renal pelvis. Physiological FDG accumulation is more likely.
  • 2023-03-27 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-17 CT - chest
    • Indication:
      • Triple cancer, synchronous (lymphoma, myeloma, bladder ca)
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugan 0 stage IV, IPI 2.2: Multiple myeloma, IgG kappa type, ISS stage II
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Diffuse nodular lesiona are found at bilateral lung fields (n>10). In comparison with CT dated on 2022-12-05, the numbers are decreased.
        • Small lymph nodes are found at right paratracheal and AP window.
        • Patent airway is found.
        • Mild bilateral pleural effusion is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found.
        • Low density lesion at spleen is found. Stable.
        • The spleen, liver, pancreas and adrenals are intact.
    • IMp:
      • Bilateral lung nodules, decresaed in numbers
      • Mediastinal small lymph nodes
  • 2023-02-19, -02-03, -01-19, -01-06 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are few nodular opacities projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-01-06 ECG
    • Atrial fibrillation
    • Inferior infarct, age undetermined
    • Abnormal ECG
  • 2022-12-28 Patho - urinary bladder TUR
    • Urinary bladder, left lateral wall, TUR-BT — Urothelial carcinoma (high grade), focally invading muscularis prorpia.
    • Section of the larger piece and the smaller piece show urothelial carcinoma composed of papillary structures lined by urothelial cells with enlarged, hyperchromatic nuclei, high N/C ratio and mitoses. The larger piece shows focal invasion of muscularis propria. The smaller piece shows no muscularis propria.
    • IHC stains: GATA-3 (+), SMA highlight muscularis propria in the larger tissue. The smaller tissue shows no muscularis propria.
  • 2022-12-27 ECG
    • Atrial flutter with variable A-V block
    • Possible Inferior infarct , age undetermined
  • 2022-12-27 CXR
    • Fibrotic infiltrates in right upper lung.
    • Consolidation in right lower lung.
    • Blunting of costophrenic angle, left side, could be due to pleural effusion.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-12-05 CT - abdomen
    • Stomach diffuse large B cell lymphoma with multiple metastasis (bilateral lungs, spleen, both kidneys), Lugano stage IV, IPI 2
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Abdominal CT with and without enhancement revealed:
      • Bilateral renal cysts are found.
      • The liver, pancreas and adrenals are intact.
      • Irregular shaped low density change at spleen up to 3.06x2.6cm is found.
      • There is no evidence of paraarotic LAPs.
      • There is no ascites accumulation at abdominal cavity.
      • One filling defect at lateral wall of the bladder base up to 1.2cm in largest dimension. Bladder uroepithelial cancer is considered. In comparison with CT dated on 2022-08-31,
      • The GB is well distended without soft tissue lesion
      • Small lymph nodes are found at paraaortic region. In regression.
      • Visible chest
        • Cardiomegaly is noted.
        • Nodular leisons at both lungs is found. In regression.
        • Increased pulmonary vasculature is found.
        • NOn-specific lymph nodes are found in the mediastinum.
    • Imp:
      • Mediastinal lymphadenopathy and splenic and lung involvement. The lung involvement regressed.
      • Bladder tumor, suspected uroepithelial cancer.
    • Imaging Report Form for Urinary Bladder Carcinoma
      • Impression (Imaging stage) : T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-12-27, -11-25, -11-18 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Otherwise, there is no significant abnormality of the chest. (Note that ground-glass lesion, small nodule or retrocardiac lesion might be missed on plain chest radiography.)
  • 2022-10-26 CXR
    • Cardiomegaly.
    • Multiple nodules at bil. lungs.
  • 2022-10-26 Panendoscopy
    • Diagnosis
      • Gastric ulcers, multiple, antrum, low and mid body
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
    • Suggestion
      • please search for other possible bleeder.
  • 2022-10-21, -10-11, -09-14 CXR
    • There are multiple nodular opacity projecting in both lung that may be lymphoma. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-09-28 Panendoscopy
    • Diagnosis
      • Gastric ulcers, Forrest classification type IIa, GC site of middle body, s/p hemostasis with APC
      • Gastric ulcers, multiple, GC/PW site of antrum, AW site of low body and middle body
      • Reflux esophagitis LA Classification grade A
      • Esophageal hematoma, EG junction, suspect NG tube friction related
      • Superficial gastritis
    • Suggestion
      • High dose PPI use
      • Consider second-look endoscopy if ACITVE BLEEDING sign or PERESISTED Tarry stool.
  • 2022-08-31 CT - abdomen
    • Findings
      • There are bilateral inguinal hernia with small bowel and omentum fat herniation on right side and omenum fat on left side.
        • In addition, fatty stranding and fluid collection in right inguinal hernia sac is suspected that may be incaceration? please correlate with clinical condition.
      • There are multiple soft tissue lesions on both lung that may be lymphoma?
      • There is a low density mass measuring 4.5 cm in the spleen that may be lymphoma involvement.
      • There are multiple enlarged nodes in gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space that may be lymphoma.
      • There is a soft tissue mass measuring 2 cm in left lateral wall of the urinary bladder. Please correlate with cystoscopy to R/O lymphoma or urothelial cell carcinoma?
      • There are several renal cysts on both kidney and the largest one measuring 4.3 cm in size at right upper pole.
    • Imp
      • Incaceration of right inguinal hernia is highly suspected.
  • 2022-08-28 CXR
    • There are multiple nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • Enlargement of cardiac silhouette.
  • 2022-08-25 SONO - nephrology
    • There are two mass lesions 2.34cm and 1.51cm in the lateral and inferior wall of urinary bladder, suspected bladder tumors.
    • Bilateral renal cysts.
    • Parenchymal renal disease.
  • 2022-08-18 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with plasma cell myeloma and free from lymphoma involvement
    • Microscopic Examination
      • Hypercellularity of bone marrow for his age
      • Marked Increased plasma cells, more than 90%, highlights by CD138 and CD117 IHC stains and favor kappa light chain restriction
      • M/E ratio about 1/3 with marked hypoplasia of both series highlights by CD71 and MPO IHC
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation, highlights by CD61 IHC
      • no increase of blast, highlights by CD34 IHC
      • No B-cell lymphoma involvement, CD20 IHC shows scant and scatter positive
      • According to all above histopathologic findings, it is compatible with plasma cell myeloma and free from lymphoma involvement. Clinical and laboratory correlation is advised.
  • 2022-08-17 Whole body PET scan
    • Glucose hypermetabolic lesions in bilateral pulmonary hilar and mediastinal lymph nodes, lymph nodes in the upper to mid-abdomen, a lymph node in the lateral aspect of the left upper thigh region, bilateral lungs, stomach, spleen, and both kidneys (Deauville score 5 in all above-mentioned lesions), highly suspected lymphoma with diffuse involvement of more extralymphatic organs with associated lymph node involvement.
    • Glucose hypermetabolism in the L2 spine (Deauville score 4) and in the right lobe of the thyroid gland (Deauville score 5), the nature is to be determined, suggesting further investigation.
    • Lymphoma, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-08-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (126 - 39) / 126 = 69.05%
      • M-mode (Teichholz) = 69
    • Mild septal hypertrophy with Gr II LV diastolic dysfunction and impaired RV relaxation; severely dilated LA.
    • Mildly dilated LV with normal LV and RV systolic function.
    • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
    • Dilated proximal ascending aorta (46mm) with mild calcification.
  • 2022-08-15 CXR
    • Nodular lesions in both lung fields

[consultation]

  • 2022-09-27 Gastroenterology
    • Q
      • vomiting blood and bloody stool today
      • genrenal weakness was noted
      • no dizziness, no dyspnea, no abdominal pain
      • PH: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys) , Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
      • NKA
    • A
      • S
        • 71M
        • Phx: Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2, anemia, Gastric ulcer, HTN
        • CC: Vomiting blood and bloody stool today
        • NPO: 20220927 12:00
      • O
        • BP: 103/62, HR:81, Conscious clear, under N/C, SpO2: 100
        • Hb: 7(9/26)-> 6.3(9/27)
        • PLT: 136(9/27)
        • INR:1.27
      • A
        • Hematemesis, suspect upper GI bleeding
      • P
        • EGD is indicated for this patient, but NPO duration is not adequate, give high dose PPI first. We will arrange EGD tomorrow
        • well inform-consent to the patient and the family, including the indication, the risks (aspiration pneumonia/respiratory failure, arrhythmias/cardiovascular events, organ perforation, etc.), and the alternatives (conservative treatment, etc.)
        • if the patient and the family all understand the EGD intervention, would take the risk, and sign the permit for EGD, we would arrange EGD
        • Arrange adequate blood transfusion and fluid resuscitation for fear of hypovolemic shock
  • 2022-09-21 Urology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2 and multiple myeloma.
      • Due to bladder tumor noted and sometimes has hernia bulge, so we need your help for assessment. Thanks!
    • A
      • This patient has diffuse large B cell lymphoma and multiple myeloma.
      • This time he was admitted for 2nd R-COP chemotherapy.
      • CT: 2cm bladder tumor at left lateral; hernia: 20220831 incarceration, GS was consulted and manual reduction was performed
      • impression: 1. bladder tumor 2. right inguinal hernia suspected incarceration
      • Plan:
        • arrange scrotal echo for suspected incarceration
        • arrange TURBT and hernia repair, time to be determined
  • 2022-09-21 Rheumatology
    • Q
      • The 71 y/o man has Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Due to gouty arthritis over left knee, so we need your help for assessment. Thanks!
    • A
      • S
        • History review & physical examination were performed. Patient was admitted due to Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
        • I was consulted for Acute L’t knee arthritis. Meanwhile, allergic skin rash was also noted (mobic or uricon-induced?).
      • O
        • RIA condition:
          • Previous GA Hx(+)
          • UA:4.5 -> 7.6 -> 4.7
          • ANA/RF/anti-CCP(-)
          • ALT/Cre:25/0.87
        • erythematous swelling, L’t knee (less effusion than week ago).
      • Suggestion:
        • Treatment as current your expert’s management.
        • Please take L’t knee x-ray, add colchicine 1#BID (if diarrhea, taper to 1#QD), acetaminophen 1#BID & decan 4mg IVD BID x 2-3 days.
        • When recovered from acute stage, please keep colchicine 1#QD & feburic 1#QD.
        • Inform me again if need.

[SOAP]

  • 2022-10-11 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20220905
      • IgG type MM stage 2
      • Diffuse large B cell lymphoma with lung involved stage 4
      • use R-COP first
  • 2022-10-04 Hemato-Oncology
    • Multidisciplinary Cancer Team Meeting Conclusion, Meeting Date: 20230213
      • Hold off on chemotherapy mR-CHOP for now,
      • First complete bladder cancer CCRT.
    • Multidisciplinary Cancer Team Meeting Conclusion> Meeting Date, 20220912
      • Synchronous DLBCL and myeloma treatment approach cannot wait due to stage 4 diffuse large B cell lymphoma, so R-COP has been used. Treatment strategy will be determined after review.
  • 2022-09-09 Hemato-Oncology
    • Multi-disciplinary team meeting conclusion for cancer patients, Meeting date: 20220829
      • Diffuse large B cell lymphoma stage 4
      • Multiple myeloma IgG kappa ISS stage 2
      • Bladder tumor nature
    • Assessment
      • Stomach diffuse large B cell lymphoma with multiple metastasis (bil. lungs, spleen, both kindeys), Lugona stage IV, IPI 2.
      • Multiple myeloma, IgG kappa type, ISS stage II
      • Gastrointestinal hemorrhage, unspecified
      • Anemia
      • Postive of anti-HBc
      • Port-a implement on 2022/08/18
      • Dilated aortic root and aortic valve sclerosis with moderate AR; mild MR; mild to moderate PR.
      • Agranulocytosis secondary to cancer chemotherapy
      • Neutropenic fever
      • Acinetobacter pittii bacteremia
      • Gouty arthritis attack over left knee
      • Groin Hernia
      • Bladder tumor natrure?

[surgical operation]

  • 2022-12-28
    • Surgery
      • Laparoscopic hernia repair, bilateral
      • Laser TUR-BT
    • Finding
      • TEP OP Finding:
        • Main defect:
          • Right
          • type: primary; M, L
          • Size: II
          • Grading: 2
          • incarceration, adhesion
          • Sac contents: omentum
        • Contralateral occult defect:
          • type: M
          • Size: II
        • Trocar number: 3
        • TEP approach
        • Mesh type: heavy weight
        • Mesh size: Left 13x15 cm; Right 12x15 cm
        • Mesh fixation: absorbatack
    • TUR-BT finding:
      • A cauliflower-like tumor at left lateral wall
      • A diverticulum at right posterior wall
      • Bilateral UO with clear efflux
    • Risk evaluation:
      • Tumor size: <=3cm (V), >3cm()
      • Multifocality: Multifocal(), solitary(V)
      • Recurrence within 1 year: Yes(), No(V)

[chemoimmunotherapy]

  • 2023-03-30 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + gemcitabine 1000mg/m2 1600mg NS 100mL 30min D2 + oxaliplatin 100mg/m2 150mg D5W 250mL 2hr D2 (R-GemOx)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-02-21 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-27 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2023-01-13 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2023-01-06 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-29 - mitomycin-C 30mg/m2 30mg ST BI 1hr (MMC)

  • 2022-12-05 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-11-14 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-10-13 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-09-22 - rituximab 375mg/m2 600mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + liposome doxorubicin 35mg/m2 57mg D5W 250mL 1hr D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 45mg BID PO D2-6 (R-CHOP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2
  • 2022-08-19 - rituximab 375mg/m2 630mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1200mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-COP)

    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + granisetron 2mg D2

==========

2023-04-17

  • Tramadol has been associated with vomiting (5% to 10%). ref: UpToDate.

  • Opioid administration can induce nausea or vomiting; the pathophysiology includes peripheral inhibitory effects of opioids on gastrointestinal transit or stimulation of the pyloric sphincter, delaying gastric emptying or causing gastroparesis. However, the primary mechanism of opioid-induced nausea and vomiting is central, with direct stimulation of the chemoreceptor trigger zone in the area postrema in the floor of the fourth ventricle. The clinical efficacy of 5-HT3 antagonists in opioid-induced emesis supports the hypothesis that stimulation of the area postrema may also be relevant to morphine-induced emesis in humans. The addition of a prokinetic (e.g., metoclopramide), prochlorperazine, or a 5-HT3 antagonist (-setron) to the opiate regimen is beneficial. ref: Opioids in Gastroenterology: Treating Adverse Effects and Creating Therapeutic Benefits. Clin Gastroenterol Hepatol. 2017;15(9):1338-1349. doi:10.1016/j.cgh.2017.05.014

  • Roumin (prochlorperazine maleate) has been prescribed properly. There is no medication reconciliation issue with the active prescription.

2023-04-07

  • On both 2023-01-06 and 2022-12-27, the patient’s ECG showed atrial fibrillation (AF), which is a significant contributor to morbidity and mortality in adults. Additionally, a transthoracic echocardiogram from 2022-08-16 indicated severe dilation of the left atrium. While ischemic stroke resulting from embolization of left atrial thrombi is the most common manifestation of embolization, embolization to other sites in the systemic circulation (as well as the pulmonary circulation from right atrial thrombi) can also occur, albeit less frequently recognized.
  • The patient’s available PLT count data in 2023 ranged from 70K to 245K /uL, touching the upper limit of grade 2 thrombocytopenia (CTCAE v5.0, grade 2: 50K~75K/uL) a few times. Due to the unstable PLT count, LMWH may be preferred over direct oral anticoagulants (DOACs). ref: EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer. Hemasphere. 2022;6(8):e750. Published 2022 Jul 13. doi:10.1097/HS9.0000000000000750

2022-10-27

  • Severe, including fatal, mucocutaneous reactions can occur in patients receiving rituximab products. Unless there is no concern for gastrointestinal bleeding, it is recommended to hold R-CHOP therapy for a period of time.

701473049

230417

[diagnosis] - 2023-04-14 admission note

  • T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB s/p chemotherapy with FOLFIRI from 2023/03/29~
  • Anemia due to antineoplastic chemotherapy
  • Chronic obstructive pulmonary disease, unspecified
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypokalemia

[past history]

  • Hypertension for 10 years without control

[allergy]

  • NKDA     

[family history]

  • Mother with HTN
  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-27 CXR
    • There are multiple nodular opacities projecting in both lung that are c/w metastases after correlate with CT.
    • Borderline cardiomegaly
  • 2023-03-25 CT - abdomen
    • History and indication: T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP.
      • Multiple lung tumors.
      • Multple bony metastases.
      • R/O left renal angiomyolipoma (1.0cm).
      • Normal appearance of liver, spleen, pancreas, adrenals.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2023-03-24 Patho - colorectal polyp
    • Colon tumor, T-colon, biopsy — Compatible with adenocarcinoma, see description
    • Microscopically, the sections show a picture of almost benign colonic mucosa with scant tumor cells arranged in glandular pattern and desmoplasia. According to clinical information and histopathologic fiinding, it is compatible with adenocarcinoma.
  • 2023-03-23 Colonoscopy
    • Suspected T-colon cancer with partial obstruction s/p biopsy
  • 2023-03-08 Patho - lung transbronchial biopsy
    • Lung, ? side, CT-guide biopsy — in favor of metastatic adenocarcinoma from colorectal origin
    • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with marked tumor necrosis.
    • The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), TTF-1(-), and Napsin A(-). The results are in favor of metastatic adenocarcinoma from colorectal origin. Please correlate with the clinical presentation and image study.
  • 2023-03-07 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-03-07 CT - chest
    • Indication: lung ca
    • MDCT (128-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: a large tumor lesion (60 mm in longest dimension, polylobular borders) over lingula.
        • numerous randomly distributed pulmonary nodules/masses of varying sizes in both lungs due to metastases.
        • centrilobular nodular and branching opacities at LUL.
      • Mediastinum and hila: enlarged LNs in the visceral space and left anterior prevascular space and Lt hilum
      • Aorta: normal caliber, minimal atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: dilated LA and concentric LVH. mild calcified mitral annulus
      • Pleura: small Rt-sided effusion with thickening.
      • Chest wall and visible lower neck: infiltrative soft-tissue mass at Rt middle posterior chest wall with destruction pof 8th rib and adjacent vertebra.
      • Visible abdominal contents: mild dilatation of CHD and CBD as well as Lt IHDs.
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. no enlarged lymph node. no ascites.
        • bilateral commonl iliac arteries.
    • Impression:
      • lingula ca T4N3M1a
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Voltage criteria for left ventricular hypertrophy
    • Abnormal ECG
  • 2023-03-05 CXR
    • Presence of multiple lung nodules/masses.

[consultation]

  • 2023-03-29 Radiation Oncology
    • Q
      • This 71-year-old man patient is a case of T-colon cancer with partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. Lower back pain developed with whole body bone scan on 2023/03/07 showede skull, multiple T- and L-spines, sternum, bilateral multiple ribs, sacrum, bilateral multiple pelvic bones, bilaterla S-I joints and left humerus multiple bone metastases. Now, for evaluate palliative radiotherapy to bone metastasis of pain control. Thank you.
    • A
      • Palliative RT is indicated. CT-simulation will be arranged on 20230406, or earlier if there is an earlier vacancy.
      • Plan to deliver 30 Gy/ 10 fx to the L-spine and pelvic bone mets. Thank you very much.

[SOAP]

  • 2023-04-02 Emergency
    • S: the patient started to diarrhea for 1 week (5 to 6 times per day) just after discharged on 20230401.
    • prescription: Smecta (dioctahedral smectite) 3mg/pk PRNQ8H for 3 days
  • 2023-03-23 Hemato-Oncology
    • O: Will on FOLFIRI with or without targeted therapy
    • P: Admission for Pelvis MRI, T spine MRI and L-S MRI and Consult RTO, Consult CS or Port-A. Then FOLFOX

[radiotherapy]

[chemotherapy]

  • 2023-04-14 - irinotecan 150mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg IVD + aprepitant 125mg PO D1-3
  • 2023-03-29 - irinotecan 120mg/m2 170mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 400mg/m2 550mg NS 100mL 10min + fluorouracil 2400mg/m2 3300mg NS 500mL 46hr (FOLFIRI Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + atropine 0.5mg SC + aprepitant 125mg PO D1-3

2023-04-17

[assessment]

  • The patient experienced diarrhea (5 to 6 times per day) immediately after discharge on 2023-04-01. Both Smecta (dioctahedral smectite) and Through (sennoside) are currently prescribed. It is suggested to confirm the patient’s bowel movement status and determine if both medications are necessary.
  • Irinotecan was increased from 120 mg to 150 mg/m2 in this second dose of the FOLFIRI regimen.
  • Hypokalemia (2.9 mmol/L) was noted on 2023-04-14 and is currently being treated with oral potassium chloride supplementation.
  • Anemia was noted prior to the patient’s first dose of FOLFIRI on 2023-03-29. A packed red blood cell (P-RBC) transfusion of 2 units was performed on 2023-04-14.
    • 2023-04-14 HGB 8.0 g/dL
    • 2023-04-02 HGB 8.9 g/dL
    • 2023-03-23 HGB 9.6 g/dL
  • There is no medication reconciliation issue with the active prescription.

2023-03-29

[assessment]

  • The patient is a senior with T-colon cancer, partial obstruction, lung and bone metastases, T4N3M1b, stage IVB. He admitted for his first cycle of FOLFIRI with a 2/3 dose of irinotecan (this time 120mg/m2, standard 180mg/m2).
  • Lab results on 2023-03-23 revealed a WBC count of 17K/uL, but no CRP or procalcitonin data were available. Please rule out any infectious symptoms.
  • The patient has a history of uncontrolled hypertension for 10 years, which requires further follow-up.

701473874

230414

[diagnosis] - 2023-04-07 admission note

  • Pancreatic head cancer with gastric and common bile duct involvement with gastric outlet obstruction and liver metastasis , cT4N1M1 stage IV; status post Roux-en-Y hepatico-Jejunosotmy and gastro-Jejunosotmy bypass and cholecsytectomy on 2023/03/27. ECOG:1
  • Encounter for adjustment and management of vascular access device with port-A insertion on 2023/04/06
  • Pancreatic head tumor with gastric and common bile duct involvement with gastric outlet obstruction and obstructive jaundice status post Percutaneous Transhepatic Cholangial Drainage on 2023/03/11
  • Hypokalemia
  • Rheumatoid arthritis history

[exam findings]

  • 2023-04-12 KUB
    • known s/p Roux-en-Y hepatico-Jejunosotmy and gastro-jejunostomy bypass and cholecsytectomy.
    • increased air in nondistended loops of small bowel over lower abdomen and pelvic
  • 2023-03-27 Patho - gallbladder (benign lesion)
    • Gallbladder, laparoscopic cholecystectomy — Chronic cholecystitis
  • 2023-03-16 Patho - pancreas biopsy
    • Labeled as “stomach pyloric wall thickening”, fine needle biopsy (B) — adenocarcinoma.
    • IHC stains: CK 19 (+), CA19-9 (+), CDX-2 (+), CK7 (+), CK20 (-). in favor of pancreato-biliary origin.
  • 2023-03-15 Endoscopic Ultrasonography, EUS
    • susp. Pancreatic IPMN main duct type s/p EUS/FNB (A)
    • Prob. gastric pyloric invasion s/p FNB (B)
    • pancreatic cystic neoplasm, tail susp. MCN type
    • Ascites, minimal
    • lymphadenopathy
  • 2023-03-10 ECG
    • Normal sinus rhythm
    • T wave abnormality, consider inferior ischemia
    • T wave abnormality, consider anterolateral ischemia
    • Prolonged QT
    • Abnormal ECG
  • 2023-03-10 CT - abdomen
    • CC:
      • Mild epigastralgia for 4 days, took medication for ulcer but jaundice noted 2 weeks, Tea color urine, clay color stool, Skin itching
      • No significant poor appetite. mild weight loss.
      • on diet, Alcohol (-) smoking (+). family hepatitis B or C history but she receive hepatitis B vaccination before.
      • PH. RA
    • Occupation: Mount Temple Services
    • Indication: biliary obstruction related jaundice was suspected.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is marked dilatation of IHDs and CHD, but small size of the gallbladder.
        • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
      • There is symmetrical wall thickening at the gastric antrum, causing marked distension of the proximal stomach that is c/w gastric outlet obstruction.
        • The differential diagnosis includes adenocarcinoma and old ulcer with deformity. Please correlate with gastroscopy.
        • In addition, there is a cystic lesion in the dorsal aspect of the stomach fundus that may be duplication cyst.
      • Several cystic lesions in the pancreatic body and tail are suspected.
        • The differential diagnosis includes pancreatic duct dilatation.
        • Please correlate with MRCP.
      • Others
        • There is no focal abnormality in the spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Cholangiocarcinoma at the CHD-CBD junction is highly suspected.
        • The differential diagnosis includes metastatic nodes in hepatoduodenal ligament and pancreatic head cancer.
        • Please correlate with tumor marker, MRCP and ERCP.
      • Stomach cancer at the antrum is highly suspected.
        • Please correlate with gastroscopy.
  • 2023-03-11 Percutaneous Transhepatic Cholangial Drainage, PTCD (drainage)
    • Dilatation of the biliary tree (by CT images).
    • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
  • 2023-03-10 Esophagogastroduodenoscopy, EGD
    • c/w tumor compression or invasion, posterior wall of antrum
    • Gastric outlet obstruction
    • duodenal ulcer, bulb
    • Possible ulcer at posterior wall of bulb or antrum
  • 2023-03-07 SONO - abdomen
    • Diagnosis
      • Suspect distal CBD tumor with biliary tract obstruction
      • Suspect pancresatic body tumor
      • Intra-abdominal cystic lesion, LUQ area
      • Gastric outlet obstruction
    • Suggestion
      • CT and EGD study.

[SOAP]

  • 2023-04-12 Hemato-Oncology
    • Refer to ER for treating BTI (Biliary Tract Infection) and then admission -> consider Abraxane (paclitaxel) plus gemcitabine (see [note] section) after infection under control

[surgical operation]

  • 2023-03-27
    • Surgery
      • Roux-en-Y hepatico-Jejunosotmy
      • GJbypass
      • cholecsytectomy
    • Finding
      • pancreatic head cancer invasion to pyloric and hepatico-duodunostomt
      • LLS liver mets with gastric anerior wall invasion

[note]

Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) for advanced pancreatic and biliary cancer 2023-04-14 https://www.uptodate.com/contents/image?imageKey=ONC%2F89668

  • Cycle length: 4 weeks.
  • Regimen
    • Nabpaclitaxel
      • 125 mg/m2 IV
      • Administer undiluted over 30 minutes.
      • Days 1, 8, and 15
    • Gemcitabine
      • 1000 mg/m2 IV
      • Dilute in 250 mL NS (concentration no greater than 40 mg/mL) and administer over 30 to 60 minutes, after nabpaclitaxel.
      • Days 1, 8, and 15

Treatment protocols for pancreatic cancer REGIMENS 2023-04-14 https://www.uptodate.com/contents/treatment-protocols-for-pancreatic-cancer

  • Adjuvant setting
    • Adjuvant gemcitabine
    • Adjuvant gemcitabine plus capecitabine
    • Modified FOLFIRINOX
  • Locally advanced/metastatic disease
    • Gemcitabine monotherapy
    • Gemcitabine plus nanoparticle albumin-bound paclitaxel (nabpaclitaxel) (see above for components)
    • Gemcitabine plus capecitabine
    • Gemcitabine plus cisplatin
    • FOLFIRINOX (fluorouracil plus leucovorin, irinotecan, and oxaliplatin)
    • Modified FOLFIRINOX
    • Modified FOLFOX6 (fluorouracil plus leucovorin and oxaliplatin)
    • Liposomal irinotecan and 5-FU for metastatic pancreatic cancer
    • Pembrolizumab monotherapy for microsatellite-unstable (mismatch repair-deficient) advanced cancer

[assessment]

  • Brosym (cefoperazone + sulbactam) 4g IVD Q12H has been prescribed fot the patient’s BTI.

  • It is considered to use nab-paclitaxel plus gemcitabine to treat the patient after her BTI is controlled. Please ensure that the ANC is >1500/uL and the platelet count is >100K/uL prior to administering the regimen. Sepsis has occurred in patients with or without neutropenia (risk factors are biliary obstruction or presence of a biliary stent). During the treatment, it is recommended to initiate broad-spectrum antibiotics in the presence of fever, even if not neutropenic. Interrupt nabpaclitaxel and gemcitabine until sepsis resolves and, if neutropenic, until neutrophils are at least 1500/uL, then resume at lower doses.

  • No medication reconciliation issues were noted for the patient.

700553084

230413

{not completed}

[past history]

  • Myelofibrosis grade 1-2 disease in March 2020 with Bokey treatment.
  • Hypertension with Norvasc since 2023/03/24 due to headache with neck soreness.

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-04-13, -04-10, -04-06, -04-03, -04-01 CXR
    • hazy areas of increased opacity and reticular opacities with poor defination of vessels over Rt and Lt lungs
  • 2023-04-06 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — compatible with essential thrombocythemia with grade 3 myelofibrosis.
    • Section shows piece(s) of bone marrow with 50% cellularity and M:E ratio of approximately 2:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are increased in number.
    • IHC stains: CD117: <2%; CD34: <2 %; MPO:50 %, CD61: 25 %; CD71: 25% (of the nucleated cells).
    • Reticulin stain: marked increased amounts of reticulin.
    • Masson-Trichrome stain: marked increased in the amounts of collage fibers.
  • 2023-03-30 Bronchoscopy
    • Trachea: mid- and lower-1/3 segments was patent and the mucosa was swelling.
    • Main carina: sharp and movable on deep breathing.
    • Right bronchial trees: swelling and easy touch bleeding with dynamic collapse of lower bronchial orifices
    • Left bronchial trees:mucosa swelling and touch bleeding was found.
  • 2023-03-29 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Possible Left atrial enlargement
  • 2022-03-31 SONO
    • Findings
      • Increased echogenicity of the liver.
      • Normal appearance of gallbladder without stone.
      • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/ bowel gas.
      • Splenomegaly.
      • No evidence of pleural effusion.
      • Normal appearance of kidneys.
    • IMP:
      • Mild fatty liver.
      • Splenomegaly
  • 2020-03-05 Patho - bone marrow biopsy
    • Bone marrow, iliac, history of myeloproliferative neoplasm, JAK2 (+), biopsy — see microscopic description.
    • IHC stains: CD117: <1%, CD34: <1%, MPO: 20-30%, CD61: 30-40%, CD71: 30-40%.
    • Reticulin stain: mild to moderately increased reticulin fibers;
    • Mason-Trichrome stain: mild increase in collagen fibers.
  • 2019-02-12 SONO - spleen
    • Sonography of spleen revealed splenomegaly without nodule.
  • 2017-08-10 SONO - abdomen
    • marked splenomegaly

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • Bokey (aspirin 100mg) QD
  • 2022-09-23 Hemato-Oncology
    • Suggest bone marrow study
    • OPD follow up x 2 months
  • 2022-03-23 Hemato-Oncology
    • Neoplasm of uncertain behavior of polycythemia vera [D45]
    • Hepatitis, unspecified [K75.2]
    • IWG-MRT score 1 (intermediate-1)
    • IPSS: 1. anti-JAK2 inhibitor is not reimbursed by NHI (will be paid on 2 or higher) (202003324).
    • A: MPN wtih myelofibrosis
    • recheck abdominal sonogram
  • 2021-10-05 Hemato-Oncology
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Hepatitis, unspecified [K75.2]
  • 2017-01-19 Hemato-Oncology
    • O
      • Marked splenomegaly.
      • JAK2 mutation: present.
      • A: Myeloproliferative neoplasms, MPN
    • A
      • Neoplasm of uncertain behavior of polycythemia vera [D45]
      • Essential hypertention, unspecified [I10]
      • Hepatitis, unspecified [K75.2]
      • Gouty arthropathy [M10.00]

[assessment]

  • Triazole antifungal agents include voriconazole, posaconazole, itraconazole, and fluconazole. Fluconazole has no activity against Aspergillus spp, and itraconazole has become a second-line agent for aspergillosis. Voriconazole should be included in the antifungal regimen in most patients with invasive aspergillosis

701244841

230413

[diagnosis] - 2023-03-24 admission note

  • Malignant neoplasm of duodenum
  • Acute duodenal ulcer without hemorrhage or perforation
  • Calculus of gallbladder with chronic cholecystitis without obstruction
  • Noninfective gastroenteritis and colitis, unspecified
  • Benign neoplasm of duodenum

[past history]

Dx history: - Gout - IDA - Alzheimer’s disease - CAD - CVA

Surgery history: - C-spine compression fracture s/p over 10 years ago    

[allergy]

  • NKDA     

[family history]

Father: Liver cancer

[lab data]

  • 2023-03-15 Anti-HBc Reactive
  • 2023-03-15 Anti-HBc-Value 7.62 S/CO
  • 2023-03-15 Anti-HBs 0.30 mIU/mL
  • 2023-03-15 Anti-HCV Nonreactive
  • 2023-03-15 Anti-HCV Value 0.26 S/CO
  • 2023-03-15 HBsAg Reactive
  • 2023-03-15 HBsAg (Value) 125.62 S/CO
  • 2022-12-13 RPR/VDRL Reactive-1:2
    • ChatGPT: RPR (Rapid Plasma Reagin) and VDRL (Venereal Disease Research Laboratory) are blood tests used to screen for syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum. In this context, “reactive 1:2” means that the test has detected the presence of antibodies against syphilis in the blood at a dilution of 1:2, indicating a low level of infection. However, further confirmatory testing is necessary to determine if the individual has an active syphilis infection or if the antibodies detected are from a past infection that has been successfully treated.
  • 2022-10-20 RPR/VDRL(CSF) Non-Reactive
  • 2022-10-06 TPHA Reactive,1:640
    • ChatGPT: A TPHA (Treponema Pallidum Hemagglutination) result of 1:640 is a high titer and indicates a strong reaction to Treponema pallidum, the bacterium that causes syphilis. This can indicate an active syphilis infection, a previous infection that has been treated, or a false positive result. Further testing and evaluation by a healthcare provider is necessary to determine the significance of the result and whether treatment is needed.
  • 2022-09-15 RPR/VDRL Reactive-1:4
    • ChatGPT: A reactive RPR/VDRL result of 1:4 indicates a higher level of antibodies against syphilis in the blood compared to a result of 1:2. A higher titer result generally indicates a more active infection, but it can also indicate a past infection that has been successfully treated. Further testing and clinical evaluation are needed to determine the stage and treatment of syphilis.

[exam findings]

  • 2023-03-22 Clinical Dementia Rating
    • CDR score: 2
  • 2023-03-22 Mini-Mental State Examination
    • MMSE score: 16
  • 2023-03-14 EEG
    • This EEG study recorded background continuous diffuse theta rhythm (6-7 Hz) and plenty beta activity with occasional frontal slow waves.
    • No epileptiform discharge.
    • This EEG study suggested mild cortical dysfunction.
    • Please correlate with clinical features.
  • 2023-02-17 Patho - small intestine resection for tumor
    • Diagnosis
      • Small intestine, duodenum, second portion, pancreatico-duodenectomy — Adenocarcinoma, moderately differentiated, s/p subtotal gastrectomy with B-II anastomosis
      • Pancreas, head, pancreatico-duodenectomy — Adenocarcinoma, by direct invasion
      • Common bile duct, pancreatico-duodenectomy — Negative for malignancy
      • Lymph node, peri-pancreatic and mesentery, dissection — Adenocarcinoma, metastatic (2/17)
      • Gallbladder, cholecystectomy — Negative for malignancy
      • Lymph node, retroperitoneal, dissection — Negative for malignancy (0/3)
      • AJCC 8th edition: pStage IIIA, pT4N1(if cM0)
    • Gross Description:
      • Specimen Type: pancreatico-duodenectomy and cholecystectomy; s/p subtotal gastrectomy with B-II anastomosis
      • Specimen and size:
        • Head of pancreas: 4.5 x 4.0 x 2.7 cm, the pancreatic duct is dilated
        • Duodenum: 17.0 cm in lenghth
        • Stomach: not received
        • Common bile duct: 6.0 cm in length and 0.8 cm in diameter
        • Gallbladder: 9.2 x 3.8 x 2.0 cm
      • Tumor Site: Duodenum
      • Tumor Size: 5.5 x 5.0 x 4.4 cm with invasion to pancreatic head
      • Sections are taken and labeled as: A1: CBD resection margin; A2-3: pancreatic and soft tissue resection margin; A4: distal duodenal resection margin; A5: blind end margin; A6: peritoneal resection margin; A7: superior soft tissue resection margin; A8: inferior soft tissue resection margin; A9: ampulla Vater, CBD and tumor; A10: panreatic dyct; A11-15: tumor; A16-17: lymph node, peripancreatic and mesentery; B: gallbladder; C: lymph node, retroperitoneal.
    • Microscopic Description:
      • Histologic Type: adenocarcinoma
      • Histologic Grade (applies to ductal carcinoma only): G2: Moderately differentiated
      • Tumor Extension: invasion to pancreatic head and retroperitoneal soft tissue
      • Margins
        • All margins are uninvolved by invasive carcinoma,
        • Distance of invasive carcinoma from closest margin: 12 mm.
        • Specify: retroperitoneal soft tissue resection margin
        • Blid end resection margin: 1.5 cm
        • distal duodenum resection margin: 12.2 cm
        • CBD resection margin: 3.0 cm
        • Pancreatic resection margin: 1.5 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Regional Lymph Nodes: peri-pancreatic and mesentery: 2/17; retroperitoneal: 0/3
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable): not applicable
          • Primary Tumor (pT): pT4: invasion of pancreas
          • Regional Lymph Nodes (pN): pN1: Metastasis in one to two regional lymph nodes
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings: The pancreatic parenchyma reveals atrophy. The pancreatic duct is dilated with low grade pancreatic intraepithelial neoplasia.
  • 2023-02-11 MRI - upper abdomen
    • History and indication: Duodenal cancer before surgery
    • With and without contrast MRI of upper abdomen revealed:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • S/P gastric operation.
      • Distention of gallbladder.
    • IMP:
      • Motion artifact.
      • Progression of duodenal cancer with adjacent structures invasion causing p-duct dilatation.
      • Distention of gallbladder.
  • 2023-02-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (81.3 - 21.7) / 81.3 = 73.31%
      • M-mode (Teichholz) = 73.3
    • Conclusion:
      • Normal chamber size
      • Adequate LV and RV systolic function
      • AV sclerosis with mild AR, mild MR, TR and PR
      • No regional wall motion abnormalities
  • 2023-02-07 Flow Volume Loop
    • poor performance
    • the family expressed that the patient is physically weak and therefore unable to blow air.
  • 2023-02-06 ECG
    • Atrial fibrillation with slow ventricular response
    • Low voltage QRS
    • Left anterior fascicular block
  • 2023-12-30 Patho - doudenum biopsy
    • Labeled as “duodenum, second portion”, biopsy — adenocarcinoma.
    • Section shows piece of duodenal tissue with dysplastic and neoplastic glands.
    • IHC stains: CK 19 (+), CK7 (+), CK20 (focal +), CD56 (-), Ki-67: 90%.
  • 2022-12-27 CT - abdomen
    • History and indication: Abdominal pain
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Pectus excavatum.
      • S/P gastric operation ?
      • Wall thickening of duodenum, 2nd portion, r/o malignancy.
      • Distention of gallbladder. Dilatation of p-duct.
    • IMP:
      • Wall thickening of duodenum, 2nd portion, suspected malignancy.
      • Distention of gallbladder.
      • Dilatation of p-duct.

[consultation]

  • 2023-02-08 Anesthesiology
    • Q
      • This is 72-year-old man with past history of C-spine s/p OP, CAD, Syphilis infection s/p Penicillin IVD x3 on 2022/10-11 (Treatment finished, 2022/12 RPR: reactive [1:2]), Alzheimer’s disease and Gout. The patient was diagnosed duedenal cancer at the end of 2022, and he admitted for operation.
      • The patient was only 50 kg with poor nutrition in recent several months, so we needed TPN to supply the nutrition for him before surgery. He was also TPN supportive care after surgery.
      • The patient had Syphilis infection, and the patient worried about the CVC insertion. We would like to consult your expertise for CVC insertion.
    • A
      • We were consulted for CVC insertion due to peripherally incompatible infusions .
      • The 3-way CVC was inserted into right IJV, fixed at 15 cm, under sonography guidance smoothly.
      • Please arrange portable CXR for CVC position examination.
      • CXR revealed proper position of the CVC.
  • 2022-10-19 Metabolism and Endocrinology
    • Q
      • This 71 y/o man has a history of CAD and C-spine s/p. He visited neurology OPD recently for cognitive decline. Laboratory survey showed syphilis infection and hypothyroidism.
      • We need your expertise for hypothyroidism evaluation and management. Thank you very much.
    • A
      • S
        • This 71-year-old male, with past history of CAD and C-spine s/p, was admitted due to cognitive decline, susp. neurosyphilis or hypothyroidism related. We were consulted for abnormal TFT.
      • O:
        • BW: 49
        • HR: 50-68
        • Possible related medication: nil
        • ALT: 15
        • Cr: 0.95
        • Na/K: unavailable
        • TSH/FT4 (nuclear medicine): 18.697/0.748
        • T3: unavailable
        • ATPO: 3.2, ATG: < 0.9
        • ACTH/Cortisol (random, 3-4pm): ?/8.17
        • Thyroid sono: nil
        • ECG: nil
      • A: Primary hypothyroidism
      • Suggestions:
        • Add on thyroxine 50 mcg, 0.5 tablet, QDAC (please take at least 30 minutes before the first meal of the day), and monitor blood pressure, heart rate, electrolytes, and any cardiovascular complications.
        • Recheck TSH/FT4 (routine biochemistry) in 2 weeks (can be done as outpatient if discharged).
        • Arrange for thyroid sonography (radiology) and ECG for bradycardia.
        • Contact us if necessary. Follow-up with the Endocrine Outpatient Department.

[surigcal operation]

  • 2023-02-16
    • Surgery
      • pancreatico-duodenectomy with retroperitoneal LN dissection
    • Finding
      • 7.5 x 6 x 4 cm fungating mass was noted at duoenal 2nd portal with pancreastic head invasion
      • no peritoneal seeding was noted
      • previous subtotal gastrectomy with B-II anastomosis

[chemotherapy]

  • 2023-04-12 - oxaliplatin 65mg/m2 100mg D5W 250mL 2hr + leucovorin 300mg/m2 450mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Oxa 65mg/m2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-24 - leucovorin 300mg/m2 400mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 48hr (FOLFOX, Hold Oxalip due to old age and performance status)
    • dexamethasone 4mg + NS 250mL

==========

2023-04-13

  • The patient has received a reduced dose of 65mg/m2 of oxaliplatin for the first time during this hospitalization, and no adverse reactions have been observed to date.

  • For the patient’s chronic viral hepatitis B and post-pancreatico-duodenectomy status, Protase (pancrelipase 280mg) TIDCC and Baraclude (entecavir 0.5mg) QDAC have been prescribed.

  • There is no medication reconciliation issue found.

2023-03-27

  • The patient has been exposed to the hepatitis B virus (HBV) at some point in his life, Baraclude (entecavir) is properly prescribed.
    • 2023-03-15 Anti-HBc Reactive
  • A decrease in RPR/VDRL titer from 1:4 to 1:2 may indicate a treatment response to syphilis (Penicillin IVD x3 on 2022/10-11).
    • 2022-12-13 RPR/VDRL Reactive-1:2
    • 2022-09-15 RPR/VDRL Reactive-1:4
  • High levels of thyroid-stimulating hormone (TSH) and normal levels of free thyroxine (T4) may indicate subclinical hypothyroidism. Subclinical hypothyroidism may not cause any symptoms, but it can increase the risk of developing overt hypothyroidism in the future. It can also increase the risk of heart disease. It is recommended to monitor the levels of TSH and T4 further evaluation and management if necessary.
    • 2022-09-19 TSH (nuclear medicine) 18.697 uIU/ml
    • 2022-09-19 Free T4 (nuclear medicine) 0.748 ng/dl
  • On 2023-02-16, the patient underwent a pancreatico-duodenectomy with retroperitoneal lymph node dissection, and started receiving 5-fluorouracil (5FU) infusion on 2023-03-24. It is important to monitor the patient closely for any signs of gastrointestinal adverse reactions, as 5FU infusion may cause such symptoms. Additionally, given the patient’s history of CAD, it is also important to keep a close eye for any potential cardiovascular adverse reactions.

700537283

230412

[exam findings]

  • 2023-04-10 CXR
    • Few nodular opacities projecting in the left middle lung are suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • S/P clips projecting at right lower medial lung.
  • 2023-02-16 CT (at SYKCC)
    • bil. breast masses
    • skin nodularities
    • bil. supraclavicular, Lt axillary and upper mediastinal lymphadenopathy.
    • liver and lung metasis

[SOAP]

  • 2023-03-30 Hemato-Oncology
    • S
      • History of breast ca before but it recurred in Sep 2021 but she did not seek formal medical attentison. She received biopsy at SYKCC where ER positive, PR (+), Her-2 (3) when multiple tumor over Rt chest wall. Double target therapy was done on 2023-03-07.
      • Swelling over port-A site (infected) (20230330)
      • She came for subsequent treatment.
    • O
      • Reason for not informing patient of her condition: Currently not suitable to inform.

[chemoimmunotherapy]

  • 2023-04-11 - docetaxel 35mg/m2 47mg NS 100mL 1hr (docetaxel + herceptin + perjeta)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL

700626863

230412

[exam findings]

  • 2023-03-20 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — hypercellularity.
    • Section shows piece(s) of bone marrow with 50-60% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with left of leukocytes. Megakaryocytes are adequate in number.
    • IHC stains: CD117: 30-40%; CD34: 30-40 %; MPO: 50-55 %, CD61: 5 %; CD71: 30-35 % (of the nucleated cells). Acute myelogenous leukemia may be considered.

[POMR]

  • 2023-04-10 Hemato-Oncology
    • Problem: Acute myeloblastic leukemia, FLT3 and NPM1 Undetectable, 46,XX,t(16;21)(p11.2;q22)[20] karyotype
      • Assessment: Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
      • Plan
        • Insertion on 2023/03/30
        • Induction chemotherapy with D3A7 was administered on 2023/03/31 - 04/06
        • Prophylasix antibiotics with Cravit po from 2023/03/31(D11) and antifungas with Fluconazole 2 tab QD from 2023/03/31(D11)
        • Adequate hydration with N/S 1500ml QD
        • Followed up laboratory test regularly  

[SOAP]

  • 2023-03-18 Medical Emergency
    • Menorrhagia for 2 weeks.
    • 2023/03/18 17:24 Blast = 9.8 %;
    • 2023/03/17 17:29 Blast = 5.9 %;
    • preliminary impression: D61.818 Other pancytopenia
      • Pancytopenia, Hb 7.2 to 6.1 to 6.8, blast 5.9% to 9.8%, OA ONC
  • 2023-03-17 Hemato-Oncology
    • 33 y female, PH: IDA (iron deficiency anemia)
    • Abnormal hemogram was informed at Taipei Mackey Hospital
    • recheck here: WBC 2540, Hb 6.1, Plt 116k, balst 5.9%
    • Imp: R/O leukemia

[chemotherapy]

  • 2023-03-31 - daunorubicin 45mg/m2 70mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 156mg NS 500mL 24hr D1-7 (3+7 daunorubicin/cytarabine Q4W)
    • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + palonosetron 250ug D1-2 + NS 250mL D1-2

Induction therapy for acute myeloid leukemia in medically-fit adults. 2023-04-10 https://www.uptodate.com/contents/induction-therapy-for-acute-myeloid-leukemia-in-medically-fit-adults

  • 7+3 therapy (cytarabine plus anthracycline)
    • The preferred approach for remission induction is a 7-day continuous infusion of cytarabine and anthracycline treatment on days 1 to 3, which is commonly referred to as “7+3 therapy.”
    • For medically fit patients, we suggest treatment as follows:
      • Cytarabine 100 to 200 mg/m2 daily as a continuous infusion for 7 days
      • Daunorubicin 60 to 90 mg/m2 on days 1 to 3 or idarubicin 12 mg/m2 on days 1 to 3
    • Treatment with 7+3 therapy generally achieves a complete remission (CR) rate of 60 to 80 percent for patients <60 to 65 years old. Long-term outcomes are influenced by cytogenetic/molecular features (the following table) and post-remission management.
      • 2017 European LeukemiaNet risk stratification of acute myeloid leukemia by genetics
        • Risk category: Favorable
          • Genetic abnormality
            • t(8;21)(q22;q22.1); RUNX1-RUNX1T1
            • inv(16)(p13.1;q22) or t(16;16)(p13.1;q22); CBFB-MYH11
            • Mutated NPM1 without FLT3-ITD or with FLT3-ITDlow
            • Biallelic mutated CEBPA
        • Risk category: Intermediate
          • Genetic abnormality
            • Mutated NPM1 and FLT3-ITDhigh
            • Wild type NPM1 without FLT3-ITD or with FLT3-ITDlow (without adverse-risk genetic lesions)
            • t(9;11)(p21.3;q23.3); MLLT3-KMT2A
            • Cytogenetic abnormalities not classified as favorable or adverse
        • Risk category: Adverse
          • Genetic abnormality
            • t(6;9)(p23;q34.1); DEK-NUP214
            • t(v;11q23.3); KMT2A rearranged
            • t(9;22)(q34.1;q11.2); BCR-ABL1
            • inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2,MECOM(EVI1) –5 or del(5q); –7; –17/abn(17p)
            • Complex karyotype, monosomal karyotype
            • Wild type NPM1 and FLT3-ITDhigh
            • Mutated RUNX1
            • Mutated ASXL1
            • Mutated TP53
    • Patients require aggressive intravenous hydration; monitoring for cardiac, renal, and liver dysfunction; blood product support; and surveillance for infections. Treatment with 7+3 therapy generally causes three to five weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. Many patients will experience nausea and vomiting, mucositis/stomatitis, alopecia, and diarrhea. Cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.
    • Bone marrow examination should be performed 14 to 21 days after initiation of therapy to assess the initial response to therapy and determine whether a second induction course is needed.
    • Approximately four to five weeks after the start of therapy, when sufficient time has passed for recovery of normal blood counts, another bone marrow examination is performed to determine whether the patient has achieved remission.
    • Broadly, findings from randomized trials that examined the dose, schedule, and choice of agents have found that outcomes are similar between daunorubicin and idarubicin; higher dose daunorubicin (ie, 60 or 90 mg/m2/d) is more efficacious but not more toxic than lower dose (ie, 45 mg/m2/d) daunorubicin; and, compared with infusional cytarabine, high dose cytarabine (HiDAC) is associated with increased toxicity without an improvement in efficacy.

==========

2023-04-12

[follow up]

  • Bicytopenia progresses, Cravit (levofloxacin) and FLU-D (fluconazole) are used to manage potential infections.

    • 2023-04-12 WBC 0.21 x10^3/uL
    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-12 Neutrophil 5.8 %
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-12 PLT 37 *10^3/uL
    • 2023-04-09 PLT 47 *10^3/uL
  • No fever in the past 7 days.

  • Blast decreased after 7+3 anthracycline plus cytarabine since 2023-03-31.

    • 2023-04-05 Blast 1.0 %
    • 2023-04-03 Blast 1.3 %
    • 2023-04-02 Blast 7.0 %
    • 2023-04-01 Blast 22.9 %
    • 2023-03-31 Blast 23.0 %
    • 2023-03-28 Blast 12.0 %
    • 2023-03-24 Blast 7.0 %
    • 2023-03-22 Blast 29.0 %
    • 2023-03-21 Blast 17.6 %
    • 2023-03-20 Blast 4.0 %
    • 2023-03-18 Blast 9.8 %
    • 2023-03-17 Blast 5.9 %

2023-04-10

  • The patient diagnosed with AML was admitted and received the first dose of “3+7 daunorubicin/cytarabine” regimen on 2023-03-31. Lab data showed the development of severe neutropenia following administration of the regimen.

    • 2023-04-09 WBC 0.42 x10^3/uL
    • 2023-04-07 WBC 0.92 x10^3/uL
    • 2023-04-05 WBC 1.43 x10^3/uL
    • 2023-04-03 WBC 1.78 x10^3/uL
    • 2023-04-02 WBC 2.64 x10^3/uL
    • 2023-04-01 WBC 3.31 x10^3/uL
    • 2023-03-31 WBC 3.63 x10^3/uL
    • 2023-03-28 WBC 4.49 x10^3/uL
    • 2023-04-09 Neutrophil 16.5 %
    • 2023-04-07 Neutrophil 55.0 %
    • 2023-04-05 Neutrophil 64.0 %
    • 2023-04-03 Neutrophil 39.9 %
    • 2023-04-02 Neutrophil 75.3 %
    • 2023-04-01 Neutrophil 60.0 %
    • 2023-03-31 Neutrophil 33.0 %
    • 2023-03-28 Neutrophil 50.0 %
  • Treatment with the regimen can cause 3 to 5 weeks of profound cytopenias and associated risks of life-threatening infections and bleeding. And cytarabine may cause a flu-like syndrome (including fever and/or rash) and daunorubicin can be associated with infusion reactions and cardiac arrhythmias.

  • It is recommended that a bone marrow examination be performed 14 to 21 days after initiation of therapy to assess the initial response to the therapy and to determine if a second induction course is needed.

  • Initial response to therapy - A bone marrow examination on day 14 of treatment provides an assessment of the clearance of blast cells and a preview of the response to induction therapy. Findings from the day 14 examination may be classified as follows:

    • Hypoplastic: Bone marrow cellularity <5 to 20 percent and <5 percent blasts
    • Indeterminate: Bone marrow cellularity <5 to 20 percent with >=5 percent blasts
    • Persistent leukemia: Some clearing of leukemia or no response, but cellularity >=20 percent
  • Institutions vary in their responses to findings of the day 14 bone marrow examination.

    • For some centers, all medically-fit patients receive a second cycle of the same induction therapy, but those with persistent disease may receive more intensive/alternate treatment (eg, high dose cytarabine [HiDAC] plus mitoxantrone; mitoxantrone, etoposide, and cytarabine [MEC], other regimen.)
    • Other centers use the following approach, guided on the day 14 marrow results:
      • Hypoplastic: Observation for two to four weeks until recovery of blood counts. If pancytopenia persists, then repeat bone marrow biopsy.
      • Indeterminate: Repeat the bone marrow examination one to two weeks later, with subsequent management guided by whether the repeat study demonstrates hypoplasia versus persistent leukemia.
      • Persistent leukemia: Repeat treatment with the regimen, or treat with a more intensive or alternate induction therapy (eg, HiDAC-based therapy, hypomethylating agent plus venetoclax, other regimen).
  • Cravit (levofloxacin) and Flu-D (fluconazole) both have been prescribed to prevent or alleviate the patient from infections. There is no problem that is identified with the active recipe.

700040129

230411

{not completed}

[exam findings]

  • 2023-04-11 MRI - brain
    • Indication: Right upper lobe lung cancer with mediastinal lymphadenopathy, lung, liver and bone metastasis, cT3N2M1c, stage IVB
    • Findings
      • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • C2 and right C3 metastases/bone destructions.
      • Abnormal enhancement after contrast administration of C2-3 bodies were noted.
    • Imp:
      • No brain or skull metastases.
      • C2 and right C3 metastases.
  • 2023-04-11 Bronchoscopy
    • Endo-bronchial tumor with partial obstruction at RB3, s/p Cryobiopsy
  • 2023-04-07 CT - chest
    • Indication: multiple bone metastasis - from chest to pelvis please,
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated mass at right upper lobe measuring 3.8cm in largest dimension is found.
        • Lymphadenopathy at right hilar and paratracheal region is found.
        • Mild bilateral pleural effusion is found.
        • One nodular lesion at right lower lobe measuring 0.85cm is found. suspected lung meta.
      • Visible abdomen:
        • Low density lesions are found at both lobes of liver are found. Liver meta is considered.
        • Diffuse wall thickening of the ascending colon is found. suspeted colitis.
        • The urinary bladder is well distended without soft tissue lesion.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
    • Imp:
      • Right upper lobe lung cancer with mediastinal lymphadenopathy, lung meta and liver meta, bone meta. T3N2M1c.
  • 2023-04-03 CXR
    • Lung markings: a nodular lesion, about 32mm, in the right upper lung field
  • 2023-04-03 ECG
    • Sinus rhythm with occasional Premature ventricular complexes
  • 2023-04-03 MRI - c-spine
    • IMP
      • mild retrolisthesis at C4-5 and C5-6
      • r/o multiple bone metastasis with pathological fracture at C2 vertebral body. PLease correlate with contrast-enhanced study.
  • 2023-03-31 C-spine AP & Lat
    • Loss of normal lordotic alignment
    • Disc space narrowing and posterior spur at C4-5-6
  • 2023-03-14 C-spine flex & ext view
    • mild angulation at the middle C-spine
    • mild anterior and posterior spur formation at the middle and lower C-spine
    • moderate decreased disc spaces in the C4/5 and C5/6 discs

[consultation]

  • 2023-04-03 Neurology
    • Q
      • posterior neck pain for a week, no arms numb nor weak.
      • c spine on 20230331:
        • Loss of normal lordotic alignment
        • Disc space narrowing and posterior spur at C4-5-6
    • A
      • S: complained of severe neck pain while axial loading (relieved by lying down)
      • O
        • E4V5M6
        • pupil: 3+/3+
        • MP full
        • no limbs paresthesia
        • MRI: suspected multiple bone metastasis with pathological fracture at C2 vertebral body
      • P
        • since there’s no MP weakness, limbs numbness, no operation is indicated now
        • suggest oncologist consultation and tumor survey

700882997

230411

{not completed}

[exam findings]

  • 2023-04-03 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Mild plasmacytosis and see description
    • The sections show normocellular marrow (30%). The erythoid precursors are decreased, dispersed, and scattered in CD71 stain. The myeloid cells show good maturation. The CD61+ megakaryocytes are normal in number and morphology. Increased CD138+ mature plasma cells, account for 15% of marrow cells without lambda or kappa light chains restriction. No CD34+ blasts can be found. Suggest further bone marrow smear evaluation and clinic correlation.
  • 2023-03-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending colon, s/p biopsy near total removal (A) — Hyperplastic polyp
    • Colorectum, transverse colon, s/p biopsy removal (B) — Hyperplastic polyp
    • Colorectum, descending colon, s/p biopsy removal (C) — Hyperplastic polyp
    • Colorectum, rectum, s/p biopsy removal (D) — Hyperplastic polyp
    • Colorectum, rectum, 5 cm above anal verge, biopsy (E) — Hyperplastic polyp
  • 2023-03-08 Patho - doudenum biopsy
    • Duodenum, bulb to second portion, biopsy — mild to moderate lymphocytic infiltration.
    • Section shows piece(s) of bland duodenal tissue with mild to moderate lymphocytic infiltration.
    • IHC stains: CD3 and CD20: no predominant sub-population, in favor of chronic inflammation.
  • 2023-03-08 SONO - abdomen
    • Parenchymal liver disease
    • Cholecystopathy
    • Gallbladder polyp
    • Minimal ascites
    • Sus lymphadenopathy, beside panc body
  • 2023-03-06 CTA - chest
    • Indication: Fever, unspecified Dizziness and giddiness, Dyspnea, unspecified Anemia, unspecified
    • MDCT (80-detector rows,Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
      • Lungs: centrilobular emphysema in both upper lobes (moderate Lt, mild RT), and mild subpleural paraseptal emphysema in LUL. dependent linear band subsegmental atelectasis at lower lobes.
      • Mediastinum and hila:
      • Vessels: mild calcified plaques of the LAD coronary artery.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification of ascending
      • Heart: normal in size of cardiac chambers.
      • Pleura: mild bilateral effusions.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal contents: hyperplasia of Lt adrenal gland
        • normal appearance of gall bladder. unremarkable of the liver, spleen, Rt adrenal gland, pancreas, and both kidneys. bile ducts: No dilatation.
        • no enlarged lymph node. no ascites.
        • Atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • emphysema in both upper lobes, most severe on Lt smoking related disease. small pleural effusion, transudate.
  • 2023-03-06 CXR
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2022-09-21 Pure Tone Audiometry
    • PTA Reliability FAIR
    • Average RE 30 dB HL; LE 35 dB HL.
    • R’t normal to moderately severe SNHL. (BC masking dilemma at 4k Hz)
    • L’t normal to moderately severe SNHL with ABG at 4k Hz.
  • 2022-03-09 ENT Hearing Test
    • Tymp:
      • R’t type Ad; L’t type A.
    • ART:
      • R’t absent.
      • L’t absent except ipsi 500 Hz.
    • PTA
      • Reliability FAIR
      • Average RE 21 dB HL; LE 26 dB HL.
      • R’t normal to moderate SNHL.
      • L’t normal to moderately severe SNHL.

[consultation]

  • 2023-03-13 Hemato-Oncology
    • Q
      • For anemia and thrombocytopenia
      • This 72-year-old male has past history of Hypertension and Af under medication control at West Garden Hospital. According to his statment, intermittent shortness of breath for 2 weeks ago, accompanied with productive cough, dizziness and bilateral hands tremor for 1 weeks. The symptom got worsen, thus he was brought to our ER for help. At ER, vital signs showed TPR: 35.6’C/121bpm/20; BP:125/60 mmHg. Con’s:E4V5M6. Laboratory data revealed normacytic anemia of Hb 7.8g/dL, elevated CRP (8.78 mg/dL), NTpro BNP (1018 pg/mL) and D-dimer (980.96 ng/mL). Chest CTA showed emphysema in both upper lobes. He denied abdomen pain, tarry stool or bloody stool. Urinalysis showed no pyuria. Denied TOCC history. Under the impression of pneumonia and suspect GI bleeding, he was admitted to our ward for further evaluation and treatment.
      • After admitted, he recevied IV fluid supplement, empirical antibiotic with unasym for infection control.
      • Stool transfirrin/FOB showed positive. EUS and colonscopy were performed for anemia survey, which showed duodenal ulcers and rectal polypoid lesions with ucer.
      • Anemia was correct with Hb > 9.0.
      • Follow laboratory data revealed thrombocytopenia (PLT 65000/uL -> 70000/uL -> 52000/uL -> 35000/uL). Abdomen echo showed no splenomegaly.
      • We need your expertise to evaluate for anemia and thrombocytopenia further evaluation, sincerely thanks.
    • A
      • This 72 year old man is a case of pneumonia. We are consulted for bicytopenia (normocytic anemia and thrombocytoepnia).
      • Pending endoscopy biopsy result. Please check RBC morphology, haptoglobin (done), total/direct bilirubin (done), ANA, RF, C3, C4, anti Ds DNA, AntiRo/La, IgG,IgA,IgM, total protein/albumin, serum EP, serum IFE, serum light chain, lupus anticoagulant, anti-cardiolipid IgM/IgG, anti B2 glycoprotein Ab, Ferritin (done), Fe/TIBC (done), B12 (done), folic acid(done) and tumor marker. Watch for any bleeding sign which may cause platelet consumption. If still unexplained cytopenia, bone marrow aspiration and biopsy is indicated.
      • Typical recommended platelet count thresholds used for some common procedures are listed below. Platelet transfusion may be considered when the patient platelet count is below the threshold for the corresponding procedure.
        • Neurosurgery or ocular surgery - <100,000/microL
        • Most other major surgery - <50,000/microL
        • Endoscopic procedures - <50,000/microL for therapeutic procedures; 20,000/microL for low risk diagnostic procedures
        • Bronchoscopy with bronchoalveolar lavage (BAL) - <20,000 to 30,000/microL
        • Central line placement - <20,000/microL
        • Lumbar puncture - <10,000 to 20,000/microL in patients with hematologic malignancies and <40,000 to 50,000 in patients without hematologic malignancies; lower thresholds may be used in patients with immune thrombocytopenia (ITP)
        • Neuraxial analgesia/anesthesia - <80,000/microL
        • Bone marrow aspiration/biopsy - <20,000/microL

[lab data]

2023-04-11 Ferritin 1154.7 ng/mL
2023-04-11 Transferrin 143.6 mg/dL
2023-04-11 Fe (Iron-bound) 123 ug/dL
2023-04-11 TIBC 206 ug/dL
2023-04-11 UIBC 83 ug/dL
2023-04-10 BUN 29 mg/dL
2023-04-10 Bilirubin direct 0.22 mg/dL
2023-03-21 Direct Coomb Test Positive
2023-03-21 Indirect Coomb Test Positive
2023-03-21 FKLC 156.0 mg/L
2023-03-21 FLLC 193.0 mg/L
2023-03-17 Anti-beta2-glycoprotein-I Ab 9.2 U/mL
2023-03-17 Gamma 44.3 %
2023-03-15 IgG (blood) 2208 mg/dL
2023-03-09 stool FOB Positive
2023-03-09 Transferrin, stool Postive

701452959

230411

[diagnosis] - 2023-04-10 admission note

  • Malignant neoplasm of rectosigmoid junction
  • Adenocarcinoma of the rectum and sigmoid colon,T4N2bM1a, stage III
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension
  • Hyperlipidemia, unspecified

[past history]

  • diabetes mellitus for years under OHA & insulin control at SanChong LMD and hepatitis B.
  • Port-A was inserted on 2023-03-14.     

[allergy]

  • NKDA     

[family history]

  • Mother: breast cancer
  • Sister: lymphoma

[exam findings]

  • 2023-04-10 KUB
    • A renal stone in left lower pole is suspected.
    • Fecal material store in the colon.
    • Vas deferens calcification is noted.
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon at right lateral aspect L4-5.
  • 2023-03-10 Whole body PET scan
    • Glucose hypermetabolism involving the rectosigmoid colon, compatible with primary rectosigmoid colon malignancy.
    • Mild glucose hypermetabolism in six regional lymph nodes. The nature is to be determined (metastatic lymph nodes of low FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • No prominent abnormal focal FDG uptake was noted in the liver and no prominent FDG uptake was noted in the left external iliac lymph node.
    • Increased FDG accumulation in some focal areas in the colon. The nature is to be determined (physiological FDG accumulation? other nature?). Please also correlate with other clinical findings for further evaluation.
  • 2023-03-01 CT - abdomen
    • CC:
      • bowel habit change and anal discomfort + tenesmus recent times.
      • Constipation with excessive straining (unstable)
    • 20230224 colonoscopy: One circumferential tumor was noted at proximal rectum, 8-9cm above anal verge, s/p biopsy x6. The scope cannot pass through the lesion.
    • Past history: (DM + HTN)
    • Indication: suspect rectum lesion
    • Findings:
      • There is long segmental circumferential asymmetrical wall thickening with irregular contour at the rectum and sigmoid colon, measuring 12 cm in length that is c/w adenocarcinoma (T4a).
        • The fat plane between the sigmoid colon lesion and the urinary bladder shows equivocal obliteration. Please correlate with MRI to R/O urinary bladder invasion or attachment.
        • In addition, there are ten enlarged nodes in the pericolic area that are c/w metastatic nodes (N2b). IIIC
      • There is an ill-defined poor enhancing lesion 1 cm in S6/7 of the liver that may be cyst, pseudo-lesion, or metastasis?
        • Please correlate with MRI.
      • There is one enlarged node in left external iliac chain, measuring 6 mm in short axis (normal cut of value: 7mm) and fat density that may be reactive node.
        • The differential diagnosis includes non-regional metastatic node (M1a).
        • Please correlate with PET scan.
    • Impression:
      • Adenocarcinoma of the rectum and sigmoid colon.
        • Please correlate with MRI.
      • According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a or T4b, N2b, M1a?
        • Please correlate with Pelvis MRI and PET scan.
  • 2023-02-24 Patho - colon biopsy
    • PATHOLOGIC DIAGNOSIS
      • Proximal rectal tumor, 8-9 cm above anal verge, biopsy — Adenocarcinoma
      • Distal rectal polyp, biopsy removal — Tubular adenoma, low grade dysplasia
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of (A) three small pieces of tumor tissue measuring up to 0.3 x 0.2 x 0.1 cm in size and (B) four tiny pieces of polyp tissue measuring up to 0.2 x 0.2 x 0.1 cm in size respectively, fixed in formalin. Grossly, they were grey in color and soft in consistence. All embedded for sections in cassette A: rectal tumor and B: sessile polyp.
    • MICROSCOPIC EXAMINATION
      • Microscopically, the sections show pictures as follows:
        • Proximal rectal tumor: adenocarcinoma characterized by cribriform or glandular tumor cell infiltrate with desmoplasia.
          • Immunohistochemistry shows CDX-2(+), MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor
        • Distal rectal polyp: tubular adenoma with low grade dysplasia
  • 2023-02-24 Colonoscopy
    • high suspected rectal cancer, s/p biopsy (A)
    • rectal polyp, s/p biopsy removal (B)
    • mixed hemorrhoid
  • 2022-10-11 Bladder Sonography
    • PVR: 71mL
  • 2022-09-28 Humerus RT
    • suspected fracture at the right proximal humeral bone.
  • 2022-09-27 Transrectal Ultrasound of Prostate, TRUS-P
    • CC:
      • small stream +
      • nocturia 5/N
    • PH:
      • DM(+), HTN(-), CAD(-), COPD(-), Asthma(-), CVA(-)
    • Surgical history: denied
    • Substance use: denied
    • Prostate:
      • Size of prostate: 4.76(T)cm x 2.59(L)cm x 5.12(AP)cm = 33.0cc
      • Size of adenoma: 3.14(T)cm x 2.25(L)cm x 2.97(AP)cm = 11.0cc
    • Seminal vesicles:
      • L
        • Size:L’t1.68 x 0.802 cm
        • Vas deferens:Normal
        • Cyst:No
        • Abscess:No
        • Tumor:No
      • R
      • Size:R’t1.55 x 1.34 cm
      • Vas deferens:Normal
      • Cyst:No
      • Abscess:No
      • Tumor:No
    • Diagnosis
      • Benign prostatic hyperplasia

[SOAP]

  • 2023-03-07 Radiation Oncology
    • Preliminary planning dose: 4500cGy/25 fractions of the pelvic, and 5040cGy/28 frcations of the rectal to sigmoid colon tumor bed area.
  • 2023-03-07 Hemato-Oncology
    • Arrange admission for C/T (FU or FOLFOX).
    • If the PET indicates as a mets, C/T regimen for CCRT and post-CCRT would be FOLFOX, and TNT is not necessary.
    • If the PET discloses the lesion of liver is not a mets, TNT (CCRT with FU -> FOLFOX x 6-8 cycles -> OP -> follow up) is indicated. The C/T regimen for CCRT would be FU.
    • note ChatGPT:
      • In the context of oncology, TNT stands for “Total Neoadjuvant Therapy.” This refers to a treatment approach where chemotherapy, radiation therapy, or both are given before surgery for the treatment of certain types of cancer. The goal of TNT is to shrink the tumor and potentially increase the chances of a successful surgical outcome.

[chemotherapy]

  • 2023-04-10 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2400mg/m2 4600mg NS 500mL 46hr (FOLFOX without 5FU bolus)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-04-11

  • The patient has been admitted for the 2nd dose of FOLFOX regimen, and there were no remarkable adverse reactions observed after the 1st dose.
  • On 2023-04-10, the lab results showed grossly normal blood counts, kidney and liver function, and selected electrolytes, indicating that scheduled chemotherapy is not contraindicated.
  • he tumor marker CEA was found to be elevated and increasing before the first chemotherapy, and further follow-up tests can be ordered as necessary.
    023-03-08 CEA: 217.89 ng/mL
    2023-02-25 CEA: 193.69 ng/mL
  • The patient’s blood pressure readings are acceptable, but the serum glucose level remains high and unstable, ranging from 229mg/dL to 150mg/dL, and should be monitored closely. If the high serum glucose level persists, metformin may be considered, given the patient’s non-insufficient kidney function.
  • No issues with medication reconciliation have been identified.

2023-03-23

  • The treatment strategy planned on 2023-03-21 is based on the results of PET: if it indicates the presence of metastases, the recommended chemotherapy regimen for concurrent chemoradiotherapy (CCRT) and post-CCRT would be FOLFOX, and total neoadjuvant therapy (TNT) would not be necessary. However, if PET shows that the lesion in the liver is not a metastasis, then the recommended treatment would be TNT, which consists of CCRT with FU, followed by FOLFOX for 6-8 cycles, then surgery and postoperative follow-up. The chemotherapy regimen for CCRT in this case would be FU.

  • On 2023-03-10, the results of the PET scan were available and the patient began receiving the FOLFOX regimen for the first time while in this hospital stay.

  • According to the patient’s blood glucose records, there is an upward trend and significant variability in his blood glucose levels despite taking Forxiga (dapagliflozin). To address this, it is recommended to investigate if there has been a significant change in the patient’s dietary intake, especially in regards to carbohydrate consumption, as this could have a substantial impact on blood glucose levels.

    • Blood sugar level 148 -> 105 -> 170 -> 173 -> 127 -> 243 mg/dL

701464758

230411

[exam findings]

  • 2023-04-07 Ascites tapping
    • 3000 ml light red color ascites was drained.
  • 2023-04-03 Ascites tapping
    • After echo localization, paracentesis was performed at RLQ and 3000ml straw-colored scites was drained out with 18Fr cathether.
  • 2023-03-29 ECG
    • Sinus rhythm with Premature atrial complexes
    • Poor wave progression
  • 2023-03-29 KUB
    • Abdominal ascites
    • increased air in nondistended loops of small bowel over abdomen and pelvic ,could be mechanical ileus.
    • marginal spurs of multiple vertebral bodies
  • 2023-03-29 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Elevation of both hemidiaphragms may be due to abdominal ascites and supine position
    • Linear band subsegmental atelectasis at lung bases
    • Multiple nodules in both lungs due to metastases.
  • 2023-03-20 Ascites tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 3000 ml for drainage, orange color and symptom relief.
  • 2023-03-17 PET
    • Glucose hypermetabolism in a focal area about ascending colon and some adjacent lymph nodes. Primary colon malignancy with some adjacent lymph node metastases may show this picture.
    • Multiple glucose hypermetabolic lesions in bilateral lungs and in the liver, compatible with multiple lung and liver metastases.
    • Increased FDG accumulation in both kidneys. Physiological FDG accumulation is more likely.
  • 2023-03-15 All-RAS + BRAF
    • ALL-RAS: Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF: There was no variant detect in the BRAF gene.
  • 2023-03-12 KUB
    • Presence of ileus.
    • Degeneration and spondylosis of L-S spine.
  • 2023-03-10 Patho - colon biopsy
    • Colorectum, ascending, biopsy — Adenocarcinoma.
    • Section shows piece(s) of colonic tissue with invasive irregular neoplastic glands.
  • 2023-03-09 Colonoscopy
    • A-colon cancer with partial obstruction
  • 2023-03-09 Asictes tapping
    • 18G needle was inserted at RLQ under echo guided insertion. Around 75ml ascites was collected for analysis and total 2000 ml for drainage and symptom relief.
  • 2023-03-07 CXR
    • Solitary pulmonary nodule at RLL.
  • 2023-03-07 CT - abdomen
    • Findings
      • Wall thickening of A-colon with adjacent fat stranding and regional LAP. Multiple liver and lung tumors. Massive ascites.
      • S/P cholecystectomy.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
  • 2022-12-19 SONO - abdomen
    • Large liver tumor in right lobe, HCC? Suggest dynamic CT or MRI study.
    • Liver cysts.

[consultation]

  • 2023-03-14 Hemato-Oncology
    • A
      • This 67 year old man is a case of ascending colon adenocarcinoma with liver and lung metastasis. We are consulted for further evaluation.
      • Please check tumor gene status for RAS and BRAF mutations (All-RAS/BRAF test), Pending tumor mismatch repair (MMR) or microsatellite instability (MSI) status (pathology IHC stains). Arrange PET for complete staging (NHI covered).
      • For metastasis colon cancer, palliative systemic chemoterapy +/- target therapy is indicated. Re-evaluate for conversion to resectable every 2-3 mo if conversion to resectability is a reasonable goal. Furthermore, consult CRS for surgery, if there is present of obstrusion, bleeding or perforation.
      • Arrange our OPD after discharge. Thanks for your consultation.
  • 2023-03-14 Colorectal Surgery
    • A
      • O
        • 2023037: CT: Wall thickening of A-colon with adjacent fat stranding and regional LAP r/o malignancy. Multiple liver and lung tumors r/o metastases. Massive ascites.
        • 20230309: Colonoscopy: One mass was noted in the ascending colon with nearly lumen obstruction biopsy — Adenocarcinoma.
        • Abdomen: distended, no tenderness or muscle guarding
      • A: Adenocarcinoma of A-colon with multiple metastases of liver and lungs, stage IVb
      • P:
        • Due to diffuse liver and lungs metastases, palliative chemotherapy with target therapy is the main treatment option
        • Surgical intervention with bypass surgery or ileostomy may be considered if obstruction symptoms developing
        • Please inform us if any problems

[medication]

  • 2023-03-21 ~ 2023-04-18 ongoing - Xeloda (capecitabine 500mg) KXELO01 2# BID

[note]

Capecitabine 2023-04-11 https://www.uptodate.com/contents/capecitabine-drug-information

  • Dosing: Adult - Colorectal cancer, unresectable or metastatic:
    • Single-agent therapy:
      • Oral: 1,250 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle; continue until disease progression or unacceptable toxicity.
        • Note: Capecitabine toxicities, particularly hand-foot syndrome, may be higher in North American populations; therapy initiation at doses of 1,000 mg/m2 twice daily (on days 1 to 14 every 21 days) may be considered.
    • XELOX/CAPOX regimen:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 of a 21-day treatment cycle (in combination with oxaliplatin); continue until disease progression or unacceptable toxicity. Some studies administered for a duration of 8 or 16 cycles. A retrospective evaluation of a modified schedule (eg, days 1 to 7 and days 15 to 21 of a 28-day cycle) found improved tolerability and no difference in efficacy outcomes.
    • CAPOX/panitumumab:
      • Oral: 1,000 mg/m2 twice daily on days 1 to 14 every 3 weeks (in combination with oxaliplatin and panitumumab) for at least 6 cycles or until disease progression or unacceptable toxicity.

[assessment]

  • The supplemental report for the IHC staining of EGFR, PMS2, MSH6, MSH2, and MLH1 for the colon biopsy pathology performed on 2023-03-10 is still pending and not yet available.

  • The patient’s last recorded height on 2023-03-30 is 172 cm, and his last recorded weight on 2023-04-10 is 75.7 kg. Based on these measurements, his body surface area (BSA) is calculated to be 1.9 m2. The patient has been receiving capecitabine at a daily dose of 2000 mg since late March 2023, which is a dose of 1052 mg/m2 based on his BSA. This is approximately 84% of the recommended daily dose of 1250 mg/m2.

  • It appears that the patient has had anemia even before the administration of capecitabine, and the cause may be gastrointestinal bleeding (in case of A-colon lesions?) as evidenced by positive occult blood in the stool. Blood transfusion performed on 2023-03-07, 2023-03-29, and 2023-04-07 and PPI is currently prescribed.

    • 2023-04-08 Stool OB 4+
    • 2023-04-01 Stool OB 3+
    • 2023-03-09 Stool OB 3+
    • 2023-04-10 HGB 9.1 g/dL
    • 2023-04-07 HGB 6.8 g/dL
    • 2023-03-29 HGB 8.3 g/dL
    • 2023-03-20 HGB 8.4 g/dL
    • 2023-03-17 HGB 8.8 g/dL
    • 2023-03-13 HGB 8.8 g/dL
    • 2023-03-09 HGB 8.4 g/dL
    • 2023-03-07 HGB 7.1 g/dL
    • 2023-03-07 HGB 5.7 g/dL
    • 2022-12-16 HGB 8.9 g/dL
  • There is currently no record of hand-and-foot syndrome (HFS) or any related symptoms such as palmar-plantar erythrodysesthesia or chemotherapy-induced acral erythema.

701465149

230411

[diagnosis] - 2023-04-02 admission note

  • Mesothelioma of pleura
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history] - 2023-04-02 admission note

  • Medical PH: 1) HTN 2) BPH
  • Inguinal hernia on 2023/01/13
  • TEP and Port-A catheter insertion on 2023/01/30
  • Hypertension for 20-30 years
    • Carvedilol HEXAC 6.25mg 1# po BID
    • Noravsc 1# po QD
    • Doxaben XL 4mg 1# po QNAC    

[allergy]

  • NKDA         

[family history]

  • His parents was DM.
  • No cancer, CAD, CVA history in his family

[exam findings]

  • 2023-04-10, -04-06 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
    • Borderline cardiomegaly
  • 2023-04-03 SONO - chest
    • Right
      • Right side pleural effusion? -> dry tapping
      • suspect mesothelioma or post R/T related
      • suggest CXR follow up
    • Left
      • Left side negative
  • 2023-04-02 CXR
    • Right pleural effusion.
    • Ground glass opacities in bil. lungs.
  • 2023-04-02 ECG
    • Atrial flutter with variable A-V block
  • 2023-02-24 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Pleura thickening in right lateral aspect is noted.
    • Partial atelectasis of RLL and RML is suspected.
    • Please correlate with CT.
  • 2023-02-23 ECG
    • Nonspecific T wave abnormality
  • 2023-02-07 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the anterior aspect of right 1st and 2nd ribs and increased activity in the maxilla, middle and lower T-spines, lower L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the middle and lower T-spines and lower L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Two hot spots in the anterior aspect of right 1st and 2nd ribs. Bone metastases can not be ruled out. Please also correlate with other imaging modalities for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-02-02 CXR
    • Rt pleural effusion with loculation still visible s/p chest tube placement,
    • partial atelectasis of RLL and RML
  • 2023-02-01 PET scan
    • Glucose-hypermetabolism in the right pleura, compatible with malignant mesothelioma of pleural status.
    • Glucose-hypermetabolism in the right upper ribs, malignancy with rib involvement should be considered, suggesting bone scan for investigation.
    • Increased FDG uptake in the right inguinal region, compatible with right inguinal hernia.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Malignant mesothelioma of pleural status with suspected right upper ribs involvement by this F-18 FDG PET scan.
  • 2023-01-31 CT - abdomen
    • History and indication: mesothelioma of pleural
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
      • A lipoma (2.8cm) in left thigh.
      • Right inguinal hernia.
      • Some poor enhancing nodules (up to 1.0cm) in liver.
      • Bil. renal cysts (up to 1.0cm).
    • IMP:
      • Right mesothelioma with pleural effusion. S/P right chest tube insertion with pneumothorax, subcutaneous emphysema.
      • Minimal pneumoperitoneum.
  • 2023-01-31 ENT Hearing Test
    • PTA
      • Reliability FAIR
      • Average RE 34 dB HL; LE 31 dB HL.
      • RE normal to severe SNHL.
      • LE normal to severe SNHL
  • 2023-01-18 Patho - pleural/pericardial biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pleura, right, VATS decortication - Malignant mesothelioma, high-grade
      • Tumor subtype — Biphasic type
      • Pathology stage:pT1Nx(if cM0); AJCC stage IA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: VATS decortication
      • Specimen site: right pleura
      • Specimen size: multiple pieces, up to 2.5x 2x 1.5 cm
      • Tumor size: fragmented, at least 2 cm in greatest dimension
      • Tumor description: ill-defined, brownish and solid
      • All for sections are taken and labeled as: F2023-38FSA1-2&A:frozen control of tumor, A1-2:tumor
    • MICROSCOPIC EXAMINATION
      • Histology Type: Malignant mesothelioma
      • Histology Grade:
        • Nuclear grade 3 [Nuclear atypia score: 3 (severe);Mitotic count score: 3 (hight, > 5 mitoses/ 10 HPF); Sum: total score 6].
        • Necrosis: present
        • Overall tumor grade: High-grade
      • Resection Margins: Cannot be assessed
      • Lymphovascular Invasion: Absent
      • Perineural Invasion: Absent
      • Tumor Necrosis: Present / Absent
      • Lymph Node : Not included
      • IHC stain — Ki-67 index: 90%, CK20(-), calretinin(focal+), CK(+), chromomgranin (-), WT-(Afocal+), D2-40(focal+), P40(-), TTF-1(-), Napsin A(-), CK7(+), vimentin (+), SOX-10(-), CK5/6(-), HBME-1(focal+), SYNAPTOPHYSIN(-), GATA-3(+),S100(-).
  • 2023-01-17 Frozen Section
    • FROZEN SECTION INITIAL DIAGNOSIS:
      • Tissue, right pleural, frozen section — Malignant tumor
  • 2023-01-16 SONO - chest
    • Echo diagnosis:
      • right side moderate amount of septated pleural effusion, pig-tail drainage via right 7th ICS posterior mid-axillary
      • line was performed and bloody fluid was drained out. The bloody fluid was sent for study.
  • 2023-01-12 CT - chest
    • The CT scan of the chest was performed without IV contrast medium enhancement and revealed that:
      • Patchy consolidation over RLL. Suggest check enhanced CT scan for furthter evaluation.
      • Moderate amount of right pleural effusion with some high-density materials. Suggest correlate with enhanced study.
      • Bilateral perirenal fatty strandings.
  • 2023-01-12 ECG
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-01-12 CXR
    • Right pleural effusion.
    • Borderline cardiomegaly.
    • Thoracic spondylosis.
  • 2022-12-22 Bladder Sonography
    • PVR 4.81 mL

[consultation]

  • 2023-01-28 Hemato-Oncology
    • Q
      • This is a 75 y/o male with underlying disease of HTN.
      • He underwent VATS decortication due to right pleural effusion on 2023-01-17, and the pathological report revealed malignant mesothelioma.
      • We would like to consult your expertise on evaluation and treatment arrangement of the patient, thank you!
    • A
      • This 75 year old man is a case of right malignant mesothelioma (initial presentation: cough and right pleura effusion). He has underline of HTN, BPH and rigth inguinal hernia.
      • For malignant mesothelioma, we are consulted.
        • We will discuss with pahtologist regarding the subtype, e.g., epitheloid, sarcomatoid or biphasic
        • May consider CCRT with weekly CDDP followed by systemic therapy is indicated (cisplatin + pemetrexed +/- bevacizumab) or immunotherapy with dual or single
        • Please check abdominal + pelvic CT extending to chest (+/- contrast), 24hr urine CCR, auditory test
        • Please check HbsAg, Anti Hbc, Anti-HBs, Anti HCV.
        • Arrange Port A insertion
        • We will discuss with patient and family
        • We wound like to follow up this case. May take over or arrange our OPD appointment after discharge.
  • 2023-01-27 Radiation Oncology
    • A
      • A:
        • Malignant mesothelioma, high-grade, of the right pleura, s/p VATS decortication.
      • P:
        • Postoperative radiotherapy is indicated for this patient with the following indicators: Malignant mesothelioma, high-grade, of the right pleura.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his daughter-in-law. They understand and agree to receive radiotherapy. Please consider PET for current tumor status and staging work-up. The treatment planning of radiotherapy will be started after completion of PET.

[SOAP}

  • 2023-03-30 Radiation Oncology
    • P: Go on the radiotherapy. Plan to complete radiotherapy on 2023-04-03. RTC: 2023-04-18.
  • 2023-03-16 Hemato-Oncology
    • Already strong request increasing the salt intake again and again
  • 2023-02-16 Thoracic Surgery
    • CT: R’t massive pleural effusion, cause? liver cysts., report?

[surgical operation]

  • 2023-01-30
    • Surgery: TEP
      • ChatGPT: TEP stands for Totally Extraperitoneal Repair, which is a minimally invasive surgical technique used to repair inguinal hernias. In this procedure, a small incision is made in the abdominal wall and a laparoscope is inserted, which allows the surgeon to view the hernia and repair it from the outside of the peritoneal cavity. The hernia is repaired with a mesh, which is placed over the defect to prevent the hernia from recurring. TEP is considered less invasive than traditional open hernia repair surgery and has a lower risk of complications.
    • Finding
      • Right indirect hernia type III
      • cord lipoma (+)
      • sac descend to scrotum
      • contralateral defect: none
      • post wall repair yes
      • mesh size 14x15 cm
      • absorbable tacks
      • peritoneal defect (+) cloosed with 3-0 Vicryl sutures
  • 2023-01-17
    • Surgery: VATS decortication
      • ChatGPT: VATS decortication refers to a surgical procedure performed to remove the fibrous layer of tissue (pleural peel) that covers the lung. The procedure is performed using a minimally invasive technique called Video-Assisted Thoracic Surgery (VATS), which involves making small incisions in the chest wall and using a video camera and specialized surgical instruments to access and remove the pleural peel. VATS decortication is commonly used to treat conditions such as empyema, a collection of pus in the pleural space, and hemothorax, a buildup of blood in the pleural cavity.
    • Finding
      • Bloody effusion was noted over right pleural cavity, about 800mL
      • Frozen section:carcinoma, unknown origin.
      • One 28 Fr. straight chest tube was inserted via right 8th ICS, another curved one was inserted via right 7th ICS.

[radiotherapy]

  • 2023-02-22 ~ 2023-04-03 - at 3060cGy/17 fractions of the right pleura to right upper ribs, and 4680cGy/26 fractions of the right pleura tumor bed.

[chemotherapy]

  • 2023-04-10 - pemetrexed 500mg/m2 800mg NS 100mL 10min + cisplatin 60mg/m2 100mg NS 500mL 2hr (Alimta + cisplatin, Q3W. cisplatin to normal 75mg/m2 next time)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-03-16 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-09 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-03-02 - cisplatin 40mg/m2 70mg NS 500mL 2hr + NS 1000mL (cisplatin within concurrently) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-02-24 - cisplatin 40mg/m2 70mg NS 500mL 24hr + magnesium sulfate 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) (CCRT with weekly CDDP)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3

==========

2023-04-11

  • The patient’s HGB levels have shown a decreasing trend since the start of CCRT in late Feb 2023, which could be a result of the cisplatin and radiotherapy.
    • 2023-04-10 HGB 7.4 g/dL
    • 2023-04-06 HGB 8.9 g/dL
    • 2023-04-02 HGB 8.2 g/dL
    • 2023-03-30 HGB 8.2 g/dL
    • 2023-03-23 HGB 8.9 g/dL
    • 2023-03-16 HGB 10.1 g/dL
    • 2023-03-09 HGB 10.8 g/dL
    • 2023-02-24 HGB 11.0 g/dL
    • 2023-02-07 HGB 9.8 g/dL
    • 2023-01-30 HGB 11.0 g/dL
    • 2023-01-23 HGB 11.1 g/dL
    • 2023-01-20 HGB 11.1 g/dL
    • 2023-01-19 HGB 11.0 g/dL
    • 2023-01-17 HGB 13.3 g/dL
    • 2023-01-12 HGB 13.1 g/dL
  • The combination of pemetrexed and cisplatin, incorporating prophylactic folic acid and vitamin B12, increased OS compared with single-agent cisplatin in patients with malignant pleural mesothelioma whose disease was either unresectable or who were not otherwise candidates for potentially curative surgery. ref: Phase III study of pemetrexed in combination with cisplatin versus cisplatin alone in patients with malignant pleural mesothelioma. J Clin Oncol. 2003;21(14):2636-2644. doi:10.1200/JCO.2003.11.136
    • 2023-04-10 MCV 100.9 fL
    • 2023-04-06 MCV 98.1 fL
    • 2023-04-02 MCV 94.8 fL

2022-04-03

The patient’s sputum Gram’s stain results on 2023-04-02 showed G(+) Cocci 2+, GNB 2+, GPB 3+ (Neutrophil/LPF < 10, Epithelial cell/LPF 15~20). Antibiotics with Betamycin 4.5gm Q6H have been prescribed since the same day to treat the patient’s respiratory symptoms. After checking the PharmaCloud database, no medication reconciliation issue is found.

700450583

230410

==========

2023-04-10

[ciclosporin TDM]

On 2023-04-08, the patient’s ciclosporin trough concentration was found to be 169ng/mL, which falls within the acceptable range of 100 to 400ng/mL. However, if the target trough concentration is between 200 and 300 ng/mL, then it is recommended to increase the daily dose from the current 200mg to 250mg and continue with regular follow-up testing.

2023-04-03

The patient’s kidney function results have returned to normal within the last 7 days.

2023-04-03 Creatinine 0.95 mg/dL
2023-03-31 Creatinine 2.45 mg/dL
2023-03-30 Creatinine 3.10 mg/dL
2023-03-28 Creatinine 3.74 mg/dL

2023-04-03 eGFR 98.94
2023-03-31 eGFR 33.16
2023-03-30 eGFR 25.27
2023-03-28 eGFR 20.35

2023-03-20

[cyclosporine IV to PO conversion]

  • There are different recommendations for converting CsA administration from intravenous to oral in HSCT patients, ranging from a 1:1 to a 1:3 conversion rate. For patients receiving voriconazole, it is suggested to use a 1:1 conversion rate. However, for patients receiving fluconazole without azole co-medication, a 1:1.3 substitution is recommended to prevent CsA concentrations from becoming subtherapeutic. ref: Converting cyclosporine A from intravenous to oral administration in hematopoietic stem cell transplant recipients and the role of azole antifungals. Eur J Clin Pharmacol. 2018;74(6):767-773. doi:10.1007/s00228-018-2434-4
  • Based on the intended IV dose of 190mg BID, the daily oral dose would range from 418 to 494mg. To start with, a feasible option would be to use Sandimmun Neoral, which is available as 4 100mg capsules, and 2 25mg capsules can be added to achieve the desired dose. The total dose can be divided into two administrations. However, it is important to monitor the patient’s cyclosporine blood levels at repeated intervals and make subsequent dose adjustments to avoid toxicity from high levels and possible rejection from low absorption of cyclosporine.

2023-03-10

[ciclosporin TDM]

  • Based on the system records, the blood was drawn for ciclosporin at 2023-03-09 08:35, while the medication was administered at 08:24 on the same day. If the intended purpose was to measure the trough concentration, the ideal time for blood draw should be within half an hour before medication administration. Please verify the accuracy of the system records or redraw an blood sample.

2023-03-07

[therapeutic drug monitoring for cyclosporine]

  • The dosage of cyclosporine has remained at 170mg Q12H since 2023-03-02. A blood sample was taken correctly on 2023-03-06 morning, just half an hour before the next scheduled administration. The trough level result was 266.6ng/mL, which falls within the target range of 100 to 400ng/mL without an issue.
  • Based on the trough level result falling within the target range, no dosage adjustment is necessary.

[assessment]

  • Today (2023-03-07) marks the 12th day since the Matched Unrelated Donor Allogeneic Peripheral Blood Stem Cell Transplantation. From the lab data, there is a noticeable upward trend in WBC count in the past two days, which is a positive sign.
    • 2023-03-06 D 11 WBC 0.70 x10^3/uL
    • 2023-03-05 D 10 WBC 0.28 x10^3/uL
    • 2023-03-03 D 8 WBC 0.01 x10^3/uL
    • 2023-03-02 D 7 WBC 0.01 x10^3/uL
    • 2023-03-01 D 6 WBC 0.01 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-27 D 4 WBC 0.02 x10^3/uL
    • 2023-02-26 D 3 WBC 0.04 x10^3/uL
    • 2023-02-24 D 1 WBC 0.07 x10^3/uL
    • 2023-02-23 D 0 WBC 0.01 x10^3/uL
    • 2023-02-22 D -1 WBC 0.01 x10^3/uL
    • 2023-02-20 D -3 WBC 0.09 x10^3/uL
    • 2023-02-19 D -4 WBC 0.09 x10^3/uL
    • 2023-02-17 D -6 WBC 0.23 x10^3/uL
    • 2023-02-15 D -8 WBC 0.86 x10^3/uL
    • 2023-02-13 D-10 WBC 1.36 x10^3/uL
    • 2023-02-12 D-11 WBC 1.70 x10^3/uL
    • 2023-02-10 D-13 WBC 4.40 x10^3/uL
    • 2023-02-08 D-15 WBC 9.26 x10^3/uL

2023-03-03

[therapeutic drug monitoring for cyclosporine]

  • The dose of cyclosporine was increased from the original 140mg to 145mg on a later time on 2023-03-01, and further increased to 170mg on 2023-03-02, while the dosing frequency remained Q12H.

  • The TDM for cyclosporine was performed on 2023-03-02 at 08:26:39, and the administration time was recorded as 2023-03-02 11:46. The scheduled administration times for Q12H should be 09:00 and 21:00, and the later actual administration time may be due to delayed medication or delayed registration in the system, so it is recommended to confirm the system usage with nursing staff. However, the 08:26 blood draw is consistent with the trough concentration at Q12H.

  • Since the dose increase has not reached steady state, it is recommended to perform another blood draw in the middle of next week.

2023-03-01

[cyclosporine TDM]

  • The cyclosporine TDM result was 79.3 ng/mL, with the blood sample drawn on February 27, 2023 at 09:09:34 and the medication given at 08:46 on the same day.
  • Since the blood sample was drawn shortly after the medication was given, the measured concentration is unlikely to be a trough concentration.
  • If a trough concentration is desired, a new blood sample should be drawn and tested.

2023-02-24

[therapeutic drug monitoring]

Sandimmun injection (ciclosporin)

  • The recommended therapeutic trough concentration range for cyclosporine typically falls within 100-400 ng/mL. The current administration is 140mg IVD Q12H.

  • Based on the TDM result on 2023-02-23 indicating a level of 43.3 ng/mL, it is suggested to administer a dosage of 180 mg per shot every 12 hours.

  • It is also recommended to perform another blood test to examine the trough concentration in the latter half of next week.

2023-02-09

  • 2023-02-08 Cre 0.72mg/dL, eGFR 136, BUN 19mg/dL, Bil T 0.7mg/dL, Bil D 0.1mg/dL, ALT 455 U/L, AST 123 U/L. The kidneys do not appear to be degraded.
    • Patient body height 180cm, body weight 97kg => BSA 2.2m2
  • Selected chemotherapy drugs in the FuCyMito conditioning regimen
    • fludarabine 30mg/m2 => 66mg, compatible with D5W, NS, L-Ringer’s
      • 250mL NS, 1h is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, dosage adjustment for hepatic impairment is not likely necessary (Krens 2019).
    • cytarabine 2000mg/m2 => 4400mg, compatible with D5W, D5NS, Sterile water for injection
      • 500mL NS, 6hr is recommended. (according to Trad Chinese package insert, max conc is 100mg/mL)
      • Dose may need to be adjusted in patients with liver failure since cytarabine is partially detoxified in the liver. There are no dosage adjustments provided in the manufacturer’s labeling.
    • mitoxantrone 6mg/m2 => 13.2mg, compatible with D5W, D5LR, D5NS, NS, L-Ringer, Ringer
      • 500mL NS, 3hr is recommended.
      • There are no dosage adjustments provided in the manufacturer’s labeling; however, clearance is reduced in hepatic dysfunction.

2023-01-30

  • The echocardiography performed on 2023-01-06 showed an improved LVEF (55% versus 33%) compared to 2022-11-11.

  • Readings of bilirubin (direct/total) are within normal limits. AST/ALT levels indicate that impaired liver function is improving. There is no need to adjust the dose of medications in the active prescription for liver function. In addition, there is no laboratory evidence of impaired kidney function.

    • 2023-01-30 S-GOT/AST 60 U/L
    • 2023-01-28 S-GOT/AST 67 U/L
    • 2023-01-27 S-GOT/AST 78 U/L
    • 2023-01-30 S-GPT/ALT 129 U/L
    • 2023-01-28 S-GPT/ALT 154 U/L
    • 2023-01-27 S-GPT/ALT 193 U/L
  • In spite of the fact that Hydrea (hydroxyurea) has been administered since 2023-01-27 afternoon, there has not been an obvious decrease in WBC counts since the second day of administration. The blast percentage remains around 60% with only minor fluctuations.

    • 2023-01-30 WBC 76.58 x10^3/uL
    • 2023-01-29 WBC 73.19 x10^3/uL
    • 2023-01-28 WBC 77.15 x10^3/uL
    • 2023-01-27 WBC 94.09 x10^3/uL
    • 2023-01-30 Blast 61.9 %
    • 2023-01-29 Blast 58.7 %
    • 2023-01-28 Blast 59.6 %
    • 2023-01-27 Blast 61.0 %
  • The PLT count has been trending downward, which should be closely monitored.

    • 2023-01-30 PLT 87 x10^3/uL
    • 2023-01-29 PLT 85 x10^3/uL
    • 2023-01-28 PLT 111 x10^3/uL
    • 2023-01-27 PLT 148 x10^3/uL
  • The active prescription does not pose a problem.

2023-01-27

[drug identification]

  • We have been requested by the patient’s primary nurse to identify one drug. The drug is identified as Vemlidy (tenofovir alafenamide 25 mg) and is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults and pediatric patients 12 years of age and older with compensated liver disease. The in-hospital porter will return the identified drug to the ward.

  • Not used:

    • The drug to be identified has not been received until the end of the working day.
    • As of the end of working hours, the drug to be identified has not been received.

700698086

230410

[exam findings]

  • 2023-04-10 SONO - abdomen
    • Parenchymal liver disease
    • Fatty liver, mild
    • Mild CBD dilatation
    • Chronic kidney disease
    • Urinary retention
    • Minimal ascites
  • 2023-04-06 MRI - brain
    • MR of the brain and MRA of the intracranial vessels and neck carotid systems were performed on a 1.5 T superconducting magnet on supine position utilizing head coil with 6 mm slice thickness and 24 cm field of view without intravenous injection of Gadolinium.
    • Findings:
      • One small cavernous malformation (5.3mm) over right posterior corona radiata.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
      • Mild paranasal sinusitis.
  • 2023-03-28 CXR
    • Solitary pulmonary nodule at right lower lung zone.
    • Normal appearance of trachea and bil. main bronchus.
    • Cardiomegaly.
  • 2023-03-28 ECG
    • Sinus tachycardia
    • Voltage criteria for left ventricular hypertrophy
  • 2023-03-07 CT - brain (at TMUH)
    • Computed tomography of the BRAIN was performed without i.v. contrast administration.
    • Findings:
      • No evidence of acute intracranial hemorrhage (ICH) or space occupying lesion is noted in this study.
      • Widening of the cortical sulci of bilateral cerebral hemispheres, mild dilatation the ventricles, the findings are indicating diffuse brain atrophy, due to aged brain change.
      • Normal mastoid air cells, no evidence of mastoiditis.
      • The paranasal sinuses are clear.
      • Clinical correlation and follow up is needed.
    • IMPRESSION:
      • No evidence of acute ICH or space occupying lesion is noted.
      • Diffuse brain atrophy, due to aged brain change.
  • 2022-11-07 CT - chest (at TMUH)
    • Findings: Chest CT without IV contrast study that show: Lung window-setting is also obtained.
      • Still focal consolidative lesion and internal amorphous calcifications in LLL, relatively prominent, as compared with prior CT on 2022-08-19, consistent with post-treatment change.
      • New small nodules in RLL, favored metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.
      • Degenerative spondylosis with marginal spur over thoracolumbar spine.
      • Otherwise, there is no evidence of masses in the anterior, middle and posterior compartment.
      • The hilar region on each side is unremarkable, and the main bronchi appear normal.
      • There is no lymphadenopathy and there are no perihilar masses.
      • The heart has a normal configuration; the cardiac chambers are normal size.
      • No evidence of abnormalities of liver, GB, pancreas, spleen, bilateral kidneys and adrenal glands.
    • IMPRESSION:
      • Post-treatment change of LLL, with focal consolidations and internal amorphous calcifications, relatively prominent, as compared with prior CT on 2022-08-19. Recommend follow-up.
      • But new presence of RLL metastatic nodules.
      • Mild left pleural effusion.
      • Mild fibrotic foci in bilateral lungs.
      • Arteriosclerotic changes with mural calcifications of aorta and coronary arteries, suspect CAD.

[consultation]

  • 2023-04-06 Neurology
    • Q
      • Impression
        • Acute delirium, suspected psychotic symptoms due to other medical condition, especially brain metastesis and renal failure
      • Suggestion
        • Treat malignancy and renal failure first. Non-contrast brain MRI could not clearly show malignancy. Please arrange contrast-enhanced brain CT instead, but beware of deterioration of renal failure and risk of developing end-stage renal failure.
        • Please consult neurosurgeon for brain metastasis treatment.
        • Check TSH, free T4, cortisol, ACTH, VDRL, vitamin B12, and folic acid. Treat them accordingly if abnormal findings.
        • I agreed with the psychiatrist’s suggestion of anti-psychotic medication (quetiapine). Please contact psychiatrist for further anti-psychotic drugs adjustment.
  • 2023-04-03 Nephrology
    • Q
      • For poor renal function, we need your further evaluation and management.
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was well, speech was coherent and showed no signs of distress. His limbs were not edematous.
      • He complained of poor appetite and minimal fluid intake over the past few days. Blood tests showed progressively deteriorating renal functions but he still urinates approximately 1L everyday.
        • 2023-04-03 BUN 65 mg/dL
        • 2023-04-03 Creatinine 5.29 mg/dL
      • Our advices are as follow:
        • consider ketosteril 2 PC PO TID
        • Keep daily I/O balance
        • CKD diet (Low K, low P)
        • Arrange renal sonography
        • OPD follow up prn
      • Please feel free to contact us should you require further assistance.
  • 2023-04-03 Psychosomatic Medicine
    • Q
      • The patient is restless and keeps saying he wants to find Chen Shui-bian, claiming that Chen Shui-bian is his friend. He is making phone calls everywhere and asking for money from anyone he meets, and he keeps saying that he is going to die. He throws all his belongings on the bed and ties the IV stand to the bed curtain.
    • A
      • This 80-year-old married man previously worked in the construction industry. According to his daughter, he was able to arrange his life and had good memory and daily function, such as supervising construction work in Luodong and taking walks in the park, until one week ago when he developed agitated and disruptive behaviors, such as attacking family members and lying down on the road. He also experienced auditory hallucinations, reality distortion, and hallucinatory behaviors, such as believing that Chen Shui-bian would come to talk to him for 15 minutes every day and telling him to do things. Poor sleep and disturbing behaviors persisted after admission, such as frequently borrowing money from the nursing station and seeking out Chen Shui-bian. The other hospital had diagnosed him with brain metastases. Brain MRI showed white matter intensities.
      • During the mental status examination, he displayed incoherent and irrelevant speech, disorientation (unable to tell the date or how many days he had been hospitalized, and thought he was at VGHTPE), talkativeness, auditory hallucinations, reality distortion, and hallucinatory behaviors.
      • IMP:
        • Acute delirium
        • Suspected Psychotic disturbance due to other medical condition (brain metastesis)
      • Suggestion:
        • Treat physical disease if possible.
        • DC mirtazapine, DC anxiedin. DC PRN haldol. Add utapine 25mg 1# HS, 1# HSPRN. Bini-U 5mg IM PRNQ6H if severe disturbing. Monitor ECG and QTC.
        • Tapper codeine and morphine use if possible.

[SOAP]

  • 2023-03-28 Medical Emergency
    • Hx of
      • Rectal cancer adenocarcinoma T3N0M0, stage IIA post anterior resection on 2015/1/23 and received radiotherapy about 45 Gy/25 fractions from 2015/02/23 to 2015/03/27 and lung metasteses, T3N0M1, stage IV in 2020, ECOG:2
      • Suspect obstructive pneumonitis
      • Left side pleural effusion
      • Hypertension
      • Chronic kidney disease, stage 4
    • Preliminary impression
      • C20 Malignant neoplasm of rectum
      • Agitation, Hx rectal Ca s/p op, R/T, lung metas (not treated), K 7 (hemolysis), F/U K 5, hsT 45 to 40, Hb 9, Cr 4.7, Hx HCVD, CKD

[multiteam]

  • 2023-03-31 Social Service
    • Referral Date: 2023-03-29
    • Reason for Referral: Patient and family members have emotional distress during hospitalization
    • Status: Not opening a case
    • Reason for Not Opening a Case: On 2023-03-30, separate interviews were conducted with the patient and the patient’s daughter:
      • Family Situation:
        • The patient is an 80-year-old married man with three daughters and one son. He is suffering from rectal cancer and has received treatment at TMUH in the past. He used to live alone in Yilan, but has been living with his son’s family in Taipei in recent years.
        • The patient’s wife is bedridden; the patient’s children are all married. The patient’s son and daughter-in-law currently live with the patient and the patient’s daughter in Zhonghe District. The patient’s daughter is currently unemployed and takes care of the patient full-time.
      • Assessment and Treatment:
        • The patient was admitted to the hospital due to a suicide attempt, which had been reported upon his arrival at the emergency department.
        • A social worker visited the patient’s ward today and found that the patient’s mood was stable, and he even smiled during the conversation. The patient said that he was feeling emotionally stable at the moment, but had trouble sleeping the night before. He was only able to fall asleep after being given sleeping pills. The patient also said that he did not remember what had happened before his hospitalization and was unsure who he was living with now.
        • The social worker talked with the patient’s daughter, who said that the patient’s recent abnormal behavior was likely caused by his illness, and the patient has forgotten what had happened during that time. The patient’s mood is stable when there are family members accompanying him. The patient’s daughter said that the patient has not yet received treatment from any relevant departments regarding his condition. However, she plans to take the patient to see a neurologist and other relevant departments in the future. The patient’s daughter is also currently taking care of the patient full-time and will continue to monitor his emotional changes.
        • This referral provides the above assessment and treatment information. It is confirmed that the patient’s suicide attempt had been reported upon his arrival at the emergency department. During his hospitalization, the patient’s mood has been stable, and he has cooperated with relevant medical treatments. The patient’s children are supportive and able to monitor his emotional changes in a timely manner. There are currently no emerging issues.

700183019

230406

[exam findings]

  • 2023-02-08 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some C- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2023-02-08 MRI - nasopharynx
    • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T:2(T_value) N:2cP16-, N2 P16+(N_value) M:0(M_value) STAGE:IVA P16-; II P16+(Stage_value)
  • 2023-02-07 SONO - abdomen
    • Liver cyst, S7
    • Gallbladder polyp or stone
  • 2023-01-27 Patho - nasopharyngeal/oropharyngeal biopsy
    • Tonsillar, left, biopsy — Squamous cell carcinoma, non-keratinizing and poorly differentiated (p16+)
    • Immunohistocyhemical stain reveals p16: positive (> 90%), CK: positive, and P40: positive
  • 2023-01-20 Nasopharyngoscopy
    • Findings
      • refer from neuro OPD
      • Suggest ENT evaluation.
    • Diagnosis/Conclusion
      • Nasopharyngoscope:
        • left deviated septum, bil. boggy turbinate
        • although NP was smooth, but MRI showed mild mucosal thickening at right lateral nasopharyngeal recess.
      • Oral:
        • left tonsillar hypertrophy - tumor lesion should rule out
        • biopsy done
  • 2023-01-12 MRA - brain
    • Indication: still complained about vertigo and unsteadiness
    • IMP:
      • Cerebral small vessel disease.
      • Mild mucosal thickening at right lateral nasopharyngeal recess. Suggest ENT evaluation.
  • 2022-11-16 Mini-Mental Status Examination
    • MMSE 23
  • 2022-11-16 Clinical Dementia Rating
    • CDR 0.5
  • 2022-11-10 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2022-11-10 Neurosonology
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Normal PSV in bilateral ICA and CCA. Normal ICA/CCA PS ratio bilaterally
    • Adequate total VA flow (135) may suggest no evidence of VBI
  • 2021-07-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (83.5 - 18.3) / 83.5 = 78.08%
      • M-mode (Teichholz) = 78.1
    • Conclusion:
      • Normal AV with no AR
      • Normal MV with trivial MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, normal IVC size

[chemotherapy]

  • 2023-03-22 - carboplatin AUC 2 120mg D5W 500mL with NS 1000mL (CCRT, carboplatin determ by AUC 2)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-15 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-07 - cisplatin 40mg/m2 70mg NS 500mL with with NS 1000mL (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • Most patients achieve cooling of the oral mucosa through intraoral administration of ice chips during chemotherapy administration. This is a cost effective and proven beneficial treatment.

  • Both topical and systemic analgesic approaches have been used to manage pain associated with mucositis.

    • Topical lidocaine solutions provide pain relief but require frequent administration. In one trial, topical viscous lidocaine (2 percent) was more effective than diphenhydramine and saline, a kaolin and pectin suspension, or placebo. ref: Treatment of radiation- and chemotherapy-induced stomatitis. Otolaryngol Head Neck Surg. 1990;102(4):326-330. doi:10.1177/019459989010200404
    • Topical lidocaine is frequently combined with cleansing and/or coating agents, a mixture that is often referred to as “miracle mouthwash.” There is no fixed formulation, and these mixtures are compounded differently by individual pharmacies, most of which have no set formula. ref: Survey of topical oral solutions for the treatment of chemo-induced oral mucositis. J Oncol Pharm Pract. 2005;11(4):139-143. doi:10.1191/1078155205jp166oa
  • Currently, lidocaine 2% PO PRNQD and tramadol IVD PRNQ6H have been prescribed.

  • The diet should be limited to foods that do not require significant chewing; acidic, salty, or dry foods should be avoided.

  • If poor feeding compromises the patient’s nutritional status, placement of a nasogastric feeding tube may be considered.

700360398

230406

[diagnosis] - 2023-04-03 discharge note

  • Immune thrombocytopenic purpura
  • Essential (primary) hypertension

[lab data]

  • 2023-02-23 HBsAg Nonreactive

  • 2023-02-23 HBsAg (Value) 0.35 S/CO

  • 2023-02-23 Anti-HCV Nonreactive

  • 2023-02-23 Anti-HCV Value 0.07 S/CO

  • 2023-02-23 Anti-HBs 11.15 mIU/mL

  • 2023-02-23 Anti-HBc Reactive

  • 2023-02-23 Anti-HBc-Value 6.43 S/CO

  • 2023-02-23 Anti-HBc IgM Nonreactive

  • 2023-02-23 Anti-HBc IgM Value 0.10 S/CO

  • 2023-02-10 ANA Negative

  • 2023-02-10 LA1 39.3 sec

  • 2023-02-10 LA2 30.7 sec

  • 2023-02-10 LA1/LA2 ratio 1.2

  • 2023-02-08 Anti-Cardiolopin IgG 0.7 GPL-U/mL

  • 2023-02-08 Anti-cardiolipin-IgM <0.8 MPL U/mL

  • 2023-02-08 Anti-β2-glycoprotein-I Ab 0.9 U/mL

  • 2023-02-08 Anti-ENA Sm 1.2 EliA U/ml

  • 2023-02-08 Anti-ENA RNP 1.1 EliA U/ml

[SOAP]

  • 2023-03-10 Hemato-Oncology
    • Plan:
      • continue steroid therapy
      • arrange admission for mabthera therapy
  • 2023-02-15 Hemato-Oncology
    • Assessment:
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan:
      • continue steroid x 1 week
      • suggest bone marrow study if persisted thrombocytopenia
  • 2023-02-08 Hemato-Oncology
    • S/O
      • He was referred on account of thrombocytopenia, referred from Cardinal Tien Hospital. Dr. Ou
        • 2021-10-24 PLT 135K/cumm
        • 2023-01-11 PLT <10K
        • 2023-01-16 PLT <10K
        • 2023-01-25 PLT <10K
        • 2023-02-08 PLT <10K
      • Past history: Nothing in particular.
      • Family history: No systemic disease in the family members.
      • Personal history: Smoking (no), alcohol consumption (no), betel nut chowing (no)
      • Allergy: NKA.
      • Travel history: No traveling history within one month.
      • Occupation: None
    • Assessment
      • ITP, suggest steroid therapy 1 mg/kg
    • Plan
      • Check BCS
      • Check CBC&DC, PT, aPTT, bleeding time and stool OB
      • Check CXR

[immunotherapy]

  • 2023-04-03 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-03-17 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL
  • 2023-02-23 - rituximab 375mg/m2 700mg NS 500mL 8hr
    • hydrocortisone 100mg + diphenhydramine 30mg + granisetron 1mg + acetaminophen 500mg PO + NS 250mL

[assessment]

  • The patient’s PharmaCloud is currently inaccessible. However, based on in-hospital records, the patient received prednisolone at a dose of 80mg daily from 2023-02-08 to 2023-02-22, and dexamethasone at a dose of 8mg daily from 2023-03-10 to 2023-04-07. The patient also received rituximab on 2023-02-23, 2023-03-17, and 2023-04-03.

  • The peak in PLT count on 2023-03-01 occurred approximately 1 week after the first dose of rituximab and was not during steroid administration. There has been no similar increase since the second dose of rituximab. It is possible that this peak was due to the delayed effect of rituximab, which can take some time for platelet production to increase after treatment. However, without further information, it is difficult to determine the exact cause. Close monitoring of the patient’s platelet levels and response to treatment is recommended.

    • 2023-04-03 PLT 7 x10^3/uL
    • 2023-03-24 PLT 6 x10^3/uL
    • 2023-03-17 PLT 27 x10^3/uL
    • 2023-03-10 PLT 4 x10^3/uL
    • 2023-03-01 PLT 113 x10^3/uL
    • 2023-02-27 PLT 13 x10^3/uL
    • 2023-02-24 PLT 21 x10^3/uL
    • 2023-02-23 PLT 1 x10^3/uL
    • 2023-02-22 PLT 1 x10^3/uL
    • 2023-02-15 PLT 1 x10^3/uL
    • 2023-02-08 PLT 2 x10^3/uL
  • Lab data from 2023-02-08 and 2023-02-10 showed normal values for ANA, LA1, LA2, LA1/LA2 ratio, anti-cardiolipin IgG, anti-cardiolipin IgM, anti-beta2-glycoprotein-I Ab, anti-ENA Sm, anti-ENA RNP, and PT, INR, APTT.

  • In the event that rituximab is no longer effective, splenectomy or TPO-RAs may be considered options.

700028729

230403

{EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB - not completed}

[diagnosis] - 2023-04-02 admission note

  • Malignant neoplasm of upper lobe, right bronchus or lung
  • Secondary malignant neoplasm of liver and intrahepatic bile duct
  • Chest pain, unspecified
  • Acute kidney failure, unspecified

[past history]

  • Denied history of Hypertension, DM, asthma
  • Denied any operation, accident and other medical Hx.                            

[allergy]

  • NKDA         

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes. 

[exam findings]

  • 2023-04-02, -03-09, -02-10, -02-06 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • S/P port-A implantation.
    • Patchy opacity projecting in the right upper lung shows stationary.
    • Peri-bronchial wall thickening of bilateral lower lung zone is noted, which may be due to old inflammatory process. Please correlate with clinical history and symptom.
  • 2023-03-24 MRI - branchial plexus
    • Indication: right arm pain from shoulder to arm, twitching like. better on lying down and hot packing. motion exacerbated.
    • Phx: lung ca.
    • MRI of brachial plexus without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneously enhancing tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • multiple high signal lesions in visible spine and ribs, compatible with bone metastases.
      • massive left pleural effusion.
    • Impression:
      • Multiple tumors at right supraclavicular region, right intercostal spaces, and right upper mediastinum, involving right ribs, right hemithorax apex, and involving right brachial plexus.
      • Multiple ribs and spine metastases.
  • 2023-01-19 SONO - nephrology
    • Left small kidney with chronic parenchymal changes.
    • Hyperechoic pyramids, both kidney, suspected nephrocalcinosis secondary to hypercalcemia, suspected gout or anagelsic nephropathy.
    • Bilateral plerual effusions.
  • 2023-01-17 Abdomen - standing (diaphragm)
    • Right side Pneumothorax with air-fluid level at right CP angle.
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • There are several small stones in bilateral kidney?
    • Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2023-01-16 SONO - chest
    • Special Procedure:
      • Pleural tapping 16 #-needle Right side 950ml yellowish, clear
      • Pleural tapping 16 #-needle Left side 1080ml yellowish, clear
    • Echo diagnosis:
      • Bilateral massive pleural effusion, post left diagnostic and bilateral therapeutic thoracentesis.
  • 2023-01-14, -01-05 CXR
    • Patchy opacity projecting in the right upper lung
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • Emphysematous change of both lung field
  • 2022-12-29 CT - chest

EGFR wild type Adenocarcinoma of RUL with liver metastases,T4N0M1c,stageIVB

Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)

Chest CT without IV contrast ehnancement shows: Chest: S/p port-A placement with its tip at Superior vena cava. Massive bilateral pleural effuison and loculated effusion at right hemithorax is found. Patent airway is found. There is no evidence of mediastinal LAP

Visible abdomen: Atrophy of both kidneys are found. The GB is well distended without soft tissue lesion The spleen, pancreas and adrenals are intact. Low density lesion at S4 and S2 of liver is found. Liver meta is considered. In comparison with CT dated on 2022-09-28, regression of the tumor is found. There is no evidence of paraarotic LAPs. There is no ascites accumulation at abdominal cavity. Suggest clinical correlation

Imp: Loculated effusion at both hemithorax. Liver tumor, in regression.

  • 2022-12-27 SONO - chest
    • Bilateral thorax: large amount pleural effusion s/p drainage of left side, 850 cc, yellowish pleural effusion.
  • 2022-12-06 KUB
    • There are several small stones in bilateral kidney? Please correlate with sonography.
    • Few small calcification projecting at left lower pelvis are noted that may be ureter stones or old granulomas?
  • 2022-09-28 CT - abdomen

History:眩暈,想吐,表偶爾會流鼻水,有血絲 Nausea without vomit for 2-3 days, mild dizziness SOB sometimes, very mild Abd distension since last chemo(6 days ago) 20220705 CT:RUL lung ca & liver mets;T3N2M1c, cSTAGE:IVB

MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT with axial and coronal reformated isotropic images were obtained in non-contrast scan.

This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.

Findings: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. There are bilateral extensive destructive centrilobular emphysema with upper lobes predominant. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT. 3. Prior CT identified few cysts in S1 and S2 are noted again, stationary. 4. There are several renal stones, bilateral. Both kidney show small size and thin parenchyma that are c/w chronic renal disease. 5. There is no hyper-or hypodense lesion in the gallbladder, biliary system, pancreas, and spleen. There is no ascites or lymphadenopathy. There is no bowel wall thickening, and no bowel obstruction. The abdominal aorta and IVC are grossly unremarkable. There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.

IMP: 1. Prior CT identified liver metastases in both lobes are noted again, mild decreasing in size. Please correlate with contrast enhanced dynamic CT or MRI. 2. Prior CT identified RUL lung periphereal mass measuring 5.2 cm is noted again, decreasing in size. Please correlate with contrast enhanced CT.

  • 2022-09-28 KUB
    • increased air in nondistended loops of small bowel over LUQ and LLQ, could be paralytic ileus.
  • 2022-09-28 CXR
    • areas of hyperlucency and decreased lung vascular markings dirty marking due to emphysematous change of both lungs upper lung predominance
    • ill-define consolidation in peripheral of RUL due to tumor
  • 2022-08-09 ALK Immunostaining Result
    • The immunostaining of the section slide labeled S2022-11085, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
  • 2022-07-20 CT - brain
    • no evidence of brain tumors.
  • 2022-07-26 ROS1 fluorescent-in-situ hybridization (FISH) report
    • Result
      • Number of invasive tumor cells counted: 50
      • Number of observers: 1
      • Number of cells (%) classified as negative: 48 (96%)
      • Number of cells (%) classified as positive: 2 ( 4%)
    • Interpretation
      • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
  • 2022-07-15 PD-L1 (SP142)
    • Pathologic Report for VENTANA PD-L1 (SP142) Assay for Non-Small Cell Lung Cancer
      • Tumor type: Adenocarcinoma, metastatic
      • Tumor location: Liver
      • Testing assay: SP142 Assay (Ventana)
      • Control slide result: [V]Pass, [ ]Fail
      • Adequate tumor cells present (>=100 viable tumor cells): [V] Yes, [ ] No
    • Result:
      • Tumor Cell Staining Assessment:
        • PD-L1 Expression: Absence of any discernible PD-L1 membrane staining in tumor cells (TC < 50%)
      • Tumor Infiltrating Immune Cell Staining Assessment:
        • PD-L1 Expression: < 3% Immune cells (IC < 10%)
    • Note:
      • Percent of PD-L1 expression in tumor cells (TC): The percentage of viable tumor cells with membrane positivity at any intensity
      • Percent of PD-L1 expression in immune cells (IC): The percentage of tumor-infiltrating immune cells with discernible staining of any intensity
  • 2022-07-15 EGFR mutation
    • No mutation was detected at exons 18, 19, 20, 21 of EGFR gene in this specimen.
      • EGFR Status: no mutation detected
      • EGFR Mutation Status: no mutation detected
    • Description
      • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 25 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees, in whole body survey.
    • IMPRESSION:
      • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the maxilla, sternum, some T-spine, bilateral shoulders, S-I joints, and knees.
  • 2022-07-12 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, consistent with lung primary
    • The sections show a picture of adenocarcinoma, composed of liver tissue with nests and cords of polygonal neoplastic cells in fibrous stroma. Focal glandular differentiation and tumor necrosis are present.
    • IHC shows: CK7(+), CK20(-), TTF1(+), Arginase-1(-), and Hepatocyte(-). The finding is consistent with metastatic adenocarcinoma, lung primary.
  • 2022-07-09 CTA - chest
    • PH: emphysema
    • With and Without contrast Chest CT and CTA showed
      • emphysematous change in the bilateral lung fields; a heterogeneous enhancing lesion, about 52mm, in the upper lobe of the right chest. suspected chest wall or pleural tumor or lung tumor. Irregular margins was noted.
      • multiple heterogeneous ill-defined tumors in the bilateral lobes of the liver, esp. left side
      • small bilateral renal stones.
    • IMP:
      • suspected right pleural or lung tumor
      • mulitple hepatic tumors
  • 2022-07-05 CT - chest
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M1c(M_value) STAGE:____(Stage_value)
  • 2022-07-02 CXR
    • upper lung hyperlucency and decreased upper lung vascular markings due to emphysema
    • Rt apicolateral pleural effusion or thickening

[SOAP]

  • 2022-09-22 Hemato-Oncology
    • EGFR, ROS1, ALK all wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stageIVB
    • No fit for cisplatin doublet due to imparied renal function
      • ChatGPT: “Cisplatin doublet” is a type of chemotherapy regimen used to treat various types of cancer, such as lung cancer, bladder cancer, and ovarian cancer. It consists of a combination of two chemotherapy drugs, with cisplatin being one of them, and the other drug depending on the specific cancer being treated. The doublet regimen is used to increase the effectiveness of chemotherapy by combining two drugs with different mechanisms of action, which can enhance tumor cell kill and reduce the likelihood of drug resistance.
  • 2022-08-23 Hemato-Oncology
    • Fail alimta but starting with weekly taxane
  • 2022-07-29 Hemato-Oncology
    • BH 169, BW 52
    • EGFR wild type Adenocarcinoma of RUL with liver metastases, T4N0M1c, stage IVB

[chemotherapy] (not completed)

  • 2023-01-05 - docetaxel 35mg/m2 54mg D5W 150mL 1hr (WBC 1.3K/uL 2023-01-12, WBC 2.15K/uL 2023-01-14)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg + NS 250mL
  • 2022-12-15 - ditto (WBC 1.87K/uL 2022-12-22, WBC 1.42K/uL 2022-12-26)

  • 2022-12-01 - ditto (WBC 2.54K/uL 2022-12-13)

  • 2022-11-15 - ditto (WBC 2.67K/uL 2022-11-29)

  • 2022-11-03 - ditto

  • 2022-10-25 - ditto

  • 2022-10-18 - ditto

  • 2022-10-06 - ditto

  • 2022-09-22 - ditto

  • 2022-09-15 - ditto

  • 2022-09-01 - ditto

  • 2022-08-25 - ditto

  • 2022-08-10 - ditto

  • 2022-07-19 - pemetrexed 500mg/m2 818mg NS 100mL 10min + NS 500mL 1hr (before cisplatin) + cisplatin 75mg/m2 120mg NS 500mL 3hr + NS 500mL 1hr (after cisplatin)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

[medication]

  • G-CSF (filgrastim 150ug) CGCSF01
    • 2022-12-26 - 2022-12-26 IPD
    • 2022-12-13 - 2022-12-13 OPD
    • 2022-11-29 - 2022-11-29 OPD
    • 2022-08-23 - 2022-08-23 OPD
    • 2022-08-07 - 2022-08-07 IPD
  • Granocyte (lenograstim 250ug) CGRAN01
    • 2023-01-12, 13, 14 - 2023-01-12 OPD

[assessment]

  • The patient is currently undergoing supportive and palliative treatment to alleviate his symptoms.
  • Cisplatin was not administered due to his insufficient renal function.
  • He experienced several episodes of leukopenia during chemotherapy, for which G-CSF was used to mitigate the side effects.
  • The last dose of docetaxel was administered on 2023-01-05.

700871378

230403

[diagnosis] - 2023-04-02 admission note

  • Diffuse large B-cell lymphoma, unspecified site
  • Essential (primary) hypertension
  • Chronic viral hepatitis B without delta-agent

[past history]

  • hypertentsion under medication control for 20+ years

[allergy]

  • NKDA                             

[family history]

  • Younger sister has lymphoma

[lab data]

2023-04-03 HBsAg Nonreactive
2023-04-03 HBsAg (Value) 0.52 S/CO
2023-04-03 Anti-HBc Nonreactive
2023-04-03 Anti-HBc-Value 0.91 S/CO
2023-04-03 Anti-HCV Nonreactive
2023-04-03 Anti-HCV Value 0.05 S/CO
2023-04-03 Anti HTLV I/II Nonreactive
2023-04-03 Anti HTLV I/II Value 0.05 S/CO
2023-04-03 HIV Ab-EIA Nonreactive
2023-04-03 Anti-HIV Value 0.06 S/CO
2023-04-03 CMV_IgG Reactive
2023-04-03 CMV_IgG Value 213.4 AU/mL
2023-04-03 CMV IgM Nonreactive
2023-04-03 CMV IgM Value 0.23 Index

[exam findings]

  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82.6 - 11.9) / 82.6 = 85.59%
      • M-mode (Teichholz) = 80.1
      • 2D(M-simpson) = 75.3
    • Conclusion:
      • Thickened AV with mild AR
      • Normal MV with no MR
      • Concentric LVH
      • Preserved LV and RV systolic function
      • No PR, no TR, mildly dilated LA
  • 2023-02-17 Myocardial perfusion SPECT with persantin
    • The Tl-201 stress myocardial perfusion SPECT performed after intravenous injection 33.6 mg of dipyridamole revealed mildly decreased perfusion of radioactivity to the apex and inferolateral wall. The Tl-201 redistribution myocardial perfusion SPECT revealed reperfusion of radioactivity to the defects and mildly decreased perfusion of radioactivity to the posterior wall.
    • IMPRESSION:
      • Probably mild myocardial ischemia at the apex and inferolateral wall.
      • Mild reverse redistribution of radioactivity to the posterior wall, either normal variant or myocardial ischemia may show this picture.
  • 2023-02-16 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-02-16 CT - chest
    • Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Minimal fibrotic change at left lingula lobe is found. Probably due to previous RT
        • The left breast tumor cannot be visualized in the study.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP
        • No evidence of bilateral pleural effusion.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • Bilateral renal cysts are found
        • The spleen, liver, pancreas and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • IMp:
      • Left breast cancer s/p RT and C/T without evidence of recurrent/residual tumor in the lung fields.
      • Suggest closely follow up.
  • 2022-11-02 CT - chest
    • Impression:
      • resolution of Lt breast tumor compared with CT on 2022-07-28.
      • extensive V-CAD, suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
  • 2022-09-24 KUB
    • S/P left femoral operation.
    • Atherosclerosis of the aorta.
  • 2022-08-02 Patho - bone marrow biopsy
    • Bone marror, biopsy— Negative for malignancy
    • Immunohistochemical stain revesls CD 20 (sparse +, < 5%), CD138 (sparse +, < 2%), CD71(+), MPO(+).
  • 2022-08-01 Whole body PET scan
    • Glucose hypermetabolism lesions in the left breast (Deauville score 5), compatible with lymphoma in the left breast.
    • Glucose hypermetabolism lesions in the left N-P region (Deauville score 5) and in bilateral axillary regions (Deauville score 3-4), the nature is to be determined (lymphoma or chronic inflammation/infection process ?), suggesting further investigation.
    • Glucose hypermetabolism lesions in bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature.
    • Lymphoma in the left breast, stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2022-07-28 CT - lung
    • Left breast cancer with left hilar lymphadenopathy
  • 2022-07-14 Patho - breast biopsy
    • Breast, left, core biopsy — Diffuse large B-cell lymphoma, in favor of non-GCB type
    • Section shows cores of breast tissue with invasion of large, pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. The results are in favor of non-GCB type of diffuse large B-cell lymphoma.
  • 2022-07-12 SONO - breast
    • Diagnosis:
      • Highly suspicious of malignancy, with sonographic negative axillary LNs
        • clacification
        • lipomas
    • Plan:
      • Core-needle biopsy
    • Suggestion:
      • Regular OPD follow-upsonography guided core biopsy of L’t breast tumor (1,1)
      • BI-RADS 4A - low suspicion for malignancy Biopsy Should Be Considered
  • 2022-07-04 Mammography
    • A 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast.
    • BI-RADS category 0, Need additional imaging evaluation.
    • Suggest ultrasound correlation for left breast tumor.

[consultation]

  • 2023-04-03 Vascular Surgery
    • Q
      • A case of Triple hit ,non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
        • will receive PBSC harvest this time, we need your expertise for double lumen insertion on 2023/04/14, thanks
    • A
      • I have had the pleasure of involving with the patient’s care. In brief, this patient is a 69 year old female seen in consultation for opinion regarding treatment options for double lumen insertion on 2023-04-14.
      • The pt’s hx/Dx was noted for
        • Diffuse large B-cell lymphoma, unspecified site
        • Essential (primary) hypertension
        • Chronic viral hepatitis B without delta-agent
      • Lab/CXR reviewed.
      • SUGGESTION & PLAN:
        • double lumen insertion will be arranged on R’t side on 2022/04/14 under LA, 8 AM.
  • 2023-02-09 Dermatology
    • Q
      • This 69 y/o woman has hypertentsion under medication control for 20+ years. She suffered from a 2.8cm lobular hyperdense mass with obscured margin at left subareolar breast mammography on 2022/07/05.
      • Owing to the symptom exacerbation, the patient called at our OPD for help. Breast sono showed highly suspicious of malignancy, with sonographic negative axillary LNs1 on 2022/07/16.
      • Biopsy on 2022/07/21 showed Diffuse large B-cell lymphoma, in favor of non-GCB type. CK(-), CD20(+), CD3(-), CD10(< 10% +), BCL6(> 90%+), BCL2(> 80% +), MUM1(> 80% +), cMYC(30% +), Cyclin D1(-). The Ki-67 is >90% positive. CT of chest was performed on 7/29 revealed Left breast cancer with left hilar lymphadenopathy.Port-A insertion on 2022/07/29. PET on 2022/08/01 showed glucose hypermetabolism lesions in the left breast, left N-P region, bilateral axillary regions, bilateral pulmonary hilar regions, right mediastinal space, bilateral palatine tonsils, and left hip joint, probably benign in nature. Bone marrow biopsy on 2022/08/02 showed negative of maglignancy. Under the diagnosis of Triple hit, non-GCB type of diffuse large B-cell lymphoma of left breast, left nasopharyngeal, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1.
      • She received C1 R-DAEPOCH (Vincristine not available) on 2022/08/03 ~ -08/08. C2 R-DAEPOCH was administered on 2022/08/29 ~ -09/03, C3 R-DAEPOCH on 2022/10/14 ~ 10/19.
      • Urgency and frequency was noted in August, 2022. Klebsiella pneumoniae urinary tract infection was noted.
      • Followed up CT on 2022/11/02 revealed resolution of Lt breast tumor compared with CT on 2022/07/28. extensive V-CAD,suggest further test for evaluation any hemodynamically significant stenosis of coronary arteries.
      • C4 R-DAEPOCH on 2022/11/14 ~ 2022/11/19.
      • She received the radiotherapy at 3240cGy/18 fractions of the left breast from 2022/12/6 ~ 12/31
      • However, Radiation dermatitis was noted after the radiotherapy. We need your expertise for further management,thanks
    • A
      • The patient had sufferred from itchy erythematous papules and plaques over left breat region.
      • Under the impression of post-radiation dermatitis
      • The following sugeetion:
        • keep oral allegra 1# bid use.
        • Rinderon-V cream 2 tube topical bid use over erytheamtous lesions first, if stable shift to Mycomb cream 1 tube bid use -> (Anti-inflammatory and redness-reducing)
          • body cream mix-up with sinphradem cream 1 tube (1:1) topical QN use.

[radiotherapy]

  • 2022-12-06 ~ 2022-12-31 - 3240cGy/18 fractions of the left breast

[chemoimmunotherapy] (not completed)

  • 2023-04-03 - rituximab 375mg/m2 598mg NS 500mL 8hr D1 + methylprednisolone 500mg NS 100mL 1hr D2-5 + etoposide 40mg/m2 63mg NS 250mL D2-5 + cisplatin 25mg/m2 40mg NS 500mL 18hr D2-5 + cytarabine 2000mg/m2 3000mg NS 500mL 2hr D6 (R-ESHAP)
    • dexamethasone 4mg D1-6 + diphenhydramine 30mg D1-6 + NS 250mL D1-6 + acetaminophen 500mg PO D1 + palonosetron 250ug D2-6
  • 2023-02-10 - rituximab 375mg/m2 580mg NS 500mL 8hr D1 + [etoposide 50mg/m2 77mg + vincristine 0.4mg/m2 0.6mg + doxorubicin 10mg/m2 15mg + NS 250mL] 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg NS 500mL 1hr D6 + prednisolone 60mg/m2 50mg PO BID D2-6 (R-DAEPOCH)
    • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + NS 250mL D1-5 + acetaminophen 500mg PO D1 + granisetron 2mg D2-6
  • 2023-01-12 - ditto R-DAEPOCH
  • 2022-11-14 - ditto R-DAEPOCH
  • 2022-10-14 - ditto R-DAEPOCH
  • 2022-08-29 - ditto R-DAEPOCH
  • 2022-08-03 - rituximab 375mg/m2 580mg 8hr D1 + etoposide 50mg/m2 77mg 24hr D2-5 + doxorubicin 10mg/m2 15mg 24hr D2-5 + cyclophosphamide 750mg/m2 1100mg 1hr D6 + prednisolone 60mg/m2 5mg/tab 10tab BID D2-6 (R-DAEPOCH without vincristine)

[note]

Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (ref: https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)

  • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
    • Administration – R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
    • Adverse effects – Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
    • Outcomes – A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

==========

2023-04-03

  • This time, the patient was admitted for PBSC collection.

2022-08-18

  • It is the first time the patient receive her first chemotherapy in this hospitalization.
  • 2022-08-17 CRP 7.2 mg/dL, 2022-08-18 01:14 body temperature 38.4 degree, Sintrix (ceftriaxone) and Mycostatin (nystatin) have been prescribed.

701134216

230403

[diagnosis] - 2023-04-01 admisstion note

  • Sepsis, unspecified organism
  • Fever, unspecified
  • Malignant neoplasm of rectosigmoid junction
  • Unspecified jaundice

[present illness] - 2023-04-01 admisstion note

  • The 57 y/o man has R-S colon with liver and bone mets s/p OP with colostomy on 2021 and closure it at Cardinal Tien Hospital in early 2023, chemotherapy also at that hospital, postive of anti-HBc.

[exam findings]

  • 2023-04-01 CT - abdomen
    • history: Rectal ca with liver mets and bone mets s/p OP with colostomy
    • With and without contrast enhancement CT of abdomen shows:
      • Recosigmoid colon CA, s/p operation.
      • Multiple lung metastasis.
      • Multiple liver metastasis.
      • Peritoneal nodules, r/o peritoneal carcinomatosis.
      • Enlarged lymph nodes in para-aortic region.
      • Mild compression fractures of L2,3,4.
    • Impression
      • Recosigmoid colon CA, s/p operation
      • Liver, lung, and lymph node metastasis
      • Peritoneal carcinomatosis
  • 2023-03-31 CXR
    • Multiple nodules at bil. lungs.
  • 2018-07-31 Fingers Rt
    • comminuted fracture of distal phalanx, 4th finger post pin fixation
  • 2018-06-19 Fingers Rt
    • fracture of distal phalanx, 4th finger post pin fixation, stable
  • 2018-06-15 Fingers Rt
    • Crush injury with distal phalange destruction is found.
    • Regional soft tissue swelling is identified.

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Admission for bilirubinemia then C/T
  • 2023-03-16 Hemato-Oncology
    • Last dose of Avastin plus FOLFOXIRI on 2023-03-09.
    • Apply cetuximab

[assessment]

  • The patient’s fever appears to have improved (with a temperature not exceeding 37.5 degrees Celsius) since the administration of Flumarin (flomoxef) on 2023-04-01. However, blood and urine cultures are not yet available.

  • The patient has a high bilirubin level and is icteric 2+. The elevation of serum alkaline phosphatase, which is out of proportion to the serum aminotransferases, indicates possible biliary obstruction or intrahepatic cholestasis. An increased serum alkaline phosphatase is also observed in granulomatous liver diseases, such as tuberculosis or sarcoidosis.

    • 2023-03-31 Alkaline phosphatase 996 U/L
    • 2023-03-31 S-GPT/ALT 50 U/L
    • 2023-03-31 Bilirubin direct 4.26 mg/dL
    • 2023-03-31 Bilirubin total 7.42 mg/dL
    • 2023-03-23 Bilirubin total 6.09 mg/dL
    • 2023-03-14 Bilirubin total 8.87 mg/dL
  • Based on the CT performed on 2023-04-01, there is evidence of liver, lung, lymph node metastasis, and peritoneal carcinomatosis. Further evaluation is recommended, such as ultrasound, magnetic resonance cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP) to investigate the presence of intra- or extrahepatic bile duct dilation.

  • The patient was prescribed Vemlidy (tenofovir alafenamide) appropriately following a positive anti-HBc test result on 2023-03-14.

  • According to PharmaCloud records, medications were prescribed for pulmonary symptoms at Cardinal Tien Hospital in January 2023. If these symptoms are no longer present, then there are no medication reconciliation issues.

700324624

230331

[diagnosis] - 2023-03-30 admission note

  • Malignant neoplasm of unspecified site of left female breast
  • Pleural effusion, not elsewhere classified
  • Acute pulmonary edema
  • Dyspnea, unspecified

[exam findings]

  • 2023-03-29 ECG
    • Atrial fibrillation
    • Low voltage QRS
    • Incomplete right bundle branch block
    • Possible Right ventricular hypertrophy
    • Possible Anterolateral infarct, age undetermined
    • Abnormal ECG
  • 2023-03-29 CTA - chest
    • Indication: Bilateral lower leg edema with shortness of breathing
    • With and Without contrast Chest CT and CTA showed
      • dilated main PA.
      • unremarkable change in the main bronchial trees and the visible trachea
      • consolidation in the lower lobes of the bilateral lung; two nodular lesions, about 17mm, in the upper lobe of the right lung; another small nodular lesion, about 14mm, in the upper lobe of the left lung.
      • moderate bilateral pleural effusion
      • unremarkable change in the chest wall
    • IMP:
      • nodular lesions in the upper lobes of the bilateral lung
      • moderate bilateral pleural effusion.
      • consolidation in the lower lobes of the bilateral lung.
      • no evidence of DAA or PE.
  • 2023-03-29 CXR
    • Unremarkable change in the visible trachea
    • Normal cardiac and vascular shadows
    • Lung markings: consolidation in the right lung field and left lower lung field
    • blurred bilateral hemidiaphrams
    • blunting bilateral costophrenic angles
    • Unremarkable change in bilateral clavicles

[assessment]

  • The patient’s renal function is showing signs of recovery.
    • 2023-03-31 Creatinine 0.91 mg/dL
    • 2023-03-29 Creatinine 1.33 mg/dL
    • 2023-03-31 eGFR 63.55
    • 2023-03-29 eGFR 41.01
  • On 2023-03-31, Ocillina (oxacillin sodium), Rolikan (sodium bicarbonate), and 0.9% saline were prescribed, which may relieve hyponatremia.
    • 2023-03-31 Na (Sodium) 131 mmol/L
    • 2023-03-29 Na (Sodium) 123 mmol/L
  • Hypokalemia was observed on the morning of 2023-03-31, which may be due to the administration of furosemide, which was started on 2023-03-30 after normal serum potassium was detected on 2023-03-29. There were 3 bowel movements without diarrhea recorded on 2023-03-30.
    • 2023-03-31 K(Potassium) 3.3 mmol/L
    • 2023-03-29 K(Potassium) 4.0 mmol/L
  • Please consider prescribing a potassium supplement if necessary and continue to closely monitor the patient’s serum electrolytes. An alternative option is to consider using the combination of furosemide and spironolactone with adequate sodium supplementation and blood pressure monitoring to prevent hypotension.

700892422

230331

[diagnosis] - 2023-03-10 discharge note

  • Squamous cell carcinoma of left upper lip cT4aN0M0 cstage IVA in process chemotherapy
  • Infection of the upper lip
  • Encounter for antineoplastic chemotherapy
  • Hypertension
  • Verrucous carcinom of right buccal mucosa and tongue post of 2017.

[exam findings]

  • 2023-02-01 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two faint hot areas at the T7 and L2-3 spines, respectively, faint hot spots in both rib cages, and increased activity in the maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • Two faint hot areas at the T7 and L2-3 spines, respectively, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, maxilla, C-spine, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-01-31 MRI - nasopharynx
    • Indication: Malignant neoplasm of upper lip, inner aspect
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • A upper lip tumor mass, up to 4.4 cm, with bone destruction.
      • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Multiple oral cavity cancers s/p operation.
    • IMP: Upper lip CA, T4N0M0 Stage IVA.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4A(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA(Stage_value)
  • 2023-01-31 SONO - abdomen
    • GB stone, multiple
    • Adenomyomatosis of GB
  • 2023-01-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Inferior infarct , age undetermined
    • ST & T wave abnormality, consider lateral ischemia
    • Abnormal ECG
  • 2023-01-05 Patho - gingival/oral mucosa biopsy
    • Chronic red lesion, left upper lip, incisional biopsy — Cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated
    • Microscopically, the sections show a picture of some subepithelial cysts with focal surface opening (fistula-like) lined by well-differentiated squamous cells and focal irregular epithelial hyperplasia with dyskeratosis as well as focal epithelial hyperplasia within inflamed and fibrous stroma. According to histopathologic finding and patient’s past history, it is compatible with well-diifferentiated squamous cell carcinoma.
  • 2019-06-19 MRI - nasopharynx
    • SOAP
      • S: He is a patient with double oral cancer at lip and cheek seperately and received operations.
      • O: oral ulcer with malignant potential on the inner surface of left upper lip is noted but improved after injection treatment.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P
        • check BUN and creatinine before MRI examination
        • arrange MRI examination with contrast to evaluate undermining tumor status
    • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and show:
      • Post-operation change at left upper lip, left buccal region, and right tongue border, without abnormal soft tissue intensity, nor abnormal enhancement.
      • An oval-shaped nodular lesion, about 16 mm x 10 mm, at left supraclavicular region, r/o an enlarged lymph node, mildly enlarged as compared with MRI on 20180815. Suggest further evaluation and close follow-up.
      • No remarkable finding at nasopharynx, oropharynx, hypopharynx and larynx.
      • No remarkable finding at parotid, submandibular and sublingual glands.
      • No remarkable finding at skull base and visible intracranial structures.
      • Mucosal thickening in bilateral ethmoid and maxillary sinuses, indicating chronic paranasal sinusitis.
    • IMP: C/W multiple oral cavity cancers s/p operation, without evidence of recurrence based on this study. A suspicious enlarged lymph node at left supraclavicular fossa. Suggest further evaluation (such as PET) and close follow-up.
  • 2018-08-15 MRI - nasopharynx
    • CC: He is a patient with double oral cancer at lip and cheek seperately. He has mild pain at his left upper lip for few days. He also has rough surface lesions on his both cheeks for weeks and mouth-opening limitation for years. He had received cancer surgery on 2015-04. He wears unfitted denture.
    • Indication:
      • S: He is a patient with double oral cancer at lip and cheek seperately. He had received cancer surgery on 2015-04 and 2017-05. He wears unfitted denture.
      • O: ulceration on the left upper lip is noted. that is probablly due to unfit denture. abnormal scar tissue with fungus patches on the bil. buccal mucosa is noted.
      • A:
        • Dysplasia of right buccal mucosa (2018-01)
        • Verrucous carcinoma of right tongue (2017-05-10)
        • Dysplasia of right buccal mucosa,and the right lower lip (2017-05-10)
        • SCC of left buccal mucosa and retromolar area post OP (2015-04)
        • Verrucous carcinoma of right tongue border (2017-05)
        • Verrucous carcinoma of inner surface of left upper lip post OP (2015-04)
      • P:
        • Chech BUN and creatinine before MRI examination
        • Arrange MRI with contrast to evaluate the undermining tumor status
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration showed:
      • No abnormal mass lesion in the nasopharynx, oropharynx, hypopharynx or larynx.
      • No neck LAP.
      • Normal appearance of parotid, submandibular and thyroid glands.
      • Mild mucosal thickening of bilateral maxillary sinuses.
      • Mucosal thickening of rightinferior nasal turbinate.
    • Impression:
      • No obvious buccal or oropharynx mass or nodule.
  • 2017-11-20 MRI - nasopharynx
    • No obvious buccal or oropharynx mass or nodule.
  • 2017-05-10 Surgical pathology Level IV
    • Clinical diagnosis: Chronic periodontits
    • Patho DIAGNOSIS:
      • Labeled as “tumor of right buccal mucosa”, wide excision — Verrucous hyperplasia with submucosa fibrosis.
      • Labeled as “tumor of right tongue”, wide excision — Verrucous carcinoma, margin free of malignancy.
      • Tongue, right, wide excision — Verrucous carcinoma
      • Lymph node—- N/A.
      • Pathology stage: pT1Nx (cM0); pStage: I.
    • MACROSCOPIC EXAMINATION CHECKLIST
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: right tongue
        • Other part(s) included: right buccal mucosa
        • Lymph node dissection: no
      • Specimen Integrity: intact
      • Specimen Size: Greatest dimensions: right tongue: 1.2 x 0.9 x 0.35 cm.
        • Additional dimensions: right buccal mucosa: 1 x 0.8 x 0.4 cm.
      • Tumor Site: right tongue, Laterality : right
      • Tumor Focality : single focus
      • Tumor Size: Greatest dimension: 0.25 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 1.5 mm
      • Mucosal Surface : Intact
      • Gross Tumor Extension : submucosa
    • MICROSCOPIC DESCRIPTION:
      • Section of the “tumor of right buccal mucosa” shows verrucous hyperplsia.
      • Section of the “tumor of right tongue” shows one piece of hyperkeratotic squamous mucosa with verrucous carcinoma 2.5 mm in width and 1.5 mm in depth. The tumor is 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
    • MICROSCOPIC EXAMINATION CHECKLIST:
      • Histologic Type: Verrucous carcinom
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: submucosa
      • Margins: Margins free, Distance from closest margin: 3. 2, 4, 3, and 2 mm away from the left, right, anterior, posterior and deep margins.
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: N/A.

[consultation]

  • 2023-02-01 Thoracic Surgery
    • Q
      • For port-A insertion
      • This is a 57 y/o male patient denied of HTN, CAD and DM major disease.
      • His oral tumor of left upper lip biposy reported cysts with focal opening and irregular epithelial hyperplasia, compatible with squamous cell carcinoma, well-diifferentiated (sample number: S2023-00290) on 2023-01-05.
      • His nasopharnyx MRI showed upper lip T4AN0M0 stage IVA.
      • His treatment plans were induction chemotherapy follow by surgery and CCRT.
      • He was admitted to ward for tumor work up and prepare induction chemotherapy.
      • We need your help for port-A insertion, Thanks!           
    • A
      • I will arrange insertion of port-A this week. Thanks for your consultation!

[SDM] - 2023-02-02

  • This afternoon, we had a meeting with Mr. Ding and his son to discuss the current status of his illness and future treatment options.
  • Dr. Xia:
    • Mr. Ding, your oral cancer examination has been completed. Currently, the diagnosis is stage III left upper lip oral cancer, which can be diagnosed by direct visual inspection or palpation. However, the magnetic resonance imaging (MRI) report shows that the cancer has invaded the adjacent maxilla bone, so it is stage IV left upper lip oral cancer. The purpose of this family meeting is to discuss your treatment options and the potential side effects of each treatment method. In general, your treatment for left upper lip oral cancer will include surgical resection of the tumor and removal of lymph nodes. Depending on the pathology report, radiotherapy may also be necessary after the surgery. Since your cancer is located in the left upper lip, we will take into consideration the future appearance, clarity of speech, and the side effects of lip dysfunction. Therefore, there are two treatment options that we can discuss, and we will arrange appropriate treatment according to your decision.
      • Treatment option 1: Directly remove the left upper lip oral cancer tumor by surgery. The advantage of this method is that it removes the cancer faster, and it makes the existence of left upper lip oral cancer invisible to the eyes and mind. However, the disadvantage of this method is that the tumor area removed is larger, which will affect your appearance in the future. Losing the upper lip will also affect the clarity of your speech, and you will lose the function of closing your lips, causing food and water to spill out while eating and drinking.
      • Treatment option 2: Use chemotherapy first to kill the left upper lip oral cancer cells. The advantage of this method is that if the chemotherapy is effective, it can shrink the tumor and reduce the surgical area in the future, thus reducing the impact on your appearance. It also reduces the impact on speech clarity and the chance of food and water spilling out while eating and drinking. The disadvantage of this method is that you will first face the side effects of chemotherapy, such as nausea, vomiting, diarrhea, decreased white blood cells causing infections, and even life-threatening conditions, anemia, hair loss, and weakness, etc. Have you and your family understood this?
  • Mr. Ding:
    • Yes, I have heard and understood. How effective is chemotherapy?
  • Dr. Xia:
    • Each person’s oral cancer cells have different characteristics, so the response to chemotherapy will also be different. Basically, about 80% of oral cancer patients respond well to chemotherapy, which can reduce the size of the oral cancer. However, we can only know if it works after injection, and cannot predict it in advance.
  • Mr. Ding:
    • I understand. How long will the chemotherapy last? How do I know if it is effective?
  • Dr. Xia:
    • This chemotherapy will last for about two months. We will treat you in cycles every three weeks, with three cycles in total, so the chemotherapy will last for a total of nine weeks. Simply put, chemotherapy is administered in the first and second weeks, and you will rest at home in the third week. Chemotherapy will resume in the fourth week, and so on. The entire chemotherapy process will last nine weeks. Two weeks after the end of chemotherapy (around the 11th week), you will undergo surgical treatment. I have a chemotherapy manual for you and your family to refer to. As for whether it is effective, it can only be known after injection, and the patient can feel and see whether the tumor has shrunk. So currently, I cannot know whether the chemotherapy will be effective for you.
  • Mr. Ding: What if chemotherapy is not effective?
  • Dr. Xia: I will schedule surgery to remove

[surgical operation]

  • 2017-05-10
    • Diagnosis: Severe dysplasia of right buccal mucosa with maliganant tendency
    • PCS code: 92014C Complicated extraction
    • Finding
      • Abnormal macule (patch) of erythroplakia 1cm x1.5cm at right buccal mucosa WAS NOTED.
      • Abnormal mass on the right tongue 0.5cm x0.5cm WAS NOTED.
      • Severe trismus is noted
      • Enlongation and caries of 17 16 25 34 32 33 34 48 47

[chemotherapy]

  • 2023-03-31 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 800mg/m2 1500mg NS 500mL 22hr + leucovorin 80mg/m2 150mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-22 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-03-06 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-27 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-13 - docetaxel 32mg/m2 60mg NS 150mL 1hr + cisplatin 32mg/m2 60mg NS 500mL 3hr + fluorouracil 900mg/m2 1700mg NS 500mL 22hr + leucovorin 90mg/m2 170mg (in 5-FU drip)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-03 - docetaxel 40mg/m2 80mg NS 200mL 1hr + cisplatin 40mg/m2 80mg NS 500mL 3hr + fluorouracil 1000mg/m2 2000mg NS 500mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

Induction chemotherapy should be used when chemotherapy occurs before radiation therapy. The term neoadjuvant chemotherapy should be used to refer to chemotherapy before surgery. ref: https://www.healthline.com/health/cancer/induction-chemotherapy

[assessment]

  • The patient has received (planned total 9-dose) TPF neoadjuvant regimen on 6 occasions, specifically on 2023-02-03, 2023-02-13, 2023-02-27, 2023-03-06, 2023-03-22, and 2023-03-31 (the 6th time during this hospitalization). There was only one episode of WBC less than 3K/uL, which occurred on 2023-02-10, approximately 1 week after the first dose. Otherwise, no other episodes of low WBC count were observed.

    • 2023-03-29 WBC 3.84 x10^3/uL
    • 2023-03-20 WBC 3.46 x10^3/uL
    • 2023-03-10 WBC 4.19 x10^3/uL
    • 2023-03-06 WBC 4.86 x10^3/uL
    • 2023-02-27 WBC 4.16 x10^3/uL
    • 2023-02-17 WBC 3.63 x10^3/uL
    • 2023-02-13 WBC 6.36 x10^3/uL
    • 2023-02-10 WBC 2.80 x10^3/uL
    • 2023-01-31 WBC 5.32 x10^3/uL
  • The TPF regimen was appropriately dose reduced from the second dose, with docetaxel at 32mg/m2 instead of 40mg/m2, cisplatin at 32mg/m2 instead of 40mg/m2, and fluorouracil at 900-800mg/m2 instead of 1000mg/m2. G-CSF was also used in a timely manner.

  • According to the latest information, there are no moderate or severe complaints for the patient about adverse reactions.

  • By the way, there is a decreasing trend in HGB, which indicates that the HGB does not seem to be fully recovered at the current administration interval/frequency. Please continue monitoring and check for need for blood transfusion for the next 3 scheduled doses.

    • 2023-03-29 HGB 9.9 g/dL
    • 2023-03-20 HGB 10.7 g/dL
    • 2023-03-10 HGB 11.4 g/dL
    • 2023-03-06 HGB 10.9 g/dL
    • 2023-02-27 HGB 12.6 g/dL
    • 2023-02-17 HGB 12.2 g/dL
    • 2023-02-13 HGB 13.8 g/dL
    • 2023-02-10 HGB 15.5 g/dL
    • 2023-01-31 HGB 14.0 g/dL

701469037

230331

[diagnosis] - 2023-03-09 admission note

  • Hypopharyngeal squamous cell carcinoma with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC s/p chemotherapy with with PF (CDDP 75mg/m2 D1 + 5-Fu 1000mg/m2 D1-4) from 2023/02/07~
  • Chronic viral hepatitis B without delta-agent
  • Constipation, unspecified
  • Hypercalcemia
  • Hypomagnesemia
  • Hyponatremia

[lab data]

  • 2023-01-30 HBsAg Reactive
  • 2023-01-30 HBsAg (Value) 686.57 S/CO
  • 2023-01-30 Anti-HCV Nonreactive
  • 2023-01-30 Anti-HCV Value 0.13 S/CO
  • 2023-01-30 HIV Ab-EIA Nonreactive
  • 2023-01-30 Anti-HIV Value 0.06 S/CO
  • 2023-01-30 Anti-HBc Reactive
  • 2023-01-30 Anti-HBc-Value 8.95 S/CO
  • 2023-01-30 Anti-HBs 6.17 mIU/mL

[exam findings]

  • 2023-03-30 CT - abdomen
    • The CT scan of the whole abdomen was performed without/with IV contrast medium enhancement and revealed that:
      • Known a case of right hypopharyngeal cancer. Still presence of this tumor at right pyriform sinus. One enlarged node (4.4cm) over right level IV of neck.
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • Small amount of bilateral pleural effusion.
      • Multiple osteoblastic lesions of T-L spine, may be metastatic lesions.
      • S/P N-G tube insertion.
  • 2023-03-09 CXR
    • Mild Increased infiltration over both lower lungs. May be active infection.
  • 2023-02-06 Patho - colorectal polyp
    • Colorectum, descending colon (60 cm from anal verge), Polypectomy — Tubular adenoma with low grade dysplasia
    • Colorectum, rectum Size (10 cm from anal verge), Biopsy removal — Tubular adenoma with low grade dysplasia
  • 2023-02-02 CT - abdomen
    • History and indication: left tongue cancer, cT4aN2CM0, echo with multiple liver lesionfor liver tumors, suspected HCC, suspected metastasis
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Multiple liver metastases.
      • Minimal ascites.
      • Focal atrophy of left kidney with stone (2mm).
      • S/P NG tube indwelling.
    • IMP:
      • Multiple liver metastases.
  • 2023-02-01 Whole body PET scan
    • Glucose-hypermetabolism in the right hypopharynx, compatible with the primary hypopharyngeal cancer.
    • Glucose-hypermetabolism in the middle to basal aspect of tongue and bilateral cervical lymph nodes, highly suspected advanced cancer with regional lymph nodes involvement.
    • Glucose-hypermetabolism in both lobes of the liver and multiple bones, highly suspected cancer with distant metastases.
    • Hypopharyngeal cancer with tonge involvement, bilateral cervical lymph nodes, liver and multiple bones metastases, cT4aN2cM1, stage IVC (AJCC 8th ed.), by this F-18 FDG PET scan.
  • 2023-02-01 Patho - esophageal biopsy
    • Labeled as “esophagus, 35 cm below incisor”, biopsy — squamous mucosa with high grade dysplasia.
    • Section shows squamous mucosa with high grade dysplasia.
    • The possibility of a more advanced lesion cannot be excluded. Please correlate with clinical, and if available, image findings. Further work up might be considered.
  • 2023-01-31 Patho - larynx biopsy
    • Labeled as “right hypopharyngeal tumor”, biopsy — squamous cell carcinoma.
    • IHC stains: p16(+, 95%), CK5/6 (+), p40 (+), Ki-67 (90%).
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Suspected esophageal mucosal lesion, L/3, s/p biopsy
    • Esophageal inlet patch, U/3
    • Superficial gastritis
    • C/W hypopharyngeal cancer
  • 2023-01-31 SONO - abdomen
    • multiple hepatic tumors, both lobe
  • 2023-01-30 ECG
    • Sinus tachycardia with short PR
    • Right atrial enlargement
    • Nonspecific ST abnormality
    • Abnormal QRS-T angle, consider primary T wave abnormality
    • Abnormal ECG
  • 2023-01-30 Laryngoscopy
    • right hypopharyngeal tumor
  • 2023-01-26 Nasopharyngoscopy
    • Findings:
      • smooth NPx; right hypopharyngeal mass involved right AE fold, pyriform sinus and laryngx with airway narrowing
    • Diagnosis/Conclusion
      • right hypopharyngeal tumor, favor malignancy
      • left tongue cancer
  • 2023-01-24 CT - neck
    • Neck CT with and without IV contrast enhancement shows:
      • Soft tissue mass occupying hypopharynx more on right side measuring 4.9cm with partially obliteration of the supraglottic airway is found. Some lymphadenopathy at bilateral neck mostly at right neck is found.
      • Abnormal necrotic lesion at tongue about 4.65cm in largest dimension is found.
      • Mild wall thickeing at upper third esophagus is found.
      • Intact bony alignment over cervical spine
    • Imp:
      • Probably tongue cancer with bilateral neck lymphadenopathy and hypopharyngeal exntesion.
    • Imaging Report Form for Oral Cavity Carcinoma
      • T4aN2c
  • 2023-01-24 Nasopharyngoscopy
    • Findings:
      • ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
      • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
      • smooth nasopharynx, oropharynx, no pharyngeal wall bulging
      • tumor mass over right hypopharynx
    • Diagnosis/Conclusion
      • mass lesion over posterior tongue, right retromolar trigone region, right hypopharynx
  • 2023-01-19 Pathology (at TuCheng Hospital)
    • SNOMED: 53000-A-M80703
    • DX: Tongue, “posterior”, incisional biopsy — squamous cell carcinoma
    • GROSS D: The specimen submitted consists of a piece of tissue measuring 0.7 x 0.5 x 0.3 cm. Submitted in toto. LYC
    • MICRO D: Sections show squamous mucosa with invasive nests of tumor cells displaying squamous differentiation.

[consultation]

  • 2023-02-26 Hemato-Oncology
    • Q
      • Consultation for take over and chemotherapy.
      • This 48 year-old man is diagnosed of (1) left tongue squamous cell carcinoma T4aN3bM1, stage IVc and (2) right hypopharyngeal squamous cell carcinoma T3-4aN3bM1, stage IVc.
      • After discussing with him and his family, he decided to undergo chemotherapy. Colonoscopy is arranged on 2023/02/06 10:30 due to hyperdensity lesion over upper rectum in abdominal CT.
      • We need your expertise to take over this patient and start chemotherapy as your plan. Thank you very much!
    • A
      • According to tumor board discussion, please arrange colonoscopy due to hyperdensity lesion over upper rectum in abdominal CT r/o colonrectal cancer.
      • In addition, please arrange 24 urine CCR and auditory test. Please book 11A and transfer to our service. Thanks for your consultation.
  • 2023-01-24 Ear Nose Throat
    • A
      • S
        • Sorethroat for a month
        • Right neck progressive swelling for a week
        • A(+)/B(-)/C(+, 1 PPD for 20 years)
        • voice change (+, for a month), trismus (-), oral bleedeing (-), dyspnea (- **), otalgia (-), fever (-), dysphagia (+, mild)
        • Posterior tongue SCC diagnosed at 土城 hospital on 2023/01/16
      • O
        • Oral cavity and oropharynx: ulcerative and fragile tissue over posterior tongue (easy bleeding during examination, status post bosmin compression)
          • 3 cm whitish leision over right retromolar trigone region, no bulging over bilateral peritonsilar region or uvular deviation
        • Neck : 6 cm non-movable painful firm mass over right neck level III-V region
        • Scope: smooth nasopharynx, oropharynx, no pharyngeal wall bulging
          • tumor mass over right hypopharynx
        • CT: heterogenous mass lesion over posterior tongue, right hypopharynx
          • mild deviated but still visible air way, 3 cm heterogenous mass lesion over right neck
      • A
        • Posterior tongue squamous cell carcinoma
        • Mass lesion over right hypopharynx, r/o metastasis, r/o second primary tumor
        • Right neck heterogenous mass, r/o metastasis
      • P
        • prohylatic antibittics with augmentin, keep oral hygeine with parmason, and adequate pain control (acetaminophen, ultracet, or self-paid comfflam) if no contraindication
        • ENT OPD f/u on 2023/01/26 AM
        • Well education. if disease progression (bleeding, short of breath…), back to ER soon

[SOAP]

  • 2023-03-23 Hemato-Oncology
    • Tx Plan: Neoadjuvant TPF followed by CCRT
    • Cancer Multidisciplinary Team Meeting Conclusion
      • Meeting Date: 2023-02-03
      • Treatment Plan:
        • Systemic therapy + Local radiation therapy.
        • Team consensus: Tongue + Hypopharynx: cT4aN3bM1, IVC.

[chemotherapy]

  • 2023-03-09 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-07 - cisplatin 75mg/m2 110mg NS 500mL 24hr + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] (post cisplatin) + fluorouracil 1000mg/m2 1500mg 24hr D1-4
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-31

2023-03-30 CRP 18.82mg/dL, WBC 12.95K/uL, urine bacteria 1+, urine protein 1+. Blood culture results are not yet available.

There have been no medication reconciliation issues found in the patient. (PharmaCloud not accessible)

2023-03-10

  • The patient is undergoing the PF regimen treatment for the second time during this hospital stay and did not experience discomfort symptoms within two weeks after the previous chemotherapy.
  • Lab results (2023-03-09) indicate the presence of hypercalcemia (2.78mmol/L), hypomagnesemia (1.6mg/dL), and hyponatremia (130mmol/L).
    • Cisplatin treatment is known to cause hyponatremia, hypomagnesemia, and hypocalcemia, as noted in “Electrolyte Disorders Induced by Antineoplastic Drugs” (Front Oncol. 2020;10:779. Published 2020 May 19. doi:10.3389/fonc.2020.00779).
    • Hypercalcemia, which is typically caused by increased osteoclastic bone resorption and affects up to 10 to 30% of cancer patients (ref: Electrolyte disorders with platinum-based chemotherapy: mechanisms, manifestations and management. Cancer Chemother Pharmacol. 2017;80(5):895-907. doi:10.1007/s00280-017-3392-8), has been confirmed to be present due to bone metastases. If this causal relationship is confirmed, the primary treatment approach would be to administer intravenous bisphosphonates. However, it’s worth noting that this treatment may potentially lower magnesium levels as well.

700029976

230330

[present illness] - 2023-03-29 admission note

This is 77-year-old man who has past medical history of Raynaud phenomenon, Diabetes Type II, right lung adenocarcioma RLL status post VATS wedge resection, prostatic cancer status post TURP under regular oral endoxan and prednisolone. This time, he complained of dyspnea for days, OPD CXR showed right pleural effusion. Loss 5 kg due to poor appetite in one month according to himself. He was admitted to our ward for further evalation and treatment.

[past history]

  • Raynaud phenomenon
  • Waldenstrom’s macroglobulinemia
  • Diabetes Type II
  • right lung adenocarcioma RLL status post VATS wedge resection
  • prostatic cancer status post TURP

[allergy]

  • NKDA         

[family history]

  • Dad and mum have diabetes mellulitus.
  • Denied any cancer history.

[SOAP]

  • 2023-03-15 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-02-09 Urology
    • Malignant neoplasm of prostate
    • PSA every six months
  • 2023-02-01 Hemato-Oncology
    • BT with PRBC 2 U today
  • 2023-01-11 Hemato-Oncology
    • Waldenstrom macroglobulinemia. (IgM myeloma less likely)
    • hold endoxan and continue steroid therapy
    • continue surgar control.
    • suggest keep warm and OPD follow up.
    • suggest mabthera therapy if continue elevation of IgM

[medication]

  • 2022-04-06 ~ undergoing - Endoxan (cyclophosphamide)

[assessment]

  • The patient has been under follow-up in our Hemato-Oncology OPD due to extremely high IgM levels and was diagnosed with Waldenstrom macroglobulinemia. Cyclophosphamide treatment was initiated in April 2022.
  • The patient’s IgM levels decreased from approximately 7000 mg/dL in Q2/Q3 2021 to approximately 3000 mg/dL in Q2 2022 and have been around 2500 mg/dL since then. However, LDH levels have remained consistently high, with a record high of 1004 U/L in Q1 2023. The patient’s serum glucose levels have fluctuated between 100-200 mg/dL during the same period.
  • The current prescription is appropriate and further evaluation is ongoing.

700199716

230330

[diagnosis] - 2023-03-06 admission note

  • Malignant neoplasm of endometrium
  • Endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1
  • Polycystic ovarian syndrome
  • Iron deficiency anemia, unspecified

[past history]

  • Heart:(-)

  • Liver:(-)

  • Kidney:(-)

  • H/T:(-)

  • DM:(-) Other

  • DVT 2 years ago

  • medication: Rivaroxaban regularly and had taken Leuplin

  • Surgical: denied

  • Menstrual history: G0P0, Last menstrual period: 2022-09-25

  • sex –

  • Menarche at the age of 12 years old

  • Menstrual cycle:irregular with duration of 7 days

  • Amount: moderate with blood clots

  • Pap smear: denied                

[allergy]

  • NKDA                       

[family history]

  • There is no family history of cancer,hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-07 CT - abdomen
    • Clinical history: 49 y/o female patient with endometroid carcinoma with marked squamous differentiation, pT1aN1mi; stage III C1; FIGO stage IIIC1.
    • With and without contrast enhancement CT of abdomen–whole:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • Presence of gallbladder stones.
      • Suspected right renal cyst, 0.58cm.
    • Impression:
      • S/P hysterectomy. Mild fatty infiltrates in the pelvic cavity, could be due to post-op change, suggest follow up.
      • GB stones.
      • Suspected right renal cyst.
    • 2022-11-16 Peripheral Vascular Test: Vein , lower limbs
      • Chronic DVT, mild intramural thrombus involved left popliteal vein with revascularization
      • Right LSV mild reflux, involved right sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Rigth CFV trivial reflux
      • Left LSV mild reflux, involved left sphenofemal junction(SFJ); with some small varicose veins(LSV) at right lower legs
      • Left CFV trivail reflux
      • Both SSV without reflux
    • 2022-10-31 CT - chest
      • no abnormality of both lungs and mediastinum.
    • 2022-10-26 Patho - ovary (tumor)
      • PATHOLOGIC DIAGNOSIS
        • Uterus, endometrium, LAVH — Endometroid carcinoma with marked squamous differentiation
        • Lymph nodes, pelvic, bilateral, BPLND — Metastatic carcinoma
        • AJCC 8 th edition, Pathology stage: pT1aN1mi; stage IIIC1; FIGO stage IIIC1
      • MACROSCOPIC EXAMINATION
        • Procedure: LAVH + BSO + BPLND
        • Specimen Size: 10.7 x 9.5 x 3.8 cm (uterus), 3 x 2 x 2 cm (Rt ovary), 4.5 x 0.8 cm (Rt tube), 3 x 2 x 2 cm (Lt ovary), 4.5 x 0.8 cm (Lt tube)
        • Specimen Integrity: Intact
        • Tumor Site: Endometrium
        • Tumor Size: Diffusely thickened, up to 2.0 cm in thickness
        • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
        • Representative parts are taken for section and labeled as: A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E1-E2= left ovary and fallopian tube, F1-F2= left ovary and fallopian tube. F2022-00502FSA1-FSA2= tumor, A1=cervix, A2= cervix + tumor, A3= parametrium, A4-A6= uterine corpus.
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Endometroid carcinoma with marked squamous differentiation
        • Histologic Grade: FIGO grade 1
        • Myometrium Invasin: Present
          • Depth of Invasion: 11 mm
          • Thickness of Myometrium: 25 mm
        • Adenomyosis: Present
        • Uterine Serosal Involvement: Not identified
        • Cervical Stromal Involvement: Not identified
        • Other Tissue/Organ Involvement: Not applicable
        • Peritoneal/Ascitic Fluid: Not submitted
        • Margins: Uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 1.8 cm
        • Lymphvascular Invasion: Present
        • Regional Lymph Nodes: Metastatic carcinoma
          • number of lymph node examined: 7 (left iliac), 4 (left obturator), 4 (right iliac), 8 (right obturator)
          • number with metastases >2 mm: 0
          • number with metastases >0.2 mm and <=2 mm: 2 (left iliac), 1 (left obturator)
          • number with isolated tumor cells (<=0.2mm): 3 (left iliac), 2 (left obturator)
        • Pathologic Stage
          • Primary Tumor: pT1a (tumor limited to endometrium or less than half of myometrium)
          • Regional Lymph Nodes: pNmi (regional lymph node metastasis > 0.2 mm but <= 2 mm)
          • Distant Metastasis: Not applicable
        • FIGO Stage: Stage IIIC1
        • Additional Pathologic Findings
          • Cervix: Chronic cervicitis
          • Myometrium: Adenomyosis
          • Ovaries, bilateral: No remarkable change
          • Fallopian tubes, blateral: No remarkable change
    • 2022-10-26 Frozen Section
      • Uterus, frozen section — Malignant (endometroid carcinoma)
    • 2022-10-03 MRI - pelvis
      • Findings
        • Diffuse thickening endometrium, endometrial hyperplasia?
        • There are cysts in bilateral adnexa, could be due to ovarian cysts.
        • There are cysts in the uterine cervical region, suggesting Nabothin cysts.
        • There are lymph nodes in bilateral obturator regions, suggest follow up.
        • Non-enhancing nodules in right kidney(up to 1cm), r/o right renal cysts.
      • Impression
        • Diffuse thickening endometrium, endometrial hyperplasia or tumor? Suggest clinical correlation.
        • Nabothin cysts.
        • Bilateral obturator lymph nodes, suggest follow up.
      • Imaging Report Form for Endometrial Carcinoma
        • Impression (Imaging stage) : T:T1a(T_value) N:N1(N_value) M:M0(M_value) STAGE:IIIc(Stage_value)
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — atypical endometrial hyperplasia with squamous differentiation
      • Microscopically, sections show atypical endometrial hyperplasia composed of complex atypical hyperplasia of endometrial glands with increased glandular complexity and glandular crowding with squamous metaplasia and nuclear atypia.
      • Immunohstochemical stain reveals p16(+), p53(patchy+, wild -type), vimentin(+), CEA (focal +).
    • 2022-09-15 Patho - endometrium curretage/biopsy
      • Uterus, endocervix, ECC — Squamous cell metaplasia with atypia
      • Microscopically, it shows hyperplasia of squamous cells with focal nuclear atypia.
      • Immunohistochemical stain reveals p16(+), p53(patchy+, wild-type), vimentin(+).
    • 2022-05-27, 2021-11-12, 2021-04-23, 2020-08-14 Gynecologic ultrasonography
      • LT adnexae: free
      • adenomyosis
    • 2020-11-16 Peripheral Vascular Test: Vein, lower limbs
      • Acute venous thrombosis from left ostial SFV to distal SFV with minimal recanalization at ostial and proximal SFV; acute venous thrombosis at left popliteal vein with minimal recanalization. Left ATV wasn’t seen. Patent left PTV and LSV.
      • No evidence of venous thrombosis at right lower limb venous systems.
      • Mild venous reflux at right saphenofemoral junction with no varicose change of right LSV.
      • The ratios of MVO and SVC were within normal limtis.

[surgical operation]

  • 2022-10-26
    • Surgery
      • Diagnosis
        • D&C show atypical endometrial hyperplasia with squamous differentiation
        • LAVH then sent uterus for frozen section. => Frozen: Malignant (endometroid carcinoma)
      • Operation:
        • Laparoscopic gynecologic oncology staging surgery        
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: grossly normal
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: free
      • Estimated blood loss: 100 ml
      • Blood transfusion: nil
      • Complication: nil
  • 2022-09-15
    • Surgery
      • D&C, theraputic and for diagnostic (D&C: Dilatation and Curettage)
    • Finding
      • Uterus: Anteversion, 8 cm.
      • some endometrial tissue were curetted out.
      • Estimated blood loss: 5 mL, Blood transfusion: nil, complication: nil.    

[radiotherapy]

  • 2022-11-30 ~ undergoing - at 2160cGy/12 fractions of the pelvic area.

[chemotherapy]

  • 2023-03-06 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 330mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-19 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + granisetron 2mg + NS 250mL
  • 2022-11-29 - paclitaxel 160mg/m2 300mg NS 250mL 3hr + carboplatin AUC 5 450mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famodidine 20mg + NS 250mL

==========

2023-03-30

On 2023-03-29, the patient’s lab results indicated generally normal blood cell counts, selected electrolytes, and liver/kidney functions. There is no evidence that contraindicates the scheduled chemotherapy. The patient was diagnosed with acute embolism and thrombosis of the femoral and iliac veins on 2020-11-16 and has been taking Xarelto (rivaroxaban) for this condition. After reviewing the PharmaCloud database, no medication reconciliation issues were identified.

2023-03-07

After a leukopenia event (WBC 1.65K/uL on 2022-12-31), all subsequent data showed WBC counts above 5K/uL. Since receiving paclitaxel + carboplatin regimen in late November 2022, there have been no observations of anemia and/or thrombocytopenia. The patient is currently taking rivaroxaban as a self-carried medication due to a history of DVT. No medication reconciliation issues were found during this hospital stay.

2022-12-20

Based on the lab results (2022-12-19), the scheduled chemotherapy did not appear to be contraindicated.

700805458

230330

[diagnosis] - 2023-03-03 admission note

  • Malignant neoplasm of nasopharynx, unspecified
  • Chronic mucoid otitis media, right ear
  • Gastro-esophageal reflux disease with esophagitis
  • Gastritis, unspecified, without bleeding
  • Postmenopausal atrophic vaginitis
  • Unspecified cirrhosis of liver

[past history]

  • Thyroid papillary cancer status post thyroidectomy in 2008
    • Eltroxin 50mg 3# po QW2,4,6
    • Eltroxin 50mg 2# po QW1,3,5,7
  • Hepatitis B virus infection under medical treatment
    • Vemlidy 1# po QDAC
  • Polyarthralgia under medical treatment  
    • Plaquenil 1# po QOD

[allergy]

  • Omnipaque (iohexol): skin rash

[family history]

  • There is no family history of cancer, diabetes, hypertension, mental diseases or asthma.

[exam findings]

  • 2023-03-03 Gynecologic ultrasonography
    • bilateral adnexae: free
    • IMP: adenomyosis
  • 2023-02-23 Patho - cervix/endometrial polyp
    • Uterus, endometrium, TCR-P— Endometrial polyp with decidual reaction
  • 2023-02-17 Hysteroscopy
    • OBS/GYN history: G 2 P 2 A ____ LMP ____
    • HSC indication/Pre-exam impression: suspect EM lesion
    • Procedure: Under lithotomy position, HSC exam was performed smoothly
    • Hysteroscopy No. : HYF-XP
    • Finding:
      • Endometrial cavity:
      • Endocervix: WNL
      • Fundus: obliterated with polyp
      • Right tubal ostium: obliterated with polyp
      • Left tubal ostium: obliterated with polyp
    • Post-exam impression: endometrial polyp
      • EBL:minimal , Complication: Nil , BT: Nil
  • 2023-02-13 Whole body PET scan
    • No previous study for comparison.
    • The lesion in the right petrous bone shown on the previous MRI of nasopharynx reveals very mildly increased FDG uptake, compatible with NPC s/p R/T.
    • Glucose-hypermetabolism in the esophagus, probably chronic inflammation process.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • NPC s/p treatment, no evidence of residual, recurrent or metastatic tumor, by this F-18 FDG PET scan.
  • 2023-02-11 SONO - abdomen
    • Cirrhosis of liver
    • GB stones/polyp, multiple
    • Hepatic cysts
    • Splenomegaly
  • 2023-02-10 Nasopharyngoscopy
    • Findings
      • bulging tumor over rt NP, subside
    • Diagnosis/conclusion
      • NPC, cT4N0M0 s/p CCRT
  • 2023-02-10 Gynecologic ultrasonography
    • LT adnexae:free
    • IMP
      • Adenomyosis
      • Uterine myoma
      • EM: 11.5mm, suspect endometrial thickening
  • 2023-02-02 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/09/08.
    • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle.
    • Regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal.
    • Favor residual tumor with progression.
  • 2023-02-02 SONO - abdomen
    • Right liver cysts (3.57x4.19cm, 1.26x1.32cm).

    • Gallbladder stones (3-5mm).

    • 2023-01-06 SONO - thyroid gland.

      • no evidence of mass lesion.
    • 2023-01-06, 2022-12-02, -10-28 Nasopharyngoscopy

      • Findings: bulging tumor over rt NP, subside
      • Summary: NPC, cT4N0M0 s/p CCRT
    • 2022-11-24 Gynecologic ultrasonography

      • Uterine myoma
      • Endometrial thickening, EM: 11.4mm
    • 2022-11-16 CT - abdomen

      • Findings:
        • There are two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • There are multiple gallstones.
        • The liver shows mild irregular contour that may be early cirrhosis or normal variation.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
      • IMP:
        • Two hepatic cysts 4.5 cm in S8/4 and 1.1 cm in S6.
        • Multiple gallstones.
        • Early cirrhosis of the liver is suspected.
        • There is suspicious endometrium or myometrium lesion in the uterus. Please correlate with GYN. sonography.
    • 2022-09-08 MRI - nasopharynx

      • Indication: NPC s/p TPF
      • Findings:
        • Abnormal soft tissue intensity and enhancement involving right cavernous sinus, foramen lacerum, foramen ovale, carotid canal, petrous bone, longus colli muscle and medial pterygoid muscle. Regression of most of the lesion involving right nasopharynx and paraspinal spce, but mild progression of the lesion involving right petrous bone around carotid canal.
        • Mottled T2-hyperintensity in right mastoid air cells, indicating mastoiditis.
      • IMP:
        • NPC s/p treatment, partial regression of most of the tumor, but with mild progression of the lesion in petrous bone, as compared with MRI on 20220426.
    • 2022-09-01, -06-02 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp, multiple
      • Hepatic cysts
      • Splenomegaly
    • 2022-06-14 ECG

      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-06-14 CXR

      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-06-14 PTA

      • Reliability FAIR
      • Average RE 78 dB HL; LE 29 dB HL.
      • R’t moderately severe to profound mixed type HL.
      • L’t normal to moderate HL. (BC masking dilemma)
    • 2022-04-28 Tc-99m MDP whole body bone scan

      • The Tc-99m MDP bone scan at 4 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the skull base, L3-4 spines, bilateral shoulders, knees and both feet in whole body survey.
      • IMPRESSION:
        • Increased activity in the skull base. Malignancy with local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
        • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        • Mildly increased activity in the L3-4 spines. Degenerative spine disease is more likely.
        • Increased activity in bilateral shoulders, knees and both feet, compatible with benign joint lesions.
    • 2022-04-28 Gynecologic ultrasonography

      • Bilateral adnexae: free
      • Uterine myoma
    • 2022-04-27 Panendoscopy

      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, body, s/p CLO test
      • Gastric erosion, antrum, LC site
    • 2022-04-27 SONO - abdomen

      • Cirrhosis of liver with splenomegaly
      • Hepatic cysts
      • GB stones/polyp
      • Suboptimal study
    • 2022-04-26 MRI - nasopharynx

      • Indication: Nasopharyngeal carcinoma for cancer work up
        • Allergy to contrast
      • Findings
        • A large lobuated right NPx tumor mass, up to 4.3 cm, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • No evident abnormal enlarged lymph node in the visible neck.
        • Decreased right mastoid air cells pneumotization indicating chronic mastoiditis.
      • IMP: Right NPC, invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base.
      • Impression (Imaging stage): T:T4(T_value) N:0(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2022-04-26 PTA

      • Reliability FAIR
      • Average RE 63 dB HL; LE 28 dB HL
      • RE mild to profound MHL
      • LE normal to mild SNHL
    • 2022-04-25 ECG

      • Possible Left atrial enlargement
      • Nonspecific T wave abnormality
    • 2022-04-18 PTA

      • Reliability FAIR
      • Average RE 53 dB HL; LE 34 dB HL.
      • R’t mild to severe MHL.
      • L’t mild to moderately severe SNHL.
    • 2022-04-11 Patho - nasopharyngeal/oropharyngeal biopsy

      • Nasopharynx, biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
      • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval vesicular nuclei, prominent nucleoli and syncytial growth pattern. Keratin formation is absent.
    • 2022-04-11 Otologic endoscopy

      • rt NP tumor
      • rt MEE
    • 2022-04-11 Nasopharyngoscopy

      • rt NP tumor
    • 2022-03-12 SONO - abdomen

      • Cirrhosis of liver
      • GB stones/polyp
      • Hepatic cysts
      • Splenomegaly
    • 2020-12-16 2D transthoracic echocardiography

      • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 25) / 89 = 71.91%
        • M-mode (Teichholz) = 72
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis and aortic root calcification; trivial TR.
      • Prominent epicardial fat.
  • consultation
    • 2022-06-21 Ophthalmology
      • Q
        • This 63-year-old woman patient is a case of Nasopharyngeal carcinoma, cT4N0M0, stage IVA. She was admitted for chemotherapy with TPF(C1D1) on 2022/06/16.
        • This time, for right eye redness with itch. Now, for evlauate right eye redness with itch therapy. Thank you.
      • A
        • S: Bilateral eye redness and itchy for 5days
        • O:
          • denied bv
          • discharge++, purulent
          • itchy++
          • BCVA od 0.4(0.5x+3.25/-4.00x90) os 0.5(0.7x+1.50/-2.00x70)
          • IOP 15/18mmHg
          • Pupil 3/3 +/+
          • MGD+
          • conj injected with purulent discharge, no pseudomembrane od>os
          • K clear ou
          • AC D/cl ou
          • Lens ns+ ou
          • Fd c/d 0.3, disc pinkish ou
        • A
          • Conjunctivitis od>os, favor EKC (epidemic keratoconjunctivitis)
        • P
          • Alminto 1gtt qid ou + tetracyclin 1qs hs
          • inform the red flags, if worsen vision, come back asap
          • opd f/u
    • 2022-04-29 Radiation Oncology
      • A
        • Diagnosis: Nasopharyngeal carcinoma, NK SqCC, undifferentiated type, cT4N0M0, with invasion of skull base, parapharyngeal space, and foramen of Ovale, ICA encasement and cavernous sinus, possible temporal base and Rt ORX, ECOG =1.
        • Suggest: Radiotherapy.
          • Goal: Curative.
          • RT Plan may be designed as the following one:
            • Target & Volume: NPX tumor and neck lymphatics.
            • Technique: VMAT.
            • Dose & Fractionation: 7140cGy/34 fx, with concurrent chemotherapy.
        • Plan:
          • Either CCRT followed by adjuvant C/T or induction C/T followed by CCRT is suggested for tumor control. Possible toxicity of radiotherapy (radiation mucositis, pharyngitis, dermatitis) is told. Diet education and psychological support are given.
    • 2022-04-28 Obstetrics and Gynecology
      • Q
        • This 63 y/o woman has historiesr of hypothyroidism, hepatitis B under regular medication control. The patient was admitted for NPC work up. The patient complaint perineal itching and urgency to urinate off and on for one month. She has treated at local clinic under Genxate 1# po tid, anbicyn 1# po tid , Amoxicillin 1# po tid.
      • A
        • This 63 y/o woman, G4P2A2(cesarean section), menopaused at her age of 50.
        • The patient complaint perineal + vaginal itching in recent 3 months, urgency to urinate off and on in recent 1 month. She had been to local clinic for help where Genxate 1# po tid, anbicyn 1# po tid, Amoxicillin 1# po tid were given.
        • Lab data: grossly normal, no leukocytosis or anemia.
          • PV: severe vaginal dryness, little whitish vaginal discharge, cervical lifting pain(-)
          • TVUS: Uterus: AVFL, 77x41mm; Endometrium: 4.3mm; 2 myomas( 26x24mm, 26x25mm)
            • Bilateral adnexa: free, no pelvic mass
            • CDS: no ascites
        • IMP: Suspected postmenopausal atrophic vaginitis
        • Suggestion:
          • May keep current LMD medications
          • Add Vaginal estrogen cream (Premarin 14gm/tube) QD HS and oral metronidazole 1# QID x 3 days.
          • GYN OPD f/u if needed
    • 2022-04-26 Oral and Maxillofacial Surgery
      • Q
        • This 52 y/o woman has history of hepatitis B and hypothyroidism for years under regular medication control. She is acase of nasopharyngeal carcinoma. She was admitted for cancer work up.
        • Due to follow up radiotherapy was indicated, we request your consultation for dental evaluation.
      • A
        • This is a 63 y/o female admitted for cancer evaluation(nasopharyngeal carcinoma). This time we were consulted for dental evaluation.
        • S: Oral examination.
          • Hx: epatitis B and hypothyroidism for years under regular medication control
        • O:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23 under ill-fitting prosthesis. Percussion pain and periapical radiolucency of tooth 14, 23 were noted.
          • Full mouth chronic periodontitis and poor oral hygiene was noted.
        • A:
          • Residual root of tooth 24, 25, 44
          • Caries of tooth 14, 15, 23
          • Full mouth chronic periodontitis
        • P:
          • Take panoramic film. Explain the findings and treatment plan to the patient and her family.
          • Suggest extraction of residual root of tooth 24, 25, 44 , patient and family want to consider.
          • Suggest removal of ill-fitting prosthesis and re-evaluation of tooth 14, 15, 23 , patient and family want to consider.
          • Suggest OPD follow up.

[SOAP]

  • 2023-03-29 Hemato-Oncology
    • Admission on 2023-03-28 for 4th PF and blood trasfusion due to syncope
  • 2023-02-21 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-05
  • 2022-12-13 Hemato-Oncology
    • EBV viral load Q3M, next in 2023-02
  • 2022-09-20 Hemato-Oncology
    • Due to the tumor invading toward brain stem based on the MRI on 2022-09-08, should consider PF4 after CCRT.
  • 2022-08-09 Hemato-Oncology
    • Already give medication education, e.g., hold Mgo and Primperan when diarrhea, hold smecta if no more diarrhea
  • 2022-08-02 Hemato-Oncology
    • Patient sustaine Gr 1 mucositis over lip, urinary tract and GYN area, Gr 1 anorexia -> does not like to take C/T on 2022-08-02
  • 2022-07-26 Hemato-Oncology
    • If first dose of cycle -> G-CSF for 2 doses
    • If 2nd dose of cycle -> G-CSF for 3 doses
  • 2022-07-19 Hemato-Oncology
    • RTC 1 week and next C/T on 2022-07-26 for OPD 2-2 course with G-CSF suport
  • 2022-05-10 Hemato-Oncology
    • Treatment plan: induction chemotherapy with TPF x 3 (if spliting dose, that would be 6 doses) followed by CCRT with weekly CDDP

[radiotherapy]

  • 2022-09-26 ~ 2022-11-11 - 7140cGy/34 fractions (6 MV photon) to NPX tumor & neck lymphatics

[chemoimmunotherapy]

  • 2023-03-30 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-03-03 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2023-01-13 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-12-14 - cisplatin 75mg/m2 130mg NS 500mL 24hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL D1-4 (PF Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + NS 250mL D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg + NS 500mL] D2 after cisplatin
  • 2022-11-08 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-01 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-25 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-18 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-11 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-10-04 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-27 - cisplatin 40mg/m2 65mg NS 500mL 2hr (CCRT QW)
    • betamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg + NS 250mL + aprepitant 125mg D1-3
  • 2022-08-16 - docetaxel 35mg/m2 50mg NS 160mL 1hr + cisplatin 35mg/m2 50mg NS 500mL 2hr + fluorouracil 2000mg/m2 3000mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-08-09 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-26 - docetaxel 35mg/m2 55mg NS 180mL 1hr + cisplatin 35mg/m2 55mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-19 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-12 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-07-05 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 170mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-4
  • 2022-06-15 - docetaxel 40mg/m2 60mg NS 200mL 1hr + cisplatin 40mg/m2 60mg NS 500mL 2hr + fluorouracil 2000mg/m2 3400mg NS 500mL 48hr (neoadjuvant TPF Q3W)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-30

  • Due to her syncope, the patient was admitted for scheduled chemotherapy and received a blood transfusion.
  • The patient is receiving PF4 regimen since Dec 2022 after CCRT due to tumor invasion towards brainstem based on MRI on 2022-09-08.
  • EBV DNA quantitative amplification results have never exceeded 120 copies/mL since Sep 2022. However, 2023-02-02 MRI showed regression of most of the lesion involving right nasopharynx and paraspinal space, but mild progression of the lesion involving right petrous bone around carotid canal, favoring residual tumor with progression.

2023-03-06

The patient was prescribed ergometrine maleate for an unspecified leiomyoma of uterus by our gynecologist on 2023-03-03. However, this drug is not currently shown in the active medication list. It has no known interaction with the patient’s current medications. Therefore, adding it as a self-carried item to the active medication list is recommended for proper medication reconciliation.

In addition, it is noted that fluorouracil, metoclopramide, and hydroxychloroquine are potential QT-prolonging agents. Administration of these drugs in an overlapping manner may enhance the QTc-prolonging effect, which should be monitored.

2023-01-16

2022-12-14

  • Since October 2022, serum potassium readings have returned to normal levels:
    • 2022-12-13 3.6 mmol/L
    • 2022-11-29 3.7 mmol/L
    • 2022-11-15 4.2 mmol/L
    • 2022-11-08 3.8 mmol/L
    • 2022-10-25 3.7 mmol/L
    • 2022-10-18 3.6 mmol/L
    • 2022-10-11 3.8 mmol/L
    • 2022-10-04 3.6 mmol/L
    • 2022-09-20 3.4 mmol/L
    • 2022-08-23 3.2 mmol/L
    • 2022-08-16 3.1 mmol/L
    • 2022-08-09 3.1 mmol/L
    • 2022-08-02 3.7 mmol/L
    • 2022-07-26 3.5 mmol/L
    • 2022-07-19 4.0 mmol/L
    • 2022-07-12 3.6 mmol/L
    • 2022-07-05 3.7 mmol/L
    • 2022-06-29 4.2 mmol/L
    • 2022-06-23 3.1 mmol/L
    • 2022-06-08 4.0 mmol/L
    • 2022-05-10 4.0 mmol/L
    • 2022-04-25 3.5 mmol/L
  • It may be appropriate to reduce the dosage of the potassium supplement Radi-K (TID -> BID/QD) as well as encourage the patient to consume more potassium-rich foods. Foods with high levels of potassium include: dried figs, molasses, seaweed, dried fruits (dates, prunes), nuts, avocados, bran cereals, wheat germ, lima beans. (Renal function is normal in the patient.)

700998905

230329

[exam findings]

  • 2023-03-24 CXR
    • Enlargement of cardiac silhouette.
  • 2023-03-09 CT - abdomen
    • History and indication: Low rectal cancer involving anal canal
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of low rectum with adjacent fat stranding, anal canal/ sphincter invasion and regional LAP.
      • Gallbladder stones (3-5mm).
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1b(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-03-07 Patho - colorectal polyp
    • Colorectum, low rectum, biopsy — Adenocarcinoma.
    • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2023-03-07 Colonoscopy
    • Low rectal cancer involving anal canal s/p biopsy
  • 2023-03-02 Anoscopy
    • mixed hemorrhoid
    • low rectal mass with bleeding suspected malignancy
  • 2017-09-08 Multiple Sleep Test
    • Summary - The diagnostic nocturnal polysomngraphy demonstrated:
      • Respiratory events were both obstructive and hypopnic (obstructive: 43.6%, central: 0%, Mixed: 0% and hypopnea: 56.4%) with an AHI of 57.1. This is consistent with severe sleep apnea. Snoring was present for 20 % of the diagnostic portion of the study.
      • The baseline oxygen saturation was normal. The oxygen desaturation index was 51.8/hr. severely increased. Desaturation events were continuous and clustered. The lowest SaO2 desaturation associated with a respiratory event was 67%.
      • Sleep structure and quality was (abnormal, fragmented due to respiratory events arousals).
      • The cardiac rate and rhythm showed (normal sinus rhythm) (frequent, PAC’s, PVC’s).
    • Conclusion:
      • This is a case of severe SAS. She had abnormal sleep architecture and nocturnal oxygen desaturation. She is a snorer, too.
        • ChatGPT: SAS in this context refers to Sleep Apnea Syndrome, a condition characterized by repeated episodes of partial or complete obstruction of the upper airway during sleep, resulting in disruptions to breathing and oxygen supply to the body.

[SOAP]

  • 2023-03-14 Radiation Oncolgoy
    • Imp: Low rectal cancer involving anal canal with bleeding, cT4bN1bM0, Stage: IIIC.
    • Plan: Pre-operative CCRT for 5040cGy/28 fx then OP
      • CT simulation on 2023/03/16, 14:30.
  • 2023-03-14 Hemato-Oncology
    • Port-A insertion
    • Arrange admission for FOLFOX on 2023-03-23
  • 2023-03-13 Colorectal Surgery
    • Suggest CCRT then OP (Laparoscopic APR ? due to sphincter invasion)

[radiotherapy]

[chemotherapy]

  • 2023-03-27 - oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with low rectal cancer involving the anal canal with bleeding, cT4bN1bM0, stage: IIIC.

  • For patients with locally advanced rectal cancer who are at high risk for a margin-positive resection or node-positive disease with a low-lying rectal tumor, total neoadjuvant therapy (TNT) is suggested instead of long-course CRT or short-course RT alone. TNT combines oxaliplatin-based chemotherapy with long-course CRT or short-course RT, leading to increased chemotherapy compliance, improved local control, and the ability to consider nonoperative treatment if the patient declines surgery.

  • The patient has been admitted to receive her first dose of FOLFOX. Lab results on 2023-03-23 showed normal liver and kidney function, blood cell counts, serum electrolytes, and no contraindications to chemotherapy.

  • The patient’s chronic viral hepatitis B without the delta agent is currently being managed with Baraclude (entecavir).

  • The current active prescription has no identified issues.

701064531

230329

[exam findings]

  • 2023-02-10 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-12-20 CT - abdomen
    • History and indication: ovary CA
    • IMP:
      • S/P operation.
      • A hypodense nodule (4.5mm) at S5-6 junction of liver.
  • 2022-12-12 SONO - kidney urology
    • Grossly normal, bilateral kidneys
  • 2022-12-09 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Borderline ECG
  • 2022-12-09 Gynecologic ultrasonography
    • ATH + BSO
    • Lt fluid
  • 2022-11-24, -11-21 KUB
    • S/P drainage tube in the pelvic cavity.
    • No disernible calcification along bilateral urotracts based on this study, suggest clinical correlation.
    • Non-specific bowel gas pattern.
  • 2022-11-16 Patho - uterus with or without SO non-neoplastic/prolapse
    • Diagnosis:
      • Ovary, right, oophorectomy —- Clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c1N0(if cM0); FIGO Stage: IC1
      • Ovary, left, oophorectomy —- Negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- Negative for malignancy
      • Uterus, corpus, total hysterectomy —- Negative for malignancy
      • Uterus, endometrium, total hysterectomy —- Negative for malignancy
      • Uterus, cervix, total hysterectomy —- Negative for malignancy
      • Omentum, omentectomy —- Negative for malignancy
      • Lymph node, left iliac, dissection —- Negative for malignancy (0/1)
      • Lymph node, left obturator, dissection —- Negative for malignancy (0/3)
      • Lymph node, right iliac, dissection —- Negative for malignancy (0/3)
      • Lymph node, right obturator, dissection —- Negative for malignancy (0/9)
      • Lymph node, left para-aortic, dissection —- Negative for malignancy (0/8)
      • Lymph node, right para-aortic, dissection —- Negative for malignancy (0/5)
    • Gross description:
      • Procedure (select all that apply): Total hysterectomy, bilateral salpingo-oophorectomy, Omentectomy
      • Specimen Integrity
        • NOTE: For primary ovarian tumors, if the ovary containing primary tumor is removed intact into a laparoscopy bag and ruptured in the bag by the surgeon without spillage into the peritoneal cavity (to allow for removal via laparoscopy port site or small incision), the specimen integrity should be listed as “capsule intact” with a comment explaining this in the report.]
        • Specimen Integrity of Right Ovary (if applicable): intra-op rupture
        • Specimen Integrity of Left Ovary (if applicable): Capsule intact
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Right ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size: Greatest dimension (centimeters): 7.0 cm
        • Additional dimensions (centimeters): 6.5 x 5.0 cm
      • Specimen size:
        • left ovary: 2.5 x 1.3 x 0.4 cm;
        • right tube: 5.0 cm in length and 0.3 cm in diameter;
        • left tube: 5.2 cm in length and 0.3 cm in diameter;
        • uterus: 7.0 x 5.1 x 4.0 cm, 88 gm; Cervix: 4.2 x 4.2 x 2.6 cm; Endometrial cavity: 3.2 x 2.0 x 0.2; A leiomyoma: 0.5 x 0.5 x 0.4 cm and adenomyosis are seen
      • Sections are taken and labeled as:
        • F2022-00542: Representative sections are taken and labeled as: FsA1-2, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: fallopian tube; X2-6: ovary.
        • S2022-20256: A: lymph node, left iliac; B: lymph node, left obturator; C: lymph node, right iliac; D1-2: lymph node, right obturator; E: lymph node, left para-aortic; F: lymph node, right para-aortic; G1: cervix; G2: endometrium; G3: left ovary and fallopian tube; G4: leiomyoma; G5: right posterior wall; G6: right adnexa soft tissue; H: omentum.
    • Microscopic Description:
      • Histologic Type: Clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), Napsin A(+), WT-1(-), p53(wild type), and PR(-).
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.): not applicable
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): not aplicable
      • Peritoneal/Ascitic Fluid: N2022-04209: Negative for malignancy (normal/benign)
      • Regional Lymph Nodes: Negative for metastasis: please see diagnosis
      • Additional Pathologic Findings: A leiomyoma and adenomyosis are seen in uterus.
  • 2022-11-16 Frozen section
    • Preliminary diagnosis: Ovary, right, oophorectomy — adenocarcinoma
  • 2022-11-15 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Gastric erosion, angularis
    • Suggestion
      • Pursue CLO test result
  • 2022-11-14 ECG
    • ICRBBB pattern
      • ChatGPT
        • ICRBBB stands for “Incomplete Right Bundle Branch Block” and refers to a specific pattern seen on an electrocardiogram (ECG). In a normal heart, electrical impulses travel through both the left and right bundle branches, allowing for coordinated contractions of the ventricles. In ICRBBB, the right bundle branch is delayed or blocked, causing a characteristic pattern on the ECG.
        • The ECG in ICRBBB typically shows a widened QRS complex (greater than 120 milliseconds) with a slurred or notched R wave in leads V1 and V2. There may also be ST segment and T wave changes in leads V1 to V3. ICRBBB is considered “incomplete” because the duration of the QRS complex is not as long as it would be in a complete right bundle branch block.
        • ICRBBB is often considered a benign finding and may be present in otherwise healthy individuals. However, it can also be associated with various underlying cardiac conditions, such as pulmonary embolism, right ventricular hypertrophy, and certain congenital heart defects. Further evaluation by a healthcare provider may be warranted in certain cases.
  • 2022-11-14 CTA - pelvis
    • Clinical history: 52 y/o female patient with s/p Chocolate cyst
      • L’t pelvic pain, constipation, Delking on 2022-11-16.
    • With and without contrast enhancement CT of abdomen–whole:
      • There is mulcystic tumor, 8.8x6.1cm in right adnexa, with solid and cystic component and septum, suspected right ovarian malignancy.
      • Liver cyst, 0.5cm in S7.
      • Fibrotic infiltrate in RUL.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
    • If proven ovarian malignancy
    • Imaging Report Form for Ovarian Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia_(Stage_value)
  • 2022-11-08 Gynecologic ultrasonography
    • LT adnexae:free
    • endometrial (+fluid)
    • IMP: Suspected Rt Ovarian mass: (92mm x65mm), papillary:(40mm x31mm), RI: 0.35

[consultation]

  • 2022-12-13 Urology
    • Q
      • This 52 years old female, Right ovarian clear cell carcinoma, pStage IC, pT1c1N0cM0; FIGO Stage IC2 status post Debulking surgery on 2022/11/16 and s/p port-A insertion on 2022/11/25. According to the patient, she had intermittent chills and left flank soreness since 2 days ago. After admitted her vital signs were stable and no fever. The PE found no abdominal tenderness, wound clean and no CP angle knocking tenderness. The lab datas revealed no leukocytosis or pyuria, but elevated CRP upto 12.68 -> 20.5 mg/dL. We need your expertised for renal echo. Thanks a lot!
    • A
      • the patient complained of flank or low back pain trigger by walk
      • USK showed no hydronephroiss
      • Therefore, low back pain (ligament, fascia, intervertebral disc) may be another possible cause of pain

[surgical operation]

  • 2022-11-16
    • Diagnosis:
      • Right ovarian tumor, suspected malignancy
      • Frozen section: adenocarcinoma
    • Surgery:
      • Debulking surgery (ATH + BSO + BPLND)   - Finding
      • Supraumbilical midline vertical skin incision
      • Uterus: normal size, tense contact with bladder, marked adhesion to the rectum
      • Adnexa:
        • LOV: capsule intact , smooth surface.
        • ROV: intra-op rupture(+)
        • Fallopian tube: bilateral grossly normal
      • CDS: adhesion (+)
      • Ascites: scanty
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: infracolic omentectomy was done.
    • Other
      • Estimated blood loss: 1000 ml
      • Blood transfusion: 2U
      • Complication: nil

[chemotherapy]

  • 2023-03-28 - paclitaxel 175mg/m2 220mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W, paclitaxel 20% off due to PLT 88K/uL)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-03-03 - paclitaxel 175mg/m2 280mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-02-09 - paclitaxel 175mg/m2 270mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2023-01-12 - paclitaxel 160mg/m2 250mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - paclitaxel 160mg/m2 240mg NS 250mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr (Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL

[assessment]

  • The patient experienced nadir levels in her WBC and/or PLT count approximately one week after receiving chemotherapy, as indicated by asterisks in the table below (WBC < 3K/uL, PLT < 100K/uL).

    • 2023-03-28 WBC 3.01 x10^3/uL
    • 2023-03-10 WBC 1.89 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 WBC 5.52 x10^3/uL
    • 2023-02-17 WBC 1.42 x10^3/uL * previous chemo on 02/09 - 7 days
    • 2023-02-08 WBC 4.19 x10^3/uL
    • 2023-01-20 WBC 2.06 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 WBC 5.31 x10^3/uL
    • 2022-12-27 WBC 3.09 x10^3/uL
    • 2022-12-19 WBC 8.25 x10^3/uL
    • 2022-12-12 WBC 5.71 x10^3/uL
    • 2022-12-09 WBC 10.45 x10^3/uL
    • 2023-03-28 PLT 88 x10^3/uL * previous chemo on 03/03 - 25 days (not fully recovered yet)
    • 2023-03-10 PLT 24 x10^3/uL * previous chemo on 03/03 - 7 days
    • 2023-03-02 PLT 100 x10^3/uL
    • 2023-02-17 PLT 131 x10^3/uL
    • 2023-02-08 PLT 117 x10^3/uL
    • 2023-01-20 PLT 64 x10^3/uL * previous chemo on 01/12 - 8 days
    • 2023-01-12 PLT 75 x10^3/uL * previous chemo on 12/20 - 8 days
    • 2022-12-27 PLT 129 x10^3/uL
    • 2022-12-19 PLT 209 x10^3/uL
    • 2022-12-12 PLT 126 x10^3/uL
    • 2022-12-09 PLT 138 x10^3/uL
  • The patient was admitted for her scheduled chemotherapy with a 20% dose reduction of paclitaxel due to her not fully recovered low PLT level.

  • No medication reconciliation issues were found after reviewing PharmaCloud and comparing it to the active prescription.

701241752

230329

[exam findings]

  • 2023-03-28 Whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the lower T- and upper L-spines, L4, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Mildly increased activity in the lower T- and upper L-spines and L4 spine. Degenerative change may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2023-03-27 KUB
    • Hepatomegaly is suspected.
  • 2023-03-23 CT - abdomen
    • Findings
      • A tumor (5.3cm) in left breast with left chest wall invasion.
      • Multiple liver tumors. A LN (1.5cm) at left subphrenic region.
      • Small amount ascites.
      • Perineural cysts at sacrum.
    • IMP
      • Left breast cancer with left chest wall invasion, LN and liver metastases.
  • 2023-03-23 KUB
    • Focal small bowel ileus in left abdomen.
    • There are calcifications in the pelvic cavity, could be due to phleboliths.
  • 2020-07-01 Gynecologic ultrasonography
    • Suspected Lt Ovarian Cyst
  • 2020-06-17 Gynecologic ultrasonography
    • Endometrial thickening
    • Suspected bilateral ovarian cyst

[assessment]

  • 2023-03-29 FOBT 4+. A result of 4+ means that a significant amount of blood was detected in the sample, indicating a possible gastrointestinal bleeding. Takepron (lansoprazole) has been prescirbed (ST). Further evaluation and testing may be needed to determine the cause of the bleeding.

701356216

230329

[past history] - 2023-03-25 admission note

  • myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment.
  • hyperlipidemia
  • hepatitis B carrier with Baraclude since 2022/05.
  • gastric ulcer for 10+ years ago.

[allergy]

  • NKDA

[family history]

  • Father: HCC
  • Mother: Type II diabetes mellitus

[exam findings]

  • 2023-03-28 CXR
    • Bilateral pleura effusion.
    • S/P pigtail catheter implantation at right CP angle.
  • 2023-03-27 L-spine AP + Lat. (including sacrum)
    • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
  • 2023-03-27 CXR
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-27 Hand Lt
    • S/P total amputation of 3rd distal phalanx and middle phalanx, and partial amputation of 3rd proximal phalanx of Left hand.
    • S/P near total amputation of 2nd distal phalanx of Left hand.
    • Angulation deformity of 2nd PIP joint.
  • 2023-03-27 C-spine AP + Lat
    • Small Nuchal ligament calcification over the posterior neck
  • 2023-03-27 Spirometry
    • Mild reduction of total lung capacity
    • Moderate restrictive ventilatory impairment, Not significant bronchodilator reversibility
    • Moderate reduction of diffusion capacity
  • 2023-03-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 26) / 102 = 74.51%
      • 2D (M-simpson) = 75
    • Conclusion
      • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
      • Preserved LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
      • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
      • Some R’t plerual effusion.
  • 2022-04-18 SONO - abdomen
    • Calcified spot, 0.45cm in right lobe liver.
    • Suspected minimal ascites in subphrenic region, right.
  • 2022-04-18 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 26) / 120 = 78.33%
      • 2D (M-simpson) = 78
    • Conclusion
      • Septal and RV hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR.
  • 2022-03-30 Spirometry
    • Normal baseline without significant reversibility
    • FEV1FVC=91.41%, FVC= 87%, FEV1= 98%
    • normal total lung capacity TLC=101%
    • suspect mild air trapping, RV/TLC=42.07%
    • normal diffusion capacity
  • 2022-03-16 Patho - bone marrow biopsy
    • Bone marrow, iliac creast, biopsy — Plasma cell myeloma
    • Microscopically, it shows hypercellularity with hemopoietic components accounting for about 70% of the marrow space, and M/E ration of 2: 1. of the bone marrow space. Plasma cells are increased (> 10%) and highlighted by CD138. Occasional megakaryocytes are seen.
    • Immunohistochemical stain reveals CD34(-), CD117(-), MPO(+), CD71(+), CD20(focal +, < 5%), Kappa light chain(-), Lambda ligh chain (+ for monoclonality).
    • ADDENDUM: Special stain — congo red (+), compatible with amyloidosis
  • 2022-03-07 Surgical pathology Level IV
    • PATHOLOGICAL DIAGNOSIS:
      • Kidney, needle biopsy for light microscopic examination — Compatible with amyloidosis (lambda light chain type) — Mild arteriosclerosis
      • COMMENT: We are limited in our assessment because the specimen submitted for light microscopy contains renal medullary tissue only. No glomerulus is available. The semithin sections prepared for electron microscopic examination show glomeruli with mesangial expansion. By immunofluorescence, the lambda staining is stronger than kappa in the glomerular mesangium and capillary walls. The electron microscopy demonstrates the presence of randomly oriented fibrils 8-12 nm in diameter within the mesangium and along the glomerular basement membranes. Although the Congo red staining is not contributory, the above features are mostly compatible with renal involvement by amyloidosis. Clinical correlation is recommended. For EM findings, please see report S111-80825.
  • 2022-03-07 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Prolonged QT
  • 2022-02-23 SONO -nephrology
    • chronic parenchymal renal disease
    • right renal cyst

[consultation]

  • 2023-03-29 Neurology
    • Q
      • for bilateral last of three fingers numbness, and fall down repeatedly.
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from bilateral last of three fingers numbness, and fall down repeatedly, and the heart echo showed suspected non-bacterial thrombotic endocarditis. So we need your help, thanks a lot!!
    • A
      • hands weakness esp. at bilateral ulnar sides after the fall
      • NE: aware, fluent speech, bil. hearing impairment, no visual field defect, no facial weakness or tongue deviation, bil. Benedict hands and diffuse hypo-reflexia
      • Impression:
        • ulnar neuropathies, suspect entrapment neuropathy
        • amyloidosis
      • Suggest:
        • C-spine MRI, nerve conduction study and BAEP might be arranged
        • I would like to follow up this patient. Thank you for your consultation.
  • 2023-03-27 Cardiology
    • Q
      • for heart function evaluation, hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL
      • This is a 54-year-old male, underlying hyperlipidemia, myeloma with amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy, s/p chemotherapy with VTD from 20220506 ~ 20230210 (C11W2) with medication treatment. The history of hepatitis B carrier with Baraclude. He visited OPD due to proteinuria found by health examination in 2021 October.
      • This time, he is admitted for Auto HSC collection, then he suffered from pitting edema 4+ at limbs,and the blood pressure lower (SBP: 70-90mmHg), CXR: bilateral pleural effusion, the lab of cardio enyzam poor (hs-Troponin I: 185.1 pg/mL, CKMB: 6.5ng/mL), 12-Lead EKG: Normal sinus rhythm, Left axis deviation, Low voltage QRS, Cannot rule out Anteroseptal infarct, age. The heart echo will be arranged. So we need your help, thanks a lot!!
    • A
      • S
        • 55 year-old male had the history of Myeloma with Amyloidosis (lambda light chain type), s/p renal biopsy and bone marrow biopsy and lab test. start chemotherapy with Velcade TD from 20220506
      • O
        • LAB NTproBNP 8184 hsTnI167.9 CKMB 6.1 Cre 0.83 ALT 32 albumin 2.2 Hb 13.5 WBC 25960 PLT 219k band 6.8%
        • echocardiogram 20230327
          • Marked asymmetric septal hypertrophy with Gr II LV diastolic dysfunction; no significant intracardiac pressure; suspected non-obstructive type hypertrophic cardiomyopathy or amyloidosis heart; moderately dilated LA.
          • Preserved LV and RV systolic function.
          • Aortic valve sclerosis with trivial AR; mild MR; mild TR.
          • Multiple oscillation lesions at posterior mitral leaflet with sized 10-12 mm and at tricuspid septal leaflet with sized 8-19 mm, nature? suspected non-bacterial thrombotic endocarditis (NTBE) if no evidence of active infection.
          • Some R’t plerual effusion.
        • CXR 20230327 right pleural effusion 20230307 clear lung field
        • ECG 20230327 sinus rhythm, low voltage, left axis deviation
      • Impression
        • Hypertrophic cardiomyopathy, suspected amyloidosis related
        • Oscillating lesions on mitral and tricuspid valves, nature?; with mild MR and TR
        • Severe hypoalbuminemia
      • Suggestion
        • Collecting blood cultures x3 to exclude bacterial endocarditis
        • Correct hypoalbuminemia
        • Right pleural effusion study
        • By echocardiogram, IVC 13mm suggested low intra-vascular volume
        • Check adrenal and thyroid function; may give midodrine for BP support

[SOAP]

  • 2023-02-24 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923, C5W2 20220930, C6W1 20221014, C6W2 20221021, C7W1 20221104, C7W2 20221111, C8W1 20221202, C8W2 20221209, C9W1 20221223, C9W2 20221230. C10W1 20230113, C10 W2 20230120, C11W1 20230203, C11W220230210 )
    • admission at March 25, prepare for GCSF injection at March 26-30, Auto HSC collection at March 30-31.
  • 2022-09-23 Hemato-Oncology
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722, C5W1 20220923)
    • Dara not approved by NHI
    • continue VTD therapy C5
  • 2022-09-09 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • velcade TD (C1W1 20220506, C1W2 20220513, C2W1 20220527, C2W2 20220610, C3W1 20220624, C3W2 20220701 , C4W1 20220715, C4W2 20220722)
    • apply for Velcade and daraturamab
  • 2022-04-20 Hemato-Oncology
    • check light chain and beta2-microglogulinemia
    • check bone marrow (plasma cell myeoloma)
    • apply for Major disease to NHI (approved)
    • apply for velcade
    • start steroid therapy and vemlidy
  • 2022-03-30 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow (plasma cell myeoloma)
      • apply for Major disease to NHI
  • 2022-03-16 Hemato-Oncology
    • P
      • check light chain and beta2-microglogulinemia
      • check bone marrow
  • 2022-03-16 Nephrology
    • P: refer to Hema OPD due to amyloidosis (lambda light chain type)

[chemotherapy]

  • 2023-02-10 - bortezomib 1.3mg/m2 2.47mg SC 5min D1,5
  • 2023-02-03 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-20 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2023-01-13 - bortezomib 1.3mg/m2 2.45mg SC 5min D1,5
  • 2022-12-30 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-23 - bortezomib 1.3mg/m2 2.46mg SC 5min D1,5
  • 2022-12-09 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-12-02 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-11 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-11-04 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-21 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-10-14 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-30 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-09-23 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-22 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-15 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-07-01 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-24 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-06-10 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-27 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-13 - bortezomib 1.3mg/m2 2.40mg SC 5min D1,5
  • 2022-05-04 - bortezomib 1.3mg/m2 2.39mg SC 5min D1,5

[medication]

  • 2022-05-04 ~ 2023-03-17 - Thado (thalidomide 50mg) 1# HS

[assessment]

  • The patient was admitted for planned HSC harvest, but bilateral numbness in the last three fingers and elevated cardiac enzymes were observed, so further studies are being conducted.
  • There is no issue with the active recipe being used.

700753896

230328

[diagnosis] - 2023-03-27 admission note

  • Squamous cell carcinoma of upper third of esophagus, cT3N1M0, stage II status post feeding jejunostomy and left port-A implantation on 2023/02/20 and concurrent chemoradiotherapy with PF(CDDP 75mg/m2, 5FU 1000mg/m2 x4 days) from 2023/02/27~
  • Gastro-esophageal reflux disease without esophagitis
  • Hypertensive heart disease without heart failure
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Hypomagnesemia

[exam findings]

  • 2023-03-03 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Scoliosis of the T-spine with convex to right side.
  • 2023-02-22 Pure Tone Audiometry
    • Reliabilty Fair
    • PTA
      • R’t : 10 dB HL, WNL
      • L’t : 13 dB HL, normal to mild SNHL.
  • 2023-02-20 CXR
    • widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
  • 2023-02-18 MRI - brain
    • no evidence of brain tumors.
  • 2023-02-17 SONO - abdomen
    • suspected liver calcification, left
    • suspected GB stones
  • 2023-02-16 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, mandible, lower L-spines, right S-I joint, bilateral shoulders, hips and left knee in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower L-spines and right S-I joint. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, hips and left knee, compatible with benign joint lesions.
      • No prominent bone abnormality was noted elsewhere.
  • 2023-02-15 Bronchoscopy
    • no endotreacheal or endobronchial lesions
  • 2023-02-14 Whole body PET scan
    • The [F-18] Fluorodeoxyglucose (FDG) PET scan from head to upper thigh regions was performed at 40 minutes after i.v. injection 284 MBq of FDG. Fasting for at least 6 hours was required prior to this examination. Images were reconstructed iteratively with CT scan attenuation correction.
    • There was increased FDG uptake in a focal area in the proximal portion of the esophagus (SUVmax early: 17.72, delay: 22.73) and in bilateral shoulders (SUVmax early: 3.37, delay: 1.72). In addition, there was increased FDG accumulation in both kidneys and bilateral ureters.
    • IMPRESSION:
      • A glucose hypermetabolic lesion in the proximal portion of the esophagus, compatible with primary esophageal malignancy.
      • Mild glucose hypermetabolism in bilateral shoulders. Arthritis may show this picture.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
      • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2023-02-13 CXR
    • Widening of Rt paratracheal stripe due to space taking lesion or paratracheal lymph node enlargement
    • Thoracic aortic arch calcified atheriosclerotic plaque
    • Minimal dextroscoliosis of the T-spine
  • 2023-02-03 CT - chest
    • Indication: esophageal inlet mucosal lesion, pending patho. suspected esophageal cancer, for staging
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Submucosa soft tissue mass at upper third esophagus measuring 2.49cm is found.
        • Patent airway is found.
        • There is no evidence of mediastinal LAP, but small lymph nodes (n=2) are found at paraesophageal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: Esophageal submucosa tumor, 2.49cm.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-02-03 Patho - esophageal biopsy
    • Esophageal tumor, 16 cm below the incisors, biopsy — Squamous cell carcinoma
    • Microscopically, the sections show a picture of squamous cell carcinoma, poorly differentiated of the esophageal tumor tissue characterized by some solid tumor nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrating in the fibrotic stroma.
    • Immunohistochemical stains of CK5/6(+), P16(-) and P63 (+) for tumor.
  • 2023-02-02 Esophagogastroduodenoscopy, EGD
    • Suspected esophageal malignancy, L/3, s/p biopsy*4
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis
  • 2022-07-22 Nasopharyngoscopy
    • suspected acute thyroiditis
  • 2021-11-08 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (86.3 - 17.7) / 86.3 = 79.49%
      • M-mode (Teichholz) = 79.5
    • Normal AV/MV with trivial MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • No PR, trivial TR, normal IVC size

[consultation]

  • 2023-02-20 Hemato-Oncology
    • A
      • We are consulted for CCRT.
      • Please check 24 urine CCR, auditory test, HbsAg, AntiHbc, Anti HCV. Arrnage our OPD after discharge.
  • 2023-02-17 Radiation Oncology
    • A
      • CCRT is indicated.
      • CT-simulation will be arranged on 2/22.
      • Plan to deliver 45 Gy/ 25 fx to the upper 2/3 esophagus and bil. SCF. Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 2/27.
  • 2023-02-14 Gastroenterology
    • Q
      • This 76-year-old woman denied any systemic disease. She has suffered from dysphagia for solid material with odynophagia for 2 months, associated with weight loss 7 kg in 6 months. She has visited our GI OPD, where PES revealed suspected esophageal malignancy S/P biopsy was done. Chest CT showed esophageal submucosa tumor, 2.49cm. suspected GIST. For this newly diagnosed esophageal cancer, she was admitted for cancer work-up.
      • Thus we need consult you for arrange EUS and abdominal ultrasound. Thank you very much.
      • schedule
        • 112/02/14 10:30 PET scan
        • 112/02/15 bronchoscope
        • 112/02/16 11:00 bone scan
        • 112/02/18 08:40 brain MRI
        • hope to arrange the examination before 112/02/17.
    • A
      • For EUS:
        • Miniprobe EUS is technically challenging and NOT recommended due to the position of the lesion.
        • Please consider other diagnostic/staging modality
      • For abd echo:
        • Already arrange abdominal echo on 0217.

[surgical operation]

  • 2023-02-20
    • Surgery
      • Feeding jejunostomy + port-A
    • Finding
      • 18 Fr. silicon Foley catheter as jejunostomy tube
      • 8.0 Fro. Polysite, left cephalic vein, cut-down method.
  • 2022-11-15
    • Surgery: Hemorrhoidectomy        
    • Finding: Prolasped hemorrhoids at 3,7,11 o’clock
  • 2021-09-23
    • Surgery: lt PF MIS lateral release
      • The patient underwent a lateral release of the lateral patellofemoral ligament using minimally invasive surgery techniques.
    • Finding: PF OA PFPS
      • The patient has patellofemoral osteoarthritis (PF OA) and patellofemoral pain syndrome (PFPS), which are conditions that affect the knee joint. The lateral release surgery was likely performed to address these conditions, as it can be used to alleviate pain and improve the alignment of the patella.
  • 2019-09-23
    • Diagnosis: left knee osteoarthritis
    • PCS code: 64164B
  • 2018-09-03
    • Diagnosis: rt OA knee
    • PCS code: 64164B

[chemotherapy]

  • 2023-03-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
  • 2023-02-27 - cisplatin 75mg/m2 80mg NS 500mL 24hr D1 + [MgSO4 10% 20mL NS 100mL 1hr + furosemide 20mg NS 30mL 10min] post cisplatin + fluorouracil 1000mg/m2 1000mg NS 500mL 24hr D1-4 (PF CCRT Q4W)
    • dexamethasone 4mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

==========

2023-03-28

  • On 2023-03-22, the patient had a BUN/serum creatinine ratio of 31. The normal ratio is 10 to 15:1 but can be greater than 20:1 in prerenal disease due to the increased passive reabsorption of urea that follows the enhanced proximal reabsorption of sodium and water. This selective rise in BUN is known as prerenal azotemia. The serum creatinine concentration will increase in this setting only if the degree of hypovolemia is severe enough to lower the GFR. Therefore, it is recommended to rule out hypovolemia or upper gastrointestinal bleeding as possible causes for the elevated BUN/serum creatinine ratio.
    • 2023-03-22 BUN 29 mg/dL
    • 2023-02-27 BUN 13 mg/dL
    • 2023-02-13 BUN 11 mg/dL
    • 2022-11-14 BUN 9 mg/dL
    • 2023-03-22 Creatinine 0.94 mg/dL
    • 2023-02-27 Creatinine 0.60 mg/dL
    • 2023-02-13 Creatinine 0.71 mg/dL
    • 2022-11-14 Creatinine 0.59 mg/dL

2023-03-01

  • The patient underwent surgery for feeding jejunostomy and port-A placement on 2023-02-20 and she began receiving cisplatin and fluorouracil starting from 2023-02-27.

  • Patients who have undergone feeding jejunostomy surgery often require additional nutritional support and close monitoring of their hydration status. All the oral drugs in the current prescription are compatible with tube feeding.

700947307

230328

[diagnosis] - 2023-03-27 admission note

  • Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel status post 3 dimensions single incision laparoscopic right hemicolectomy with laparoscopic adhesion lysis and resection of small bowel on 2021/12/01
  • Metastatic uterine adenocarcinoma status psot Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy on 2021/12/01
  • Hepatitis B carrier

[past history]

  • The patient is B hepatitis carrier
  • history of operation:
    • Status post Caesarean section about 40 years ago
    • Status post Tympanoplasty on 2011/04/19
    • Right renal stone status post extracorporeal shock wave lithotripsy on 2009/04/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid): OK。
  • Regular medications or herb:no                                                                     

[allergy]

  • NKDA                                                             

[family history]

  • Father had liver cancer
  • Mom had diabetes mellitus type 2 and hypertension

[exam findings]

  • 2023-03-27 KUB
    • S/P metalic autosuture and few clips projecting at right lower abdomen.
    • Fecal material store in the colon.
  • 2023-02-09 All-RAS + BRAF mutations assay
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GTT, p.G12V)
    • BRAF
      • There was no variant detect in the BRAF gene.
  • 2023-02-08 CT - abdomen
    • History: cecal CA wt terminal ileum invasion (T4b), lung, liver, uterus mets (M1b), pT4bN2aM1b; stage IVB,
    • Indication: multiple lung metastases
    • Findings:
      • There is a newly-developed lobulated enhancing soft tissue mass 1.3 cm in right middle pelvis with direct invasion right L/3 ureter causing moderate hydroureteronephrosis but no delayed contrast excretion of right kidney.
        • Metastasis in right middle pelvis induce obstructive uropathy is highly suspected.
        • In addition, There is a newly-developed lobulated enhancing soft tissue mass 3.2 cm in right uterine fossa that is also c/w tumor recurrence.
      • There are at least seven newly-developed soft tissue nodules in right lower omentum that are c/w tumor seeding.
      • There are several newly-developed metastatic nodes in para-aortic space and para-cava space .
      • Prior CT identified Multiple metastase in bil. lungs are noted again, increasing in size and number that is c/w progressive disease.
      • S/P right hemicolectomy and S/P hysterectomy
      • Right renal stone (5mm).
      • Tiny gallbladder stones.
    • Impression:
      • Two metastases or local recurrent tumor in right middle pelvis and right uterine fossa.
      • Seven tumor seeding in right lower omentum.
      • Metastatic nodes in para-aortic space and para-cava space
      • Multiple lung metastases show progressive disease.
  • 2022-10-04 CT - chest
    • Indication
      • Secondary malignant neoplasm of right lung
      • Malignant neoplasm of cecum
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Several nodular lesions are found at both lungs with some of them shows cavitation. Recurrent/residual metatsatic lung nodules are considered.
          • In comparison with CT dated on 2022-07-25, the numbers of the lesions increased.
        • S/p port-A placement with its tip at Superior vena cava.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Tiny low density lesion at S6/7 of liver is found. Suspected liver meta.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp:
      • Bilaeral lung meta. In progression.
      • Suspected liver meta.
  • 2022-07-26 Patho - lung transbronchial biopsy
    • Lung, RLL, CT-guide biopsy — adenocarcinoma, moderately differetiated, consistent with metastatic colorectal orgin
    • Sections show cribriform glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal CDX2(+) and TTF-1(-).
    • The results are consistent with metastatic colorectal adenocarcinoma.
  • 2022-07-25 CXR
    • a ndular lesion with extensive ground glass opacity over Rt upper lobe s/p cryoablation
    • recticular opacities over both lower lung zones
  • 2022-07-25 Right Lower Lobe Lung Mets Cryotherapy
    • Indication: right lower lobe lung meta
    • Position: Prone
    • Cryotherapy was done with cryoneedles placed into right lower lobe lung tumor region. One session of cryotherap with 3-7-10 minutes of cryotherapy was done. Iceball was visualized with total coverage of the tumor.
  • 2022-07-05 CT - abdomen
    • History and indication: cecal cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs.
      • Right renal stone (4mm).
      • Tiny gallbladder stones.
    • IMP:
      • Cecal cancer s/p operation.
      • Multiple nodules in bil. lungs c/w metastases.
  • 2022-06-26 Colonoscopy
    • Diagnosis
      • C/W post right hemicolectomy, no evidence of cancer recurrence.
      • Internal hemorrhoid
    • Suggestion
      • OPD F/U
    • Complication
      • No immediate complication
  • 2022-05-17 CT - abdomen
    • Cecal cancer s/p operation.
    • Multiple nodules in bil. lungs suspected metastases.
  • 2021-12-28 CT - chest
    • Indication: colon cancer with liver & lung mets
    • Comparison made with previous CT dated on 2021/11/29 abdominal CT.
      • lungs:
        • multiple numerous nodules of variable sizes in both lungs (up to 8.2 mm at RLL), consistent wth metastatic lesions
      • Mediastinum: no enlarged LN or mass.
      • Hila: unremarkable.
      • Vessels: the great vessels in the hila and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall: unremarkable.
      • Visible abdominal-pelvic contents:
        • a metastitc hepatic tumor 23 mm in S7.
        • several small bilateral renal cysts.
        • unremarkable of the spleen, adrenal glands, pancreas, and gall baldder.
        • no enlarged lymph node or ascites.
        • s/p Rt hemicolectomy with retained surgical clips.
      • Visualized bones: unremarkable.
    • Impression:
      • colon ca s/p with multiple lung metastatic tumors and solitary hepatic metastatic tumor.
  • 2021-12-02 Patho - uterus with or without SO non-neoplastic/prolapse
    • DIAGNOSIS:
      • Uterus, myometrium, laparoscopic hysterectomy — Metastatic adenocarcinoma, compatible with colorectal origin — Intramural leiomyoma
      • Uterus, endometrium, laparoscopic hysterectomy — Postmenopausal state.
      • Uterus, cervix, laparoscopic hysterectomy — Negative for malignancy
      • Adnexae, bilateral, salpingo-oophorectomy — Negative for malignancy
    • Microscopically, the myometrium shows metastatic adenocarcinoma composed of invasive neoplastic glands
  • 2021-12-02 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Large intestine, ascending colon, laparoscopic right hemicolectomy — Adenocarcinoma, moderately differentiated
      • Resection margins, proximal and distal — Free
      • Terminal ileum — Involved by adenocarcinoma
      • Lymph node, mesocolic, dissection — Positive for adenocarcinoma (4/12)
      • Labeled posterior abdominal wall — Involved by adenocarcinoma
      • Pathology stage: pT4bN2aM1a; AJCC stage IVA
    • MICROSCOPIC EXAMINATION
      • Histology: Adenocarcinoma
  • 2021-11-29 CT - abdomen
    • Impression:
      • Cecal tumor, with extension to appendix and terminal ileum, and lymphadenopathy at right lower quadrant. Malignancy is highly suspected.
      • A 5.4cm uterine tumor, suspect malignancy. Suggest GYN ultrasound correlation.
      • RLL pulmonary nodule.
      • Mild ascites.
      • Bilateral renal cysts. Right renal stone.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:4b(T_value) N:2a(N_value) M:1a(M_value) STAGE:IV(Stage_value)
  • 2021-11-29 Gynecologic Ultrasonography
    • RT adnexae: free
    • IMP : Uterine mass: (1) 45x38mm, (2) 21x18mm

[surigcal operation]

  • 2021-12-01
    • Surgery
      • Laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy
    • Finding
      • Uterus: enlarged, 11x6x3cm, corpus – right posterior uterine mass 6x5cm with iiregular border, primary uterine tumor or colon cancer metastasis?
      • border adhesion to right pelvic wall, tumor adhesion?
      • another small myomas 2~3# 2cm for each
      • EM – np
      • cervix eroded
      • bil adnexa: normal-looking
      • CDS: some pelvic adhesion (due to previous cesarean section and tumor asdhesion>?) were noted between ant peritoneum and bladder; between post uterus, right pelvic wall and bowels s/p laparoscopic lysis
  • 2021-12-01
    • Surgery
      • 3D SILS right hemicolectomy + laparoscopic adhesion lysis + resection of small bowel      
    • Finding
      • Lower abdomen adhesion due to previous C/S Advanced cecal cancer partial obstruction with perforation to retroperitoneum and dense adhesion/invasion to small bowel

[chemoimmunotherapy]

  • 2023-03-27 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3600mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - oxaliplatin 70mg/m2 100mg D5W 250mL 2hr + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (FOLFOXIRI)

    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-07 (Avastin + FOLFOX)

  • 2023-01-09 (Avastin + FOLFOX)

  • 2022-12-12 (Avastin + FOLFOX)

  • 2022-11-18 (Avastin + FOLFOX)

  • 2022-10-26 (Avastin + FOLFOX)

  • 2022-07-04 (Avastin + FOLFIRI)

  • 2022-06-08 (Avastin + FOLFIRI)

  • 2022-05-16 (Avastin + FOLFIRI)

  • 2022-04-20 (Avastin + FOLFIRI)

  • 2022-03-29 (Avastin + FOLFIRI)

  • 2022-03-04 (Avastin + FOLFIRI)

  • 2022-02-11 (Avastin + FOLFIRI)

  • 2022-01-12 (Avastin + FOLFIRI)

  • 2021-12-27 (Avastin + FOLFIRI)

[assessment]

  • On 2021-12-01, the patient underwent surgery for cecal cancer with terminal ileum invasion and metastases to the lung, liver, and uterus, resulting in a diagnosis of pT4bN2aM1b, stage IVB. The surgery involved a 3D SILS right hemicolectomy with laparoscopic adhesion lysis and resection of the small bowel, as well as a laparoscopic hysterectomy (LESS - laparoendoscopic single site surgery) and bilateral salpingo-oophorectomy. The patient then received Avastin + FOLFIRI from 2021-12-27 to 2022-07-04, and Avastin + FOLFOX from 2022-10-26 to 2023-02-07.
  • On 2023-02-08, a CT scan showed two metastases or a local recurrent tumor in the right middle pelvis and right uterine fossa, seven tumor seedings in the right lower omentum, and metastatic nodes in the para-aortic space and para-cava space, as well as multiple lung metastases showing progressive disease. Consequently, the patient’s regimen was changed to FOLFOXIRI from 2023-03-01 and the treatment is ongoing.
  • On 2023-02-09, a KRAS mutation was identified in the patient’s tumor (codon 12 GGT>GTT, p.G12V), which suggests that certain targeted therapies, including anti-EGFR therapies such as cetuximab or panitumumab, are unlikely to be effective. Patients with KRAS mutations are typically not eligible for these treatments.
  • The patient has received the 2nd cycle of FOLFOXIRI during this hospital stay, and it is too early to determine its effectiveness. There have been no severe adverse reactions related to the treatment so far.
  • Based on the patient’s prescription records in the PharmaCloud database for the last 3 months, there are no issues with medication reconciliation.

701027894

230328

[diagnosis] - 2023-03-28 discharge note

  • Malignant neoplasm of endometrium
  • Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Hypomagnesemia
  • Anemia due to antineoplastic chemotherapy

[exam findings]

  • 2023-03-03 Mammography
    • Old mammographic study: 2021-04-15 (BIRADS 1)
    • Digital mammography of both breasts with MLO and CC views:
      • Breast composition: category c (The breasts are heteregeneously dense, which may obscure small masses).
      • There is no obvious mass lesion.
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative.-annual screening.
  • 2022-11-23 ECG
    • Sinus tachycardia
    • Left axis deviation
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2022-10-27 CT - abdomen
    • History and indication: Endometrial cancer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy. Swelling of anterior abdominal wall. A LN (1.5cm) at left paraaortic region. Small LNs at bil. inguinal regions.
      • Grade 4 fatty liver.
      • Left renal cyst (5mm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S/P hysterectomy.
      • Swelling of anterior abdominal wall. A LN at left paraaortic region.
  • 2022-10-27 ENT Hearing Test
    • PTA
    • Reliability FAIR
    • Average RE 19 dB HL; LE 23 dB HL.
    • Bil WNL.
  • 2022-10-01 CT - chest
    • Indication: GYN cancer, suspected metastasis
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Linear atelectatic change at right lower lobe is found.
        • Subpleural nodule at left upper lobe up to 0.4cm in largest dimension is found. (Se8 Im44).
        • Non-specific lymph nodes are found at right hilar and left paratracheal region.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Marked fatty liver is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Compatible with endometrial cancer s/p C/T, No definte lung meta but non-specific lymph nodes in the mediastinum. Suggest follow up.
  • 2022-09-26 Patho - uterus with or without SO
    • pathologic diagnosis
      • Uterus, endometrium, staging surgery — Endometroid carcinoma
      • Fallopian tube, right, BSO — Endometriosis with atypical hyperplasia
      • Lymph nodes, pelvic and para-aortic, bilateral, BPLND+PALND— Metastatic carcinoma (8/35)
      • AJCC 8 th edition, Pathology stage: pT1bN1a; stage IIIC1; FIGO stage IIIC1
    • macroscopic examination
      • Procedure: LAVH + BSO + partial omentectomy + BPLND + para-aortic LN dissection
      • Specimen Size: 15 x 11 x 7.0 cm and 430 gm (uterus), 2.5 x 1.4 cm (Rt ovary), 5.2 x 1.0 cm (Rt tube), 2.2 x 1.5 cm (Lt ovary), 5.0 x 1.2 cm (Lt tube), and 25 x 12 x 5.0 cm (omentum)
      • Specimen Integrity: Intact
      • Tumor Site: Endometrium, diffuse
      • Tumor Size: 7.5 x 5.6 x 2.8 cm
      • Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic LNs
      • Representative parts are taken for section and labeled as: A= left iliac LNs, B1-B4= left obturator LNs, C= right iliac LNs, D1-D2= right obturator LNs, E= left para-aoric LNs, F1-F2= right para-aortic LNs, G1-G4= cerivx, G5-G8= endometrial tumor, G9-G10= right ovary and fallopian tube, G11-G12= left ovary and fallopian tube, H1-H2= omentum
    • microscopic examination
      • Histologic Type: Endometroid carcinoma
      • Histologic Grade: FIGO grade 2
      • Adenomyosis: Present
      • Uterine Serosal Involvement: Not identified
      • Cervical Stromal Involvement: Not identified
      • Other Tissue/Organ Involvement: Not applicable
      • Peritoneal/Ascitic Fluid: Negative
      • Margins: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: 1.5 cm
      • Lymphvascular Invasion: Present
      • Regional Lymph Nodes: Metastatic carcinoma (8/35)
        • number of lymph node examined: 3 (left iliac), 11 (left obturator), 4 (right iliac), 10 (right obturator), 2 (left para-aortic), and 5 (right para-aortic)
        • number with metastases >2 mm: 4 (left obturator), 4 (right obturator)
        • number with metastases <=2 mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1b (tumor invading one-half or more of the myometrium)
        • Regional Lymph Nodes: pN1a (regional lymph node metastasis(> 2mm) to pelvic lymph nodes)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIC1
      • AdditionalPathologic Findings
        • Cervix: Chronic cervicitis with Nabothian cyst and squamous metaplasia
        • Myometrium: Adenomyosis
        • Ovary, right: Unremarkable
        • Ovary, left: Endometriosis
        • Fallopian tube, right: Endometriosis with atypical hyperplasia
        • Fallopian tube, left: Endometriosis
        • Omentum: No remarkable change
  • 2022-09-21 MRI - pelvis
    • Clinical history: 47 y/o female patient with 2022/09/14 PATHO-endometrium curretage/biopsy, DIAGNOSIS: Uterus, endometrium, TCR — Endometrioid carcinoma.
    • With and without contrast enhancement MRI: Pelvis (Sag T2, axial T1, T2 and T1FS, coronal T2, post contrast enhancement axial and coronal T1FS, upper abdomen survey)
      • There are diffuse soft tissue tumors in the uterine cavity, suspected endometrial malignancy.
      • Tubular cystic lesion in right adnexa, suggesting hydrosalpinx.
      • Cysts in the uterine cervix, suggesting Nabothin cysts.
      • Unremarkable change of the liver, spleen, pancreas.
      • There are multiple enlarged lymph nodes in bilateral obturator region, internal and common iliac regions. Could be due to metastatic lymph nodes.
      • Non-enhancing nodule in left kidney, 0.45cm, suspected left renal cyst.
      • No ascites.
    • Imaging Report Form for Endometrial Carcinoma
      • Impression (Imaging stage) : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIC1____(Stage_value)
  • 2022-09-14 Patho - endometrium curretage/biopsy
    • Uterus, endometrium, TCR — Endometrioid carcinoma
    • Specimen submitted in formalin consists of multiple pieces of red, irregular tissue measuring up to 3.2 x 1.4 x 0.5 cm. All for section in 5 cassettes A1-5.
    • Sections show pieces of blood clots and endometrial tissue with solid and cribriform glands. Moderate to severe nuclear atypia and frequent mitoses are seen.
  • 2022-09-09 Gynecologic ultrasonography
    • LT adnexae: free
    • Endometrial thickening (RI:0.15)
    • Rt Ovarian cyst suspected hydrosalpinx

[consultation]

  • 2022-11-28 Radiation Oncology
    • Q
      • This 47-year-old woman patient is a case of Endometrial cancer, grade 2 endometroid carcinoma with bilateral obturator LAP metastasis s/p LAVH + BSO + BPLND + PA LN dissection, partial omentectomy on 2022/09/26, pT1bN1acM0, stage IIIC1; FIGO stage IIIC1, ECOG =1 s/p concurrent chemoradiotherapy.
      • This time, for severe nausea with vomiting after concurrent chemoradiotherapy. Now, for follow up. Thank you.
    • A
      • This 47 Y/O female has received adjuvant CCRT since 2022/10/24. She suffers from grade 2 nausea and vomiting during CCRT, although self-paid Emend has been prescribed.
      • RT dose: 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics, 2022/10/24 to 11/28.
      • Concurrent weekly cisplatin: 10/29, 11/04, 11/11, 11/18, 11/25.
      • RT side effects, 11/28: Radiation dermatitis, grade 0; nausea, grade 2; enteritis, grade 1; proctitis, grade 1; cystitis, grade 0.

[surgical operation]

  • 2022-09-26
    • Surgery
      • Diagnosis
        • Pelvic MRI on 09/21 showed Diffuse soft tissue in the uterus with multiple enlarged pelvic lymph nodes, suspected endometrial malignancy, cstage T1bN1aM0, IIIC1.
        • Endometrial cancer
      • Operation
        • Laparoscopic gynecologic oncology staging surgery  
        • change to exploratory laparoscopy + laparotomy (ope) gynecologic oncology staging surgery (BPLND and bilateral para-aortic lymphadenectomy)    
    • Finding
      • Uterus: normal size, smooth surface, papillary mass in uterus cavity, myometrium invasion depth <1/2
      • Bilateral adnexa: severe adhesion, s/p adhesiolysis
      • Bilateral pelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • CDS: ascites (+)
    • Others
      • Estimated blood loss: 300ml
      • Blood transfusion: nil
      • Complication: nil  
  • 2022-09-26
    • Surgery
      • Operation
        • Adhesionolysis
    • Finding
      • s/p lower midline incision with periumbilical hernia
      • severe adhesion of omentum and small bowel in lower peritoneal cavity
  • 2022-09-14
    • Surgery
      • TCR, for endometrial thickening.
      • with D&C      
    • Finding
      • Endometrial thickening, occupying the whole uterine cavity, suspected endometrial hyperplasia.
      • Bilateral ostium: difficult to see.
      • Usage of dextrose water: 1000ml/900 ml.
      • Estimated bloodloss: 10 ml;
      • Blood Transfusion: nil; Complication: nil.  

[radiotherapy]

  • 2022-10-24 ~ 2022-11-28 - 4680cGy/26 fractions to vaginal stump, pelvic & PA lymphatics

[chemotherapy]

  • 2023-03-27 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-03 - paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - paclitaxel 140mg/m2 240mg NS 500mL 3hr + carboplatin AUC 5 450mg 2hr (adjuvant Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-24 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + magnesium sulfate 10% 20mL 1hr + aprepitant 125mg D1-3
  • 2022-11-17 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-10 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-11-03 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 8mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-28 - cisplatin 40mg/m2 70mg 2hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg D1-3

==========

2023-03-28

  • The patient’s hypomagnesemia, which has been ongoing since November 2022, continues to persist (2023-03-23 serum Mg 1.7mg/dL). It is recommended to include magnesium supplements in the patient’s discharge plan.

2023-01-16

  • The hypomagnesemia observed since Nov 2022 might be related to the cisplatin administered as part of the CCRT in early October and November 2022. Creatinine levels rose from roughly 0.6 mg/dL in late September 2022 to 1.0 mg/dL in late November 2022. Hypomagnesemia due to urinary magnesium wasting can occur in over one-half of cases of cisplatin-induced nephrotoxicity. Magnesium supplements have been prescribed for the patient both orally (MgO) and intravenously (MgSO4).
  • Since the end of December 2022, no further hypocalcemia has been observed.
  • At this hospitalization, there have been no symptoms of nausea or vomiting observed (as a result of concurrent chemotherapy and radiotherapy, the patient experienced severe nausea and vomiting in late November 2022).

701320413

230328

{Chronic myelomonocytic leukemia, CMMoL}

  • diagnosis
    • 2022-10-19 adminsion note
      • Anemia, unspecified
      • Chronic myelomonocytic leukemia not having achieved remission
      • Unspecified viral hepatitis B without hepatic coma
      • Type 2 diabetes mellitus without complications
      • Chronic myeloproliferative disease
  • exam finding
    • 2022-11-19 Skull, Pelvis, Femur
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • 2022-11-18 Abdomen
      • Eqivocal osteoblastic change of the L-spine are suspected. please correlate with clinical condition or CT.
      • Splenomegaly is highly suspected.
    • 2022-10-21 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (84 - 19) / 84 = 77.38%
        • M-mode (Teichholz) = 77
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA
      • Mild MR, TR
    • 2022-10-20 Bronchodilator Test
      • normal ventilation, non-significant bronchodilator response
    • 2022-10-19 Abdomen, standing (diaphragm)
      • Eqivocal osteoblastic change of the L-spine are suspected.
      • Splenomegaly is highly suspected.
    • 2022-09-07 Cardiac Catheter
      • In conclusion
        • Coronary artery disease, tripple vessel disease, with stage PCI to right coronary artery, long diffuse stenosis with 86 % stenosis lesion in RCA-P with 83% stenosis in RCA-M.
        • S/P PTCA to RCA-P, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 4.0 X 38 mm), self expense, successful, from 86% stenosis reduced to 0% residual stenosis.
        • S/P PTCA to RCA-M, with drug eluting stent (Abbott Xience Sierra drug-eluting stent. 3.5 X 33 mm), successful, from 83% stenosis reduced to 11% residual stenosis.
      • Recommendation
        • Keep DAPT (dual antiplatelet therapy).
    • 2022-08-12 Cardiac Catheter
      • In conclusion :
        • Coronary artery disease, triple vessel diseases, with a A 74% stenosis lesion in LAD-P to LAD-M, A 72% stenosis lesion in LCx and A 85% stenosis lesion in RCA-M.
        • S/P PTCA to LAD-P to LAD-M, Drug eluting stent (Abbott Xience. 3.0 X 48 mm), successful, from 74% stenosis lesion reduced to 4% residual stenosis.
        • S/P PTCA to LCX, Drug eluting stent, (: Abbott Xience. 3.5 X 15 mm), successful, from 72% stenosis lesion reduced to 10% residual stenosis lesion.
      • Recommendation
        • Continue DAPT (dual antiplatelet therapy).
        • Stage PCI for RCA-M later.
    • 2022-07-25 Cardiac Catheter
      • Syntax Score = 22
      • In conclusion: CAD TVD
      • Recommendation: Due the comorbidity of pancytopenia, stem cell transplantation need revascularization earlier, will discuss with the patient and family for further management about CABG or PCI.
      • Left Ventriculogram: Normal LV size and LV wall motion, no MR, LVEF = 66%
      • Left Main: Patent
      • Left Anterior Descending: 80% stenosis ovre proximal LAD and 70% stenosis over mid LAD
      • Left Circumflex: 80% stenosis over proximal LCX and 70% stenosis over mid LCX
      • Right Coronary: diffuse atherosclerosis with 70% stenosis and 90% tandem lesions at mid RCA
    • 2022-07-19 CT - coronary artery calcium score, without contrast
      • Indication: a case of CKD and suspected CAD with chest pain, Hb 6.4
      • Findings
        • Extensive calcification of coronary arteries. LAD:419 LCX:302 RCA:187 total calcium score=908 (Agatston)
        • Unremarkable of the pericardium.
        • Normal size of cardiac chambers.
        • Mild calcified atherosclerosis of the thoracic aorta
      • Impression:
        • extensive atherosclerotic plaque plaque indicating very high cardiovascular disease risk
    • 2022-07-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 29) / 104 = 72.12%
        • M-mode (Teichholz) = 71.8
      • Dilated LA
      • Adequate LV,RV systolic function with normal wall motion
      • Mild LV hypertrophy, Impaired LV relaxation
    • 2022-06-17 Myocardial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia at the inferoseptal wall and mild myocardial ischemia at the apex and anteroseptal wall.
      • Mild reverse redistribution of radioactivity to the inferoapical wall, either normal variant or myocardial ischemia may show this picture.
    • 2022-04-26 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm, favor chronic myelomonocytic leukemia
      • Microscopically, it shows hypercellularity of bone marrow (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<=1%), CD71(focal+), CD34(-) and CD117.
    • 2022-10-20 Patho - bone marrow biopsy
      • Bone marrow, iliac creast, biopsy — myeloproliferative neoplasm
        • NOTE: The differential diagnosis includes chronic myelomonocytic leukemia and ….. etc.
      • Microscopically, the bone marrow shows hypercellularity (90%) with a proliferation of myeloid and monocytic lineage cells highlighted by CD68 and MPO, decreased erythrocytoid cells and a few megakaryocytes.
      • Immunohistochemical stain reveals CD68(diffuse+), MPO(diffuse+), TdT(-), CD138(<5%), CD71(<5%), CD20(-), CD34(-) and CD117(<5%).
  • 2021-07-26 Abdominal Ultrasonography
    • Diagnosis
      • Mild splenomegaly
      • Fatty liver, mild
      • Fatty pancreas
      • Hydropelvis, bilateral
      • Atrophy of right kidney
    • Suggestion
      • Please correlate with clinical information, other imaging and follow sonography in 3-6 mon.
      • Please check LFTs, tumor markers, and metabolic profiles.
  • chemoimmunotherapy
    • 2022-07-08 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-06-10 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-04-25 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-03-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-02-21 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2022-01-24 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-12-27 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7
    • 2021-11-30 - Vidaza (azacitidine) 75mg/m2 120mg SC D1-7

2023-03-28

[ciclosporin TDM]

Based on the available system records, the blood for ciclosporin was drawn at 00:48 on 2023-03-27, approximately 4 hours after medication administration at 20:32 on 2023-03-26. If the purpose of the blood draw was to measure the trough concentration, the ideal time to draw blood is within 30 minutes before next scheduled medication administration. Therefore, it is recommended to verify the accuracy of the system records or to redraw a blood sample at the appropriate time for accurate measurement.

The recorded concentration result for ciclosporin is 331.4ng/mL, but its accuracy as a trough level may be questionable due to the possibility of an inappropriate blood draw time.

2022-12-13

The peak concentration of cyclosporine-A was 326 ng/mL on 2022-12-12, which is within the normal therapeutic range.

2022-12-13 WBC 670/uL, PLT 2000/uL.

2022-11-28

[cyclosporine trough concentration]

As a follow-up of the change in dose of cyclosporine from 100mg Q12H to 120mg Q12H since 2022-11-25, it is recommended that the trough concentration of cyclosporine be renewed by drawing blood within 30 minutes of the first dose on 2022-11-29.

2022-11-25

[cyclosporine trough concentration]

Following the administration of 100 mg Q12H since 2022-11-21, a blood sample was taken for cyclosporine trough concentration, and the level was 63.9 ng/mL. In general, the effective range is considered to be between 100 and 400 ng/mL. In the event that the clinical effect not shown, increasing the daily dose to 300mg (divided in 3 seperate administration) can be considered and then recheck the trough concentration 3 days after the dose alteration. The goal is to limit the concentration with a minimum dose while retaining the necessary clinical effect.

According to UpToDate database, cyclosporine for patients with altered kidney function, CrCl <60 mL/minute: No dosage adjustment necessary (0.1% excreted in the urine unchanged) (Nemecek 2019; expert opinion). For nontransplant indications (eg, autoimmune disease), the manufacturer’s labeling states use is contraindicated in patients with abnormal renal function (not defined); however, when potential benefits outweigh the risks, may consider cautious use with frequent monitoring of kidney function, or consider use of an alternative agent due to increased risk of worsening kidney function, especially for patients with more severe impairment (expert opinion).

2022-10-20

2022-10-20 eGFR 35. The dosage of prescribed drugs is within the recommended range for patients with altered kidney function.

701471705

230328

[Diagnosis] - 2023-03-27 admission note

  • High grade serouns carcinoma of bilateral ovaries, pT2bNxMx, at least 2B, s/p Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) the 2023/03/09, ypTxN0(if cM0)
  • Chronic viral hepatitis B without delta-agent

[present illness] - 2023-03-27 admission note

  • This 47-year-old woman patient is a case of Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital). She had palpable progressively enlarging masses over right inguinal area for 4 months. Three months ago, she went to HuaLien TzhChi Hospital GYN OPD due to her progressively enlarging masses over right inguinal area and LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy were done.
  • This time, she came to our GYN OPD on 2023/02/16 seeking second opinion for surgical intervention. Received 3 rd times chemotherapy with Taxol/Carboplatin in Hualien (due to high grade serous carcinoma) on 2023/01/30. Transvaginal sonography on 2023/02/17 revealed multiple myomas 22x18, 23x20, 17x16mm and EM 5.00mm. PES on 2023/03/08 showed chronic superficial gastritis. Colonoscopy on 2023/03/08 showed no immediate complication. Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection) on 2023/03/09 and pathology showed AJCC 8th edition pathology stage: ypTxN0(if cM0), high grade serouns carcinoma of bilateral ovaries: pT2b NxMx, at least 2B. Tumor markers on 2023/03/24 showed normal (CA-125:17.8 U/mL, CEA:0.94 ng/mL, CA199- 6.52U/mL). Now, she was admitted to ward for adjuvant chemotherapy with TP (Taxol 175mg/m2, Carboplatin AUC:5)(C4) on 2023/03/28.

[past history] - 2023-03-27 admission note

  • Hypertension without medication control
  • DM:(-) Other
  • medical:denied
  • Not taking any hormone medications
  • Surgical: Ovarian malignancy s/p LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15 and three times of taxol chemotherapy (at HuaLien TzhChi Hospital)
  • Menstrual history: G0P0, Last menstrual period: 2022/11
  • Menarche at the age of 13 years old
  • Menstrual cycle: Duration/Interval: 4-5days/14-28days
  • Amount: moderate without blood clots
  • Last pap smear examination at 2022/9            

[allergy]

  • NKDA

[family history]

  • Father has colon cancer and hypertension.
  • No members of the family with diabetes.

[exam findings]

  • 2023-03-09 Patho - uterus with or without SO non-neoplastic/prolapse
    • Ovarian/ Fallopian tube/ Peritoneum Cancer Checklist
    • Diagnosis:
      • Uterus, endometrium, debulking surgery — No residual malignant tumor
      • Uterus, myometrium, debulking surgery — Intramural myoma; adenomatoid tumor; adenomyosis
      • Uterus, cervix, debulking surgery — No residual malignant tumor
      • Omentum, infracolic omentectomy — No residual malignant tumor
      • Lymph node, left iliac, dissection — Negative for malignancy ( 0 / 9)
      • Lymph node, left obturator, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right iliac, dissection — Negative for malignancy ( 0 / 5)
      • Lymph node, right obturator, dissection — Negative for malignancy ( 0 / 5)
    • AJCC 8th edition pathology stage: ypTxN0(if cM0)
  • 2023-03-08 Colonoscopy
    • Diagnosis
      • Mixed hemorrhoid, gr 3-4
      • incomplete study due to poor preparation.
    • Suggestion
      • Small lesions may be missed due to inadequate colon preparation.
    • Complication
      • No immediate complication
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Nonspecific T wave abnormality
  • 2023-02-16 Gynecologic ultrasonography
    • Bilateral adnexae: free
    • Uterine myoma

[surgical operation]

  • 2023-03-09
    • Diagnosis
      • High grade serous carcinoma of bilateral ovaries, pT2bNxMx (2022/12/15), at least IIB, status post glove-port LSO + right ovarian cystectomy + right salpingectomy on 2022/12/15.
    • Surgery:
      • Debulking surgery for ovarian cancer (hysterectomy + right oophorectomy + infracolic omentectomy + bilateral pelvic lymph node dissection).
    • Finding
      • uterus with multiple small myomas, its total size measuring 7x5cm
      • right side atrophic partial ovary was attached to the posterior wall of the uterus
      • there was dense adhesion from last surgery found between the intestine and left side pelvic wall, adhesionlysis was performed
      • left side pelvic lymph nodes enlarged (+)
      • right side pelvic lymph nodes (-)
      • cytology was performed
      • there was no residual tumor found while entering the pelvic cavity
      • omentectomy was done

[chemotherapy]

  • 2023-03-27 paclitaxel 175mg/m2 300mg NS 500mL 3hr + carboplatin AUC 5 600mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + NS 250mL + aprepitant 125mg PO D1-3

[assessment]

  • The patient was diagnosed with high grade serous carcinoma of bilateral ovaries, with a pathological stage of pT2bNxMx, at least IIB. She underwent LSO, right ovarian cystectomy, and right salpingectomy on 2022/12/15 and received three cycles of taxol chemotherapy at HuaLien TzhChi Hospital, with the last dose on 2023-01-30. On 2023-03-09, she underwent debulking surgery for ovarian cancer, which included a hysterectomy, right oophorectomy, infracolic omentectomy, and bilateral pelvic lymph node dissection.
  • She was admitted this time for the fourth adjuvant chemotherapy cycle using paclitaxel and carboplatin, with the previous three cycles being administered at HuaLien TzhChi Hospital.
  • Paclitaxel can cause severe hypersensitivity reactions, so the premedication regimen includes dexamethasone, an H1 receptor antagonist (diphenhydramine), and an H2 receptor antagonist (famotidine).
  • Carboplatin is also associated with infusion reactions, which typically occur after six cycles, and no specific premedication regimen is recommended.
  • Lab data on 2023-03-27 showed normal liver and kidney function with CBC grossly in normal range. No dose adjustment is needed for the scheduled chemotherapy.
  • According to the PharmaCloud database, the patient has only taken drugs prescribed at our hospital in the last three months, and there is no medication reconciliation issue.

700335007

230327

[diagnosis] - 2023-03-13 admission note

  • Intrahepatic bile duct carcinoma
  • Type 2 diabetes mellitus without complications
  • Cardiac arrhythmia, unspecified

[past history]

  • Medical PH: recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. NTUH, anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
  • Hospitalization: several times due to UTI
  • urethral stone s/p at NTUH
  • DM (+): under pioglitazone 15mg/metformin 850mg BID, glimepride 2mg QD
  • HTN (-)
  • Peptic ulcer

    

[allergy]

  • NKDA     

[family history]

  • Mother: DM

[exam findings]

  • 2023-03-24, -03-13 KUB
    • S/P clips projecting at the liver
    • Spondylosis of the L-spine is noted.
  • 2023-03-16 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (67 - 28) / 67 = 58.21%
      • M-mode (Teichholz) = 57
    • Conclusion:
      • Adequate LV systolic function with normal resting wall motion
      • Mild to moderate MR, mild AR, moderate TR and trivial PR
        • ChatGPT: In a cardiac echocardiogram, the abbreviations MR, AR, TR, and PR refer to different types of heart valve regurgitation:
          • MR: Mitral regurgitation, which is the backflow of blood from the left ventricle to the left atrium through the mitral valve during systole.
          • AR: Aortic regurgitation, which is the backflow of blood from the aorta to the left ventricle during diastole.
          • TR: Tricuspid regurgitation, which is the backflow of blood from the right ventricle to the right atrium through the tricuspid valve during systole.
          • PR: Pulmonary regurgitation, which is the backflow of blood from the pulmonary artery to the right ventricle during diastole.
      • Preserved RV systolic function
      • Atrial fibrillation with HR 90~128 at the exam
  • 2023-03-14 SONO - abdomen
    • Parenchymal liver disease
    • Post left lobectomy of liver
    • Postcholecystectcomy
  • 2023-03-13 CXR
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-03-13 ECG
    • Atrial fibrillation with rapid ventricular response
  • 2023-02-16 CT - abdomen
    • History and indication: intraheapatic cholangiocarcinoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P left liver operation without interval change.
      • Hydrops of left scrotum.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • S/P cholecystectomy.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • A calcified spot (4.7mm) at RLL.
    • IMP:
      • S/P left liver operation without interval change.
  • 2022-10-24 CT - abdomen
    • Indication
      • First operation for intraheapatic cholangiocarcinoma, cT2N0M0 post Lt lobectomy on 2020/04/15, pT2pNx, well differentiated.
      • NTUH - Anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 NIDDM under OHA for 4 yrs (20220624)
      • History of arrhythmia
    • Abdominal CT with and without enhancement revealed:
      • s/p left hepatic lobectomy.
      • Low density change at caudate lobe about 2.79cm in largest dimension. post op change or others? Suggest closely follow up.
      • Minimal ascites at abdominal cavity is found.
      • Enlarged prostate up to 4.8cm in largest dimension is found.
      • The spleen, pancreas, both kidneys and adrenals are intact.
      • There is no evidence of paraarotic LAPs.
      • Non-specific bowel gas at abdominal cavity is found.
      • Visible chest
        • Cardiomegaly is noted.
        • The lung fields are clear.
        • No pleural effusion is found.
      • Suggest clinical correlation
    • Imp: s/p left hepatic lobectomy with low density lesion at caudate lobe about 2.79cm, post op change or recurrent tumor should be D.D. Suggest closely follow up.
  • 2022-06-30 CXR
    • S/P Port-A infusion catheter insertion.
    • Blunted right costophrenic angle.
    • S/P operation with retention of surgical clips.
  • 2022-06-24 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?

MRI (111-2-5, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. focal area 39.5mm in the surgical margins is noted; the lesion was not identified on MR 2020/9/8; new recurrent tumor is considered. (arrow key images) 3. hepatic veins and portal veins are patent 4. there are no focal lesions in the spleen pancreas both adrenal and kidneys; a tiny cyst in the left kidney; 5. there is no evidence of paraaortic LAPs in abdomen; there is no evidence of paraaortic LAPs in pelvic cavity and bilateral inguingal areas. 6. there is no ascites 7. enlarged prostate is noted with posterior urinary bladder indentation; 8. hydrocele of the left scrotum. PET (111-3-2, NTUH): Some intense hot areas along medial border of the liver (figures 1-1 to 1-4, SUVmax=11.85). * Some moderate hot spots at abdominal paraaortic nodes and left iliac nodes (figures 1-5 to 1-9, SUVmax=5.79). * A faint hot spot at right iliac crest (figure 1-10, SUVmax=1.34), probably benign. * Some mild hot areas at L1-L2 vertebral junction, right hip joint, and right ischial enthesis, probably arthritis and enthesitis. * Intense curvilinear-shaped hot areas at bowel loops, suspicious Metformin-related activity. Pathology (P2202854, 2022-3-26, NTUH): Liver segment 5 8 anatomical hepatectomy cholangiocarcinoma Gallbladder cholecystectomy chronic cholecystitis Lymph node peri-gallbladder lymphadenectomy minimal histological change (1/1). Histologic Grade Grade 2: Moderately differentiated (50% to 95% of tumor composed of glands). Margins (check all that apply) Hepatic Parenchymal Margin Uninvolved by invasive carcinoma. Lymph-Vascular Invasion: not identified. Perineural Invasion Not identified. Pathologic Staging (pTNM according to AJCC v.8): Primary Tumor (pT) pT1b: Solitary tumor >5cm without vascular invasion Regional Lymph Nodes (pN) pN0: No regional lymph node metastasis. MRI (111-5-4, NTUH): 1. operative change of the left lobe of liver; no evidence of local residual tumor is noted; 2. operative change of the anterior right lobe of liver; no evidence of local residual tumor is noted; a small biloma. 3. a recurrent tumor 34.5mm is noted at the S1 of the liver; cholangiocarcinoma is considered. 4. hepatic veins and portal veins are patent 5. there are no focal lesions in the spleen pancreas both adrenal and kidneys 6. there is no evidence of paraaortic LAPs in abdomen 7. there is no ascites

[consultation]

  • 2023-03-24 Gastroenterology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • The patient was just discharged last week under the diagnosis of general weakness with mild eleavted liver enzyme suspected poor intake related.
      • The patient sufferred from poor appetite with progressive body weight loss from 54kg -> 50kg in recent one month. Easy satiety with nausea and vomit sensation, he can only tolerate liquid diet intake (the solid food can be swallowed, but the patient vomits immediately after eating.) Mild elevated liver enzyme also noted. KUB during last admission: no ileus, will be followed today. Stool passage only under laxative use recently. Depressive mood also noted and had went to PSY OPD for further managment on 2023/03/22, mertazapine 0.5# HS was precribed. Stool OB obtained in last admission: negative.
      • For poor appeitte with general weakness, we need your expertise for further evaluation and management, thank you!
    • A
      • This time, he was admitted for poor appetite and general weakness. And, we are consulted for problem above.
      • S + O
        • At bedside, stable vital signs noted
        • Recieving blood transfusion
        • Clear conscious,
        • According to his daughter, patient ate well without vomitus yesterday, after stool passage
        • But, vomtius noted today
        • Local tenderness at upper quadrat of abdomen, no rebounding pain
        • normoactive bowel sound
        • Percussion: no tympanic
        • Lab
          • 2023-03-24 Na (Sodium) 133 mmol/L
          • 2023-03-24 K(Potassium) 3.9 mmol/L
          • 2023-03-24 Ca (Calcium) 2.03 mmol/L
          • 2023-03-24 Albumin 2.7 g/dL
          • 2023-03-24 Neutrophil 98.0 %
          • 2023-03-24 S-GPT/ALT 101 U/L
          • 2023-03-24 S-GOT/AST 116 U/L
          • 2023-03-24 Alkaline phosphatase 844 U/L
          • 2023-03-24 Creatinine 0.64 mg/dL
          • 2023-03-24 WBC 14.70 x10^3/uL
          • 2023-03-24 HGB 7.9 g/dL
          • 2023-03-24 PLT 396 x10^3/uL
          • 2023-03-17 HbA1c 8.4 %
      • A: poor appetite, vomitus, suspect gastroparesis, suspected obstruction
      • P:
        • Might be on NG feeding with feeding bag or feeding pump for nutrition support, if still vomitus
        • IVF supplement
        • Give medication with gascon and prokinetic agent such as metoclopramide (IV or PO), mosapride or domperidone
        • Regular follow up KUB (standing KUB) to see if symptoms improved
        • Give medication such as sennoside, dulcolax, lactulose, EVAC to keep stool passage
        • Correct electrolytes imbalance
        • Check thyroid and adrenal function.
        • Correct hypoalbuminemia to improve bowel edema.
        • Arrange upper GI series or EGD to rule out mechanical lesion
        • Arrange abdominal CT (with contrast if no contraindication), if still unknow etiology
        • Consider to use megestrol, if cachexia was suspicious and rule out other cause of poor appetite
  • 2023-03-14 Cardiology
    • Q
      • This is a 74-year-old male with underlying DM (under pioglitazone 15mg/metformin 850mg BID, glimepirde 2mg QD) and recurrent intraductal cholangeicarcinoma cT2N0M0 s/p Lt lobectomy on 2020/04/15, pT2pNx, well differentiated. (NTUH), anatomical hepatectomy S5,8 plus cholecystectomy on 2022/03/23 and CCRT under gemcitabine treatment.
      • Under the impression of unintentional body weight loss with elevated liver enzyme, suspected cancer progression, he was admitted for further survey.
      • Tachycardia with follow up ECG showed Af on admission. According to the patient, he knew he had Af and had ever follow up in CV in the past but lost of follow up for years, anticoagulation was suggested but refused due to personal reasons.
      • We add apixaben 5mg BID for stroke prevention (CHA2DS2 VASC score 2 points)
      • We need your expertise for further evaluation and follow up, thank you!
    • A
      • The patient was examined and hx was reviewed.
      • CHA2DS2 score = 2’ ; HAS-BLED 1’-2’;
      • Suggestion
        • Anticoagulant is indicated for the patient; the risk (eg.: major bleeding rate around 0.1-0.3 %) and indication have been well explained to the patient and his family.
        • Educate about the timing of medication withdrawl.
        • Arrange 2D echo for LV function work-ip.
        • Nebivolol 0.5# qd for rate control.
      • Thanks for your consultation.

[radiotherapy]

  • 2022-07-18 ~ 2022-08-22 - 4500cGy/25 fractions of the recurrent tumor and peripheral area.

[chemotherapy]

  • 2023-02-21 - gemcitabine 1000mg/m2 1544mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-14 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-02-07 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-31 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-17 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2023-01-03 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-20 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-12-06 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-22 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-11-08 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-25 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-10-11 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-27 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-09-06 - gemcitabine 1000mg/m2 1530mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-16 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-08-02 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-19 - gemcitabine 200mg/m2 312mg NS 50mL 15min (reduced dose)
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL
  • 2022-07-05 - gemcitabine 1000mg/m2 1556mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + NS 250mL

==========

2023-03-27

  • The patient was prescribed regular insulin 10 units Q12H at 08:05 on 2023-03-27, while his serum glucose levels have been fluctuating significantly, ranging from less than 100mg/dL to over 200mg/dL (81mg/dL at 06:06 on 2023-03-25 and 109mg/dL at 06:22 on 2023-03-27). It is recommended to closely monitor the patient for signs of hypoglycemia after administering the insulin and adjust the dosage as needed.
  • The patient’s stool occult blood test (OB) is positive (4+, 2023-03-26). Hemoclot (tranexamic acid) 500mg IVD Q12H has been prescribed. The anticoagulant indicated for the patient’s atrial fibrillation is currently withheld due to the patient’s current bleeding.
  • The patient’s constipation has been alleviated with the use of Through (sennoside), lactulose, and EVAC Enema, resulting in 1, 0, 0, and 3 bowel movements on March 23rd to March 26th, respectively.
  • There are no issues with the current prescription.

2023-03-14

  • Elevated liver-related enzymes and hemoglobin breakdown readings above the normal range strongly suggest the possibility of hepatic problems.
    • 2023-03-13 S-GOT/AST 89 U/L
    • 2023-03-13 S-GPT/ALT 113 U/L
    • 2023-03-13 Bilirubin total 1.59 mg/dL
    • 2023-03-13 Bilirubin direct 0.66 mg/dL
    • 2023-03-13 Alkaline phosphatase 688 U/L
    • 2023-03-13 r-GT 876 U/L
  • Despite the administration of insulin and oral antiglycemic agents, the patient has experienced blood sugar levels ranging between 320 to 600 mg/dL during this hospitalization. This marked hyperglycemia can lead to an increase in serum glucose, which in turn raises the serum tonicity. This process draws water out of cells and expands the extracellular water space, resulting in a subsequent lowering of the serum sodium concentration. It is recommended to appropriately increase the insulin dose in order to better manage the patient’s hyperglycemia (and the possibly induced hyponatremia).
    • 2023-03-14 Free-T4 1.18 ng/dL
    • 2023-03-14 TSH 0.890 uIU/mL
    • 2023-03-13 Urine osmolarity 675 mOsm/Kg
    • 2023-03-13 Na (Urine) 46 mmol/L
    • 2023-03-13 K (Urine) 19.9 mmol/L
    • 2023-03-13 Na (Sodium) 127 mmol/L
    • 2023-03-13 Albumin 2.7 g/dL

700537683

230327

[exam findings]

  • 2023-03-23 Ascites tapping
    • 3000mL
  • 2023-03-22, -03-21 CXR
    • S/P port-A implantation.
    • Enlargement of cardiac silhouette.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion.
    • Few gallstones.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-03-21 CT - abdomen
    • History and indication: Pancreatic cancer
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (6.8cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Bil. pleural erffusions with adjacent lung collapse.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity with ascites.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • No obvious extraluminal free air.
      • Minimal pericardial effusion.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion.
      • Cystic lesions (up to 3.1cm) at thyroid glands.
    • IMP:
      • Pancreatic tail with adjacent structures invasion, peritoneal carcinomatosis and liver metastases (progression). Ascites and pleural effusion.
  • 2023-03-20, -03-16 Standing KUB
    • Gallbladder stones.
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-03-14, -02-22 ECG
    • Sinus tachycardia
  • 2022-12-22 CT - chest
    • Indication: pancrease cancer, cT3N1M1, stage IV, for lung metastasis evaluation
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Lungs: multiple small randomly distributed pulmonary nodules of varying sizes up to 11mm at RML consistent metastases.
      • Mediastinum and hila: no enlarged LN or mass.
        • small pericardial effusion.
        • mild calcified plaques of the LAD coronary arter.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace effusion.
      • Chest wall and visible lower neck: enlarged thyroid gland with nodular calcifications and cystic lesions up to 42mm.
      • Visible abdominal contents: a large (6cm) at pancreatic tail canceer with adjacent organs invasion, multiple metastatic tumors, regional LNs metastasis, suspect a small tumor in pancreatic head. two gallstones (1.3mm).
    • Impression:
      • advanced pancreatic cancer (stage IV) with lung metastasis.
      • thyroid goiter.
  • 2022-12-21 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the right aspect of mandible, faint hot spots in both rib cages, and increased activity in the skull, maxilla, a upper T-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot area in the right aspect of mandible and increased activity in a upper T-spine, the nature is to be determined (early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
      • Suspected benign lesions in both rib cages, skull, maxilla, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-12-20 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, pancreatobiliary type, compatible with metastatic pancreatic ductal adenocarcinoma
    • The sections show a picture of pancreatobiliary-type adenocarcinoma, moderately differentiated, composed of nests, and cords of low columnar neoplastic cells with intracytoplasmic and intraluminal mucin, arranged in tubular and cribriform patterns, and embdded in fibrous stroma.
    • IHC shows: CK7(+), CA19-9(+), amd CK20 (focal +).
    • The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
    • Suggest clinic coirrelation.
  • 2022-12-17 CT - abdomen
    • History and indication:
      • liver tumors: suspected metastatic tumors. suspected pancreatic tumor(tail)
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
      • Some LNs at retroperitoneum.
      • Multiple liver tumors.
      • Some soft tissues in peritoneal cavity.
      • Normal appearance of kidneys.
      • Gallbladder stones (up to 1.2cm).
      • Patency of portal vein.
      • Intact bony structures.
      • Small amount ascites.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • Some nodules at bilateral basal lungs.
    • Imaging Report Form for Pancreatic Carcinoma
      • Impression (Imaging stage) : T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IV(Stage_value)
  • 2022-12-14 SONO - abdomen
    • Diagnosis
      • Hepatic tumors suspected mets
      • Gall stones, two
      • Pancreatic tumor suspected cancer, tail
    • Suggestion
      • abdomen CT
  • 2022-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A(minimal)
      • Superficial and atrophic gastritis, antrum, s/p CLO test
      • Gastric polypoid lesion, high body, GC site, suspicious external compression
    • Suggestion
      • Pursue CLO test result
      • Consider arrange CT scan for suspicious external compression
  • 2019-06-03 ENT Hearing Test
    • Tymp: R’t type As; L’t type A
    • ART:
      • R’t ipsi 4k Hz and contra 500 Hz absent
      • L’t ipsi 4k Hz reduced and contra 500 & 4k Hz absent
    • PTA:
      • Reliability fair
      • Average R’t 45 dB HL; L’t 54 dB HL
      • R’t mild to moderately severe SNHL
      • L’t moderate to moderately severe SNHL

[consultation]

  • 2022-12-20 Hemato-Oncology
    • Q
      • This 70 years old female has the history of DM under medication control for years
      • she came to GI OPD for abdomen pain for days and body weight loss 5+ in one month. At OPD abdomen CT was perfromed and reported A poor enhancing lesion (5.9cm) at pancreatic tail with adjacent gastric/ spleen/ left adrenal/ colon/ splenic artery/ splenic vein invasion.
        • Some LNs at retroperitoneum.
        • Multiple liver tumors.
        • Some soft tissues in peritoneal cavity.
      • Pancreatic Carcinoma T3N1M1 STAGE:IV
      • Bone scan was arranged, we need your further further advise. Thanks
    • A
      • This 70 year old woman is a case of suspect pancreae tail cancer with liver and lung metastasis. She receive CT guide bioipsy for liver tumor on 2022/12/20 morning and pending the result. For pancrease cancer, cT3N1M1, stage IV, we are consulted.
      • Suggestions:
        • Well explain to patient and daughter.
        • May arrange contrast enhance chest CT for lung metastasis during this admission, or arrange in my clinics.
        • Please check AntiHbc, HbsAg, AntiHCV
        • Pending the pathology. We will discuss with patient about further treatment according to pathology result.
        • Please arrange our OPD after being discharged.

[chemotherapy]

  • 2023-03-07 - nab-paclitaxel 100mg/m2 170mg 90min D1,8,15 + gemcitabine 1000mg/m2 1700mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-14 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-02-07 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-31 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-17 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-10 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL
  • 2023-01-03 - nab-paclitaxel 100mg/m2 175mg 90min D1,8,15 + gemcitabine 1000mg/m2 1750mg NS 100mL 30min
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + NS 250mL

700490718

230324

[exam findings]

  • 2023-03-23 CXR
    • Consolidation or mass lesions in left lower lung zone
  • 2023-03-21 Nasopharyngoscopy
    • right OME(+) –> suggest right grommet
  • 2023-03-14 MRI - nasopharynx
    • The current study was compared to the prior one obtained on 2022/10/25.
    • The previously seen mucosal enhancing lesion on the nasopharyngeal posterior wall is less distinct. Favor tumor in regression.
    • Severe paranasal sinusitis.
    • Severe bilateral mastoiditis.
  • 2023-03-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113 - 27) / 113 = 76.11%
      • M-mode (Teichholz) = 76
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild PR, AR
  • 2023-03-07 Nasopharyngoscopy
    • Findings: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
    • Conclusion: NPC
  • 2023-03-06 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-03-02 CXR
    • Atherosclerotic change of aortic arch
    • Spondylosis of the T-spine
    • Peri-bronchial wall thickening of the left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2023-02-23 CXR
    • Atherosclerosis of the aorta.
    • Ground glass opacity in LLL.
  • 2023-02-23 ECG
    • Sinus rhythm with Premature atrial complexes
    • Nonspecific ST and T wave abnormality
  • 2023-02-04 Nasopharyngoscopy
    • Findings: stage cT1N1M0, under CCRT
    • Conclusion: NPscope: left NP tumor regression, NE of tumor noted, crust(+)
  • 2023-01-07 Nasopharyngoscopy
    • Findings: NPC
    • Conclusion: left NP tumor regression, but still residual tumor
  • 2022-11-20 CXR
    • No cardiomegaly
    • No active lung lesion
    • Normal bony contour
  • 2022-11-10 ENT Hearing Test
    • Reliabilty Fair
    • PTA
      • R’t : 33 dB HL
      • L’t : 35 dB HL
      • Bil normal to moderate SNHL.
  • 2022-11-09 CXR
    • Multiple nodules at bil. lungs.
    • Normal appearance of trachea and bil. main bronchus.
    • Normal size of heart.
    • Intact bony structure(s).
  • 2022-11-02 CXR
    • Blunted left costophrenic angle.
    • Normal appearance of trachea and bil. main bronchus.
    • Atherosclerosis of the aorta.
    • Multiple nodules at RUL.
  • 2022-10-25 CXR
    • No cardiomegaly
    • Increased infiltration over right lung and LLL. May be active infection.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-10-26 Tc-99m MDP whole body bone scan
    • IMPRESSION:
      • Increased activity in the skull base and maxilla, either local hyperemia or local bony involvement may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Suspected benign lesions in some T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and left knee.
    • SUGGESTION:
      • Please arrange F-18 FDG PET/CT scan for further staging (Insurance reimbursement indication for head and neck cancer staging).
  • 2022-10-25 MRI - nasopharynx
    • Nasopharyngeal Carcinoma
    • Impression ( Imaging stage ): T:T1(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-10-18 Patho - nasopharyngeal/oropharyngeal biopsy
    • Nasopharynx, left, NP biopsy — Non-keratinizing squamous cell carcinoma, undifferentiated type
    • The specimen submitted consists of a small piece of gray-tan soft tissue, labeled left nasopharynx, measuring 0.5 x 0.3 x 0.2 cm. All for section.
    • The sections show a picture of non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of nests of large neoplastic cells with oval to spindle-shaped vesicular nuclei and syncytial growth pattern. Keratin formation is absent.
  • 2022-10-18 Nasopharyngoscopy
    • Findings
      • blood tinged NR for one month
      • patient has strong gap reflex, hard to assess NP and larynx by mirror
      • no ABC
    • Diagnosis
      • left NP tumor, suggest NP biopsy
  • 2022-07-27 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • fatty infiltration of pancreas
    • Suggestion
      • OPD follow-up
  • 2022-04-25 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis, s/p CLO test
      • Gastric erosions
      • Cardiac insufficiency
    • Suggestion
      • May give PPI trial
      • Pursue CLO test
  • 2022-01-26 SONO - abdomen
    • Diagnosis
      • Probable small hemangioma, S6/7
      • Liver cyst, S8
      • Right renal cyst
      • Splenomegaly, mild
    • Suggestion
      • OPD follow-up

[consultation]

  • 2023-03-07 Ear Nose Throat
    • Q
      • This 67-year-old man patient is a case of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II s/p concurrent chemoradiotherapy from 2022/12/05 ~ 2022/12/29 and chemotherapy with PF4 (CDDP 80mg/m2, 5FU 1000mg/m2 x4 days) from 2022/11/11. Patient refuse chemotherapy. This time, for F/U. Thank you.
    • A
      • S
        • Hx of Non-keratinizing squamous cell carcinoma, undifferentiated type, of the nasopharynx, cT1N1M0, stage II
        • Suffered from bilateral hearing impairment (tympanocentesis was done before but in vain), dysphagia, sticky sputum, PND, tachycardia after chemo with PF4
      • O
        • Ear drum: bil OME
        • Scope: curst over NPx, NE of left NP tumor noted, sticky sputum over posterior pharyngeal wall
      • Imp:
        • NPC, regression
        • OME, bil, suspect side effects of RT
      • Plan:
        • Treat his symptoms with your expertise
        • ENT OPD f/u for NPC and hearing problem

[cancer multidisciplinary team meeting conclusion] - meeting date: 20221111

  • Treatment Plan: Concurrent chemoradiotherapy (CCRT) + adjuvant chemotherapy.
  • Consensus of the team: cT1N1M0, Stage II.

[chemoimmunotherapy]

  • 2023-02-08 - cisplatin 80mg/m2 130mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-28 - cisplatin 40mg/m2 65mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-21 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-15 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-12-05 - cisplatin 40mg/m2 70mg NS 500mL 24hr (CCRT)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - cisplatin 80mg/m2 135mg NS 500mL 24hr (5-FU side insertion) + MgSO4 10% 20mL NS 100mL 1hr (after cisplatin) + furosemide 20mg NS 30mL 10min (after cisplatin) + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (PF)
    • dexamethasone 4mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-24

  • Although the patient’s serum sodium levels have never reached the lower limit of normal based on available laboratory data in HIS5 since 2022-10-25, it is worth noting that the patient has been receiving CCRT (CDDP) and PF regimen since 2022-11-11. Cisplatin, a component of the chemotherapy regimen, is known to induce nephrotoxicity, which can manifest as acute kidney injury (AKI) or electrolyte disturbances such as hypomagnesemia and salt-wasting hyponatremia. The patient’s creatinine levels have been observed to be above the normal range more frequently after receiving chemotherapeutic agents. The patient has also experienced hypomagnesemia, which has shown a similar trend despite receiving sodium and magnesium supplements.
    • ref:
      • Cisplatin nephrotoxicity: a review of the literature. J Nephrol. 2018;31(1):15-25. doi:10.1007/s40620-017-0392-z
      • Risk Factors for Severe Hyponatremia Related to Cisplatin: A Retrospective Case-Control Study. Biol Pharm Bull. 2019;42(11):1891-1897. doi:10.1248/bpb.b19-00477
      • Hyponatremia timing, incidence, and associated risk factors in patients treated with cisplatin for lung cancer: a retrospective study. J Popul Ther Clin Pharmacol. 2022;29(4):e1-e10. Published 2022 Oct 7. doi:10.47750/jptcp.2022.907
  • Sodium level correction rate recommendation (ref: Diagnosis and treatment of hyponatremia: compilation of the guidelines. J Am Soc Nephrol 2017; 28(5):1340-1349.)
    • Minimum, 4 to 8 mmol/L/day; MAX 10 to 12 mmol/L/day
    • For patients with high-risk of osmotic demyelination syndrome: Minimum, 4 to 6 mmol/L/day; MAX 8 mmol/L/day

2023-02-09

[mucositis]

As of now, Comfflam Anti-inflammatory Spray (benzydamine 1.5 mg/mL) is available in this hospital and can be used as a rinse three to four times daily (depending on the severity of the mucositis).

701337783

230324

{not completed}

[diagnosis] - 2023-03-22 admission note

  • Adenocarcinoma of middle rectum with lung metastasis, cT4bN0M1a, stage IVA, status post T-colostomy on 2022/11/24 s/p concurrent chemoradiotherapy (radiotherapy to the pelvis and rectal tumor) with FOLFOX (Oxalip 85mg/m2, LV 400mg/m2, 5-FU 2800mg/m2) from 2022/12/06 ongoing
  • Chronic viral hepatitis B without delta-agent
  • Type 2 diabetes mellitus without complications
  • Essential (primary) hypertension

[past history]

Irregular drug use

  • Type 2 diabetes mellitus
    • Onglyza 5mg 1# po QD
    • Loditon(Metformin) 850mg 1# po BID
  • Hypertension
    • Carvedilol 6.25mg 1# po QD
    • Nidil 5mg 1# po BID
    • Funazine 10mg 1# po QD
    • Bestan 300mg 1# po QD
    • Rixia 0.5mg 1# po QD
    • Fylin 400mg 1# po QD
    • Lorazepam 1mg 1# po BID
  • Hyperlipidemia
    • Rosuvastatin 5mg 1# po QD
  • Hyperuricemia
    • Febuton 40mg 1# po QD                    

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-20 CT - abdomen
    • Indication: Adenocarcinoma of middle rectum with lung metastasis, cT4aN0M1b, stage IVB
    • Abdominal and Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lobulated soft tissue nodule at left upper lobe measuring 2.6cm in largest dimension is found. (Se401 Im15).
        • Enlarged lymph nodes are found at bilateral paratracheal region.
      • Visible abdomen:
        • There is stone at dependent portion of GB. GB stone(s) are noted.
        • s/p colostomy with its orifice at RLQ.
        • Low density lesion at tip of S6 of liver measuring 0.41cm in largest dimension. Simple cyst is favored. Suggest follow up.
        • Eccentric wall thickening at rectum measuring 2.96cm in largest dimension is found. Rectal cancer is favored.
    • Imp:
      • Rectal cancer with suspected left upper lobe lung meta? Mediastinal lymph nodes
  • 2023-02-17 Sigmoidoscopy
    • ircumfererntial rectal cancer s/p CCRT with partial regression (middle rectum, about 7cm AAV). The scope can not be passed through it.
  • 2022-11-23 All-RAS + BRAF mutation
    • Cell Block: S2022-20665
    • RESULTS
      • There was no variant detect in the KRAS/NRAS gene.
      • There was no variant detect in the BRAF gene.
  • 2022-11-23 Whole body PET scan
    • Glucose hypermetabolic lesions at the rectal region, compatible with the primary rectal cancer.
    • Glucose hypermetabolic lesions in the left upper lung, probably a chronic inflammation process, suggesting follow-up.
    • Glucose hypermetabolic lesions in bilateral mediastinal lymph nodes, probably reactive nodes.
    • Glucose hypermetabolic lesions in the right clavicle bone, P/3, gastric region, and left shoulder joint, probably benign in nature.
    • Rectal cancer, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
  • 2022-11-22 Patho - colon biopsy
    • Rectum, biopsy — Adenocarcinoma, moderately differentiated
    • The sections show adenocarcinoma, composed of cords and single columnarto cuboidal neoplastic cells, arranged in focal glandular pattern with desmoplastic stromal reaction. Mucosal ulcer is present.
    • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
  • 2022-11-22 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (113- 34) / 113 = 69.91%
      • M-mode (Teichholz) = 69
    • Conclusion:
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild MR, TR and PR
  • 2022-11-21 Flow Volume Loop
    • mild obstructive ventilatory impairment
  • 2021-11-02 Ga-67 Whole body inflammatory scan with SPECT
    • The whole-body gallium inflammation scan with SPECT was performed 24th and 48th hours after injecting 6 mCi of the radiotracer to the patient. The images showed increased radiotracer uptake in a lower C-spine, maxilla, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet. In addition, there was inhomogenously increased tracer uptake in the urethra.
    • IMPRESSION:
      • Increased radiotracer uptake in a lower C-spine, bilateral sternoclavicular junctions, shoulders, elbows, wrists, hands, knees, and feet, probably polyarthritis.
      • Increased radiotracer uptake in the maxilla, probably dental problems.
      • Increased radiotracer in the urethra, probably UTI, suggesting further investigation.
  • 2021-10-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (117.9- 46.4) / 117.9 = 60.64%
      • M-mode (Teichholz) = 60.6
    • Conclusion:
      • Adequate LV Systolic function with no regional wall motion abnormality at resting state
      • Mild mitral, tricuspid and pulmonic regurgitation
      • Dilated LA and aortic root
  • 2021-10-25 CT - brain
    • IMP: Brain atrophy.
  • 2021-09-28 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (63.1- 20) / 63.1 = 68.30%
      • M-mode (Teichholz) = 68.3
      • 2D (M-simpson) =70.8
    • Conclusion:
      • Adequate LV systolic function with no regional wall motion abnormality (under dopamine infusion)
      • Moderate mitral regurgitation, mild tricuspid regurgitation
      • Dilated LA and aortic root, thick IVS and LVPW

[consultation, not completed]

  • 2022-11-28 Hemato-Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. Port-A will be arranged today.
      • RT: CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06.
      • We need your expertise for neoadjuvant CCRT.
    • A
      • Patient examined and Chart reviewed. A case of rectal cancer with suspicious lung and liver mets is noted. I am consulted for the CCRT.
      • My suggestions are:
        • Well discussion with patient and family. (Done)
        • Anti-HBV medication will be prescribed if C/T will be given.
        • For covering the possibility of lung and liver mets, the regimen would be FOLFOX
        • Please arrange the admission to my service if he is discharged.
  • 2022-11-25 Radiation Oncology
    • Q
      • This was a 63 y/o male with history of TB. And he was diagnosed with adnocarcinoma of middle rectum, cT4aN0M1b (suspected left lung metastasis) status post T-colostomy on 2022-11-24. We need your expertise for neoadjuvant CCRT.
    • A
      • Neoadjuvant CCRT is indicated.
      • CT-simulation will be arranged on 2022/11/30. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor to 50.4 Gy/ 28 fx. RT will start around 2022/12/05 or 06. Thank you very much.

[radiotheray]

  • 2022-12-06 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor: 50.4 Gy/ 28 fx.

[chemotherapy]

  • 2023-03-22 - oxaliplatin 85mg/m2 150mg D5W 250mL 2hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 2800mg/m2 5000mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-09 - ditto
  • 2023-02-16 - ditto
  • 2023-01-30 - ditto
  • 2023-01-03 - ditto
  • 2022-12-06 - ditto

[assessment]

  • The patient is tolerating the FOLFOX regimen without any major issues. In addition, based on the TPR panel results, the patient’s blood pressure and blood glucose levels are well-controlled despite having comorbidities of hypertension and diabetes mellitus. Furthermore, there are no identified issues with the active prescription.

700018223

230323

[diagnosis] - 2023-03-22 admission note

  • Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15
  • Gastro-esophageal reflux disease with esophagitis
  • Essential (primary) hypertension
  • Constipation, unspecified
  • Unspecified hemorrhoids

[past history] - 20221213 admission note

  • HTN for 15+ years under medical control
  • History of operation: Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0M1.   

[family history]

  • father: colon cancer was diagnosed at the age of 92, died at the age of 99
  • mother: HTN, aplastic anemia
  • younger brother: HTN
  • elder sister: CVA

[exam findings]

  • 2023-01-31 CT - abdomen
    • S/P left hemicolectomy with focal peritoneal infiltrates, post-op change or recurrence? suggest clinical correlation and follow up study.
    • Focal poor enhancement at right renal parenchyma.
    • Bilateral renal cysts, up to 1.3cm in right kidney.
  • 2022-10-12 Patho - soft tissue tumor, extensive resection
    • Pathologic diagnosis
      • Soft tissue, inguinal area, right, excision — Compatible with angiofibroma of soft tissue
    • Microscopic examination
      • Histologic type: Compatible with angiofibroma of soft tissue, composed of uniform spindle cells in a variable myxoid and collagenous stroma with a nectwork of innumerous small thin-walled, branching blood vessels. Prominent collagenous bundles can be identified focally. Neither necrosis nor marked cellular atypia can be found
      • Mitotic rate: <1/10 high power fields
      • Necrosis: Absent
      • Margins: Free and 0.3 cm from closest margin
      • Lymphvascular invasion: No identified
    • IHC
      • IHC: MUC4(-), SMA(-), Beta-catenin(-), MDM2(-), STAT6(-)
      • Previous IHC (S2022-15033): CD34(-), CD117(-), DOG-1(-), Desmin(-), S100(-), MUC4(-), EMA(-).
  • 2022-09-16 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Colon, splenic flexure, left hemicolectomy — Mucinous adenocarcinoma, moderately differentiated
      • Resection margins, left hemicolectomy — Radical margin is involved by carcinoma
      • Lymph nodes, mesocolic, left hemicolectomy — Negative for malignancy (0/19)
      • Pathology stage: pT4aN0(cM1a); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Operation procedure: Left hemicolectomy
      • Specimen site: Left colon
      • Specimen size: 20.5 cm in length
      • Tumor size: 12.0 x 4.5 cm
      • Tumor location: 3.0 cm and 5.5 cm away from the two resection margins, respectively .
      • Depth of invasion grossly: Pericolic soft tissue
      • Mucosa elsewhere: Unremarkable
      • Representative parts are taken for section and labeled: A1-A2 = bilateral resection margins, A3 = omentum, A4-A6 = pericolic LNs, A7-A12 = tumor.
    • MICROSCOPIC EXAMINATION
      • Histology: Mucinous adenocarcinoma
      • Histology Grade: Moderately differentiated
      • Depth of invasion: To serosa
      • Angiolymphatic invasion: Not identified
      • Perineural invasion: Not identified
      • Tumor cell budding: Intermediate
      • Margins:
        • Bilateral resection margins: Free
        • Circumferential (radial) margin: Involved by carcinoma
      • Lymph node metastasis, mesocolic: Negative (0/19) (No. Positive / No. Total)
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • Primary Tumor (pT): pT4a (Tumor invades serosa)
        • Regional Lymph Nodes (pN): pN0 (no regional lymph node metastasis)
        • Distant Metastasis (pM): cM1a
      • Type of polyp in which invasive carcinoma arose: Not identified
      • Additional pathologic findings: Abscess formation around tumor
      • Tumor regression grading S/P CCRT: N/A
      • IHC: EGFR(+), MLH1(-), PMS2(-), MSH2(+), MSH6(+)
        • Labeled as “right inguinal”, core needle biopsy — spindle cell tumor-like lesion.
        • IHC stains: CD34 (-), CD117 (-), Dog-1 (-): dis-favor gastro-intestinal stromal tumor; desmin (-): dis-favor myomatous origin; S-100 (-): dis-favor nerve origin; Ki-67: <1%. MUC4 (-), EMA (-). No meatstatic adenocarcinoma is present in this specimen.
        • REFERENCE: S2022-15295: colon, splenic flexure: compatible with adenocarcinoma.
  • 2022-09-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 34) / 93 = 63.44%
      • M-mode (Teichholz) = 64
    • Normal LV filling pressure.
    • Normal LV and RV systolic function.
    • Trivial MR.
    • Prominent epicardial fat.
  • 2022-09-12 Patho - colon biopsy
    • Colon, splenic flexure, biopsy — Compatible with adenocarcinoma, well differentiated
  • 2022-09-06 CT - abdomen
    • Findings
      • Soft tissue tumor, 11x7.6cm in left upper abdomen with central necrosis, suspected spelnic fluxure malignancy. With left abdominal wall involvement.
      • Large soft tissue tumor, 9.3cm in right inguinal region, suspected metastasis.
      • Right renal cyst, 1.4cm.
      • Unremarkable change of the liver, spleen, pancreas and left kidney.
      • No enlarged lymph node in the paraaortic region.
      • Presence of ascites.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4a(T_value) N:N1b(N_value) M:M1(M_value) STAGE:____(Stage_value)
    • Impression:
      • Left upper abdomen tumor, r/o splenic flexure colon malignancy. Right inguinal tumor, r/o metastasis. If proven colon malignancy, cstage T4aN1M1. Suggest tissue study.
      • Right renal cyst.

[consultation]

  • 2023-01-14 Dermatology
    • Q
      • This 71-year-old woman patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02 and Target therapy with Avastin (self pay) from 2022/11/15.
      • This time, of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome. Now, for F/U and evaluate therapy. Thank you.
    • A
      • This patient suffered from dyskeratotic nails for months.
      • Imp: Tinea unguium
      • Suggestion:
        • Zalain cream * 2 tubes/bid (sertaconazole)
  • 2022-12-13 Plastic and Reconstructive Surgery
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15. He was admitted for chemotherapy. He underwent excision of the big tumor over right inguinal region on 2022/10/12. Now, for F/U. Thank you.
    • A
      • I will talk to the patient and explain about the temporary post-operative paresthesia. Thanks.
  • 2022-11-29 Dermatology
    • Q
      • This 71-year-old man patient is a case of Mucinous adenocarcinoma of splenic flexure with obstruction, cstage: T4aN1M1 status post diagnostic laparoscopy and left hemicolectomy on 2022/09/15, pT4aN0(cM1a); Stage IVA s/p chemotherapy with FOLFIRI from 2022/11/02~ and Target therapy with Avastin(self pay) from 2022/11/15~. He was admitted for chemotherapy. This time, for bilateral toenails desquamation, suspected athlete’s foot. Thank you.
    • A
      • The patient had sufferred from thickening nail with desqumation change on the toenail with nearby keratosis.
      • Under the impression of tinea unguium et keratosis suspected possible chemotherapy alert hand-foot syndrome.
      • The following sugestion:
        • step 1: Exelderm lotion 2 bot QN use. Apply the lotion to the nail crevices (sulconazole)
        • step 2: Sinphraderm cream 1 tube topical QN use over keratotic scales. (urea)

[surgical operation]

  • 2022-10-12
    • Surgery
      • Dx: soft tissue tumor over right inguinal region
      • OP: excision
    • Finding
      • 12cm X 9cm X 9cm, multi-lobulated, smooth surfaced mass located between the sartorius, iliopsoas muscles, inguinal cannal, and the femoral artery
      • a 10F JP was placed over anterior side of upper right thigh for post operative drainage
  • 2022-09-15
    • Surgery
      • Gisgnostic laparoscopy + left hemicolectomy
    • Finding
      • very large tumor with sorrounding adhesion over LUQ.
      • anastomosis by endoGIA*3 + V-lock.
      • Drain into pelvis

[chemoimmunotherapy]

  • 2023-03-22 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-31 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovirin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 400mg/m2 650mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 630mg NS 250mL 2hr + fluorouracil 400mg/m2 630mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-27 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-13 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 280mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 620mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-29 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 150mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-15 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 120mg/m2 180mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3700mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-11-02 - irinotecan 120mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 100mL 10min + fluorouracil 2400mg/m2 3800mg NS 500mL 46hr (Avastin + FOLFIRI, Q2W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + NS 250mL + aprepitant 125mg PO D1-3

[assessment 2023-01-14, not posted]

  • For tinea unguium, if topical Exelderm (sulconazole, applied since late Nov 2022) and Zalain (sertaconazole, applied since mid Jan 2023) failed to cure it, then oral Fungitech (terbinafine 250mg/tab) 1# QD might be considered as a next line treatment.

[assessment]

  • The patient had developed tinea unguium in Jan 2023, but there is no longer any evidence of the condition in the updated medical records.

  • The patient is currently admitted for his 10th cycle of Avastin + FOLFIRI chemoimmunotherapy, and it is planned that he will receive a total of 12 cycles. His liver and kidney function, as well as his electrolyte levels, are normal, although there is a slight anemia based on the 2023-03-21 lab results.

  • There were no medication reconciliation issues found in the patient.

  • CT results from 2023-01-31 indicate the presence of focal peritoneal infiltrates, which could suggest post-operative changes or disease recurrence. Further diagnostic tests or imaging studies may be necessary to make a definitive diagnosis and determine whether new treatment should be planned.

700313252

230322

{not completed}

[exam findings]

  • 2023-03-20, -03-06 CXR
    • S/P tracheostomy
    • S/P nasogastric tube insertion
    • Borderline cardiomegaly
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-03-15 Nasopharyngoscopy
    • hypopharynx lymphoma under R/T
  • 2023-02-17 Whole body PET scan
    • Glucose hypermetabolism in the hypopharynx with downward extension to the proximal portion of the esophagus, compatible wtih lymphoma.
    • Glucose hypermetabolism in a focal area in the dome of the liver and in the left adrenal gland. Lymphoma should be considered.
    • Mild and diffuse glucose hypermetabolism in the bone marrow of the skeleton. Lymphoma involving the bone marrow should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the posterior aspect of bilateral lower lung fields and around the tracheostomy. Inflammatory process is more likely.
  • 2023-02-11 CT - chest
    • Indication: hypopharyngeal lymphoma, suspect recurrent rectal cancer lung metastasis
    • Multidetector CT (256 multislice, 16 cm wide, Revolution CT GE, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Spiculated nodular lesiosn at right upper lobe and left upper lobe. Nature?
        • Soft tissue mass encircling upper esophagus is found measuring 3.8cm in largest dimension.
        • Calcified coronary arteries is found.
        • Mild bilateral pleural effusion is found.
        • Increased pulmonary vasculature is found.
      • Visible abdomen:
        • One low density lesion at dome measuring 3.9cm in largest dimension. Liver meta is considered.
        • The spleen, pancreas, both kidneys and adrenals are intact.
    • IMP:
      • Nodular lesions at both lungs (n>5). Suggest PET
      • Cervical esophageal tumor. 3.8cm
      • Liver meta.
      • Calcified coronary arteries is found.
  • 2023-02-08 Patho - larynx biopsy
    • PATHOLOGIC DIAGNOSIS
      • Pyriform sinus, right, LMS with laser — Diffuse large B-cell lymphoma, NOS
      • Arytenoid, right, LMS with laser — Diffuse large B-cell lymphoma
      • AE fold, right, LMS with laser — Diffuse large B-cell lymphoma
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consists of (1) four small pieces of brownish soft tissue received for frozen section, labeled right pyriform sinus, measuring up to 0.6 x 0.4 x 0.2 cm. All for paraffin section as: F2023-00056FS. (2) multiple small pieces of tan-gray soft tissue, labeled right arytenoid, measuring up to 0.5 x 0.4 x 0.1 cm. All for section as: S2023-02055A. (3) six small pieces of tan-gray soft tissue, labeled right AE fold, measuring up to 0.8 x 0.2 x 0.1 cm. All for section as: S2023-02055B.
    • MICROSCOPIC EXAMINATION
      • The sections of all three specimens show a picture of malignant lymphoma with following features:
      • Specimen: Right pyriform sinus, right arytenoid, and right AE fold
      • Procedure: LMS with laser
      • Tumor site: Right pyriform sinus, right arytenoid, and right AE fold
      • Histologic type: Diffuse large B-cell lymphoma, NOS
      • Immunophenotyping: CD3(-), CD20(+), BCL2(+), CD10(+), BCL6(+), MUM1(+), c-MYC(-) and CD56(-)
  • 2023-02-06 CT - abdomen
    • History and indication: Hypopharyngeal cancer, cT4aN0M0. 20230203 Cr:1.69 liver mass noticed, r/o HCC, r/o metastaisis. DM under metformin
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing tumor (3.5cm) at liver dome.
      • A nodule (6mm) at RML.
      • Left adrenal tumors (1.4cm, 1.6cm).
      • S/P rectal operation.
      • Renal cysts (up to 4.7cm).
      • Normal appearance of spleen, pancreas.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • Suspected liver and lung metastases.
  • 2023-02-03 Tc-99m MDP whole body bone scan
    • Increased activity in some C-, T- and L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
    • Increased activity in the maxilla and mandible. Dental problem may show this picture.
    • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, sternoclavicular junction and right foot, compatible with benign joint lesions.
  • 2023-02-03 SONO - abdomen
    • Diagnosis
      • Hepatic tumor, right lobe, nature?
      • Collapse GB
      • Renal cysts, both kidney
      • Poor echo window and poor cooperation.
    • Suggestion
      • 4 phase CT or dynamic MRI study
      • tumor markers
  • 2023-02-01 ENT Hearing Test
    • Tymp:
      • RE type C; LE type Ad.
    • ART:
      • Bil absent.
    • PTA
      • Reliability FAIR
      • Average RE 80 dB HL; LE >80 dB HL.
      • RE moderately severe to profound MHL.
      • LE moderately severe to profound SNHL.
  • 2023-01-31 CT - neck
    • Imaging Report Form for Hypopharynx Carcinoma
      • Impression (Imaging stage) : T:4a(T_value) N:0(N_value) M:IVA(M_value) STAGE:____(Stage_value)
  • 2023-01-31 Patho - stomach biopsy
    • Stomach, GC of body, biopsy — erosive gastritis with Helicobacter infection
  • 2023-01-31 Patho - gingival/oral mucosa biopsy
    • Labeled as “right hypopharyx”, biopsy — round blue cell infiltration with marked crush artifact.
    • IHC stains: CK (-), dis-favor carcinoma. CD3 and CD20 stains show a predominant B lymphoid sub-population.
    • The possibility of lymphmoa cannot be excluded. Plaes correlate with clinical and image findings. Further work up, including repeat biopsy, might be considered.
  • 2023-01-31 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Superficial gastritis, antrum
    • Suspected gastric erosion, GC of body s/p biopsy
  • 2023-01-30, -01-27 Nasopharyngoscopy
    • rt pyriform sinus tumor, bil movable cords
    • suspected rt HP cancer
  • 2019-11-19 SONO - nephrology
    • Chronic renal parenchymal disease, mild degree
    • Bilateral renal cysts
  • 2019-11-11 L spine AP + Lat (indluding sacrum)
    • Osteoporosis and spondylosis of L-spine.
    • Disc collapse at L5-S1.
    • Surgical clips at RUQ.
    • Calcification along abdominal aorta.

[consultation]

  • 2023-03-09 Rehabilitation
    • A
      • P
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2023-02-20 Radiation Oncology
    • A
      • Palliative RT to HPX tumor for 3600cGy/20 fx is suggested for symptom control. CT simulation on 2023/02/20 15:30, and RT will be started on Feb 22 or 23 if feasible.
  • 2023-02-09 Colorectal Surgery
    • Q
      • This 90 year-old man has history of
        • hypertension
        • diabetic mellitus
        • Rectal cancer, stage III, s/p operation twice due to recurrence and oral chemotherapy many years ago
      • This time, he was admitted to our ward for Hypopharyngeal cancer (biopsy: pending) survey. Abdominal echogram and CT revealed liver tumor, favor metastasis, origin unknown. We need your expertise on further examination.
      • The patient has had recurrent rectal cancer for several years but has not been followed up on. CT scans were unable to rule out the presence of a rectal tumor. The patient also has a pharyngeal tumor, and if a colonoscopy is needed, it is not suitable for painless general anesthesia.
  • 2023-02-06 Hemato-Oncology
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for hypopharyngeal cancer (cT4aN0M0) workup. Concurrent chemoradiotherapy may be arranged after staging. We need your expertise for possible chemotherapy arrangement. Thanks a lot!
    • A
      • This 90 year old man with HTN and DM history is a case of suspect Hypopharyngeal cancer, cT4aN0M0, status post biopsy via LMS on 2023/1/30 (pathology: pending). We are consulted for CCRT.
      • Concurrent cisplatin or cetuximab with radiotherapy may consider in this case. (Due to old age, may prefer bioRT)
        • note: BioRT stands for Biological Radiation Therapy, which is a type of radiation therapy that uses biological agents, such as monoclonal antibodies or immunomodulators, to enhance the effects of radiation treatment. The aim of BioRT is to improve the response of tumor cells to radiation by modifying the tumor microenvironment or by enhancing the immune system’s ability to attack cancer cells.
      • Pending pathology report. Please check HbsAg, Anti Hbc, Anti HCV. 24 hr urine CCR. Arrange port A insertion.
      • Please arrange our OPD after discharge.
  • 2023-02-01 Radiation Oncology
    • A
      • Plan: I will discuss with the patient and his second son on Feb 2, 2pm. RT to HPX and cervical esophagus tumor for 7140cGy/34 fx is suggested for locoregional control if he and his son agree. CT simulation will be arranged after teeth extraction (or teeth extraction is declined).
  • 2023-02-01 Oral and Maxillofacial Surgery
    • Q
      • This is a 90-year-old man with history of
        • Hypertension
        • Type 2 diabetic mellitus
      • This time, he was admitted to our ward for right hypopharyngeal cancer workup. Concurrent chemoradiotherapy may be arranged after staging. We need yout expertise for dental evaluation bfore radiotherapy. Thanks a lot!
    • A
      • After an oral surgical examination, it is recommended that at least 9 teeth be extracted.
        • If the patient is to continue staying in the hospital, arrangements will be made to begin extracting the teeth during the hospital stay.
        • If the patient is to be discharged, arrangements will be made for outpatient tooth extraction.
        • A family member should be present to accompany the patient during tooth extraction to be aware of the risks involved.
      • If the patient will be discharged first, a NP should prescribe antibiotics to be taken by the patient, and please inform us of the follow-up progress.

[multiteam]

  • 2023-03-12 Social Service
    • Family situation:
      • The patient is a 90-year-old married individual with three sons. The patient, his spouse, and his eldest son live together, and during the hospitalization period, a foreign caregiver was hired to care for the patient in the hospital.
      • The eldest son is unmarried; the second son is married with a son (in college) and a daughter (in junior high school); the third son is married with a son (in junior high school).
    • Assessment and Treatment:
      • The social worker visited the patient in the hospital and had a written conversation with him about his emotional state and sleep condition. The patient wrote that he was suffering due to poor sleep and recent obstructive bowel movements. The social worker promised to communicate with the team and the patient accepted. The patient had no other concerns. The social worker also had a written conversation with the patient about his family situation, to which the patient responded in writing. During the assessment, the patient did not show any suicidal ideation and his low mood was primarily due to illness and poor sleep, but he was cooperating with medical treatment.
      • During the assessment, it was found that the patient’s mood was mainly affected by illness, but he was still able to cooperate with medical treatment. The social worker conveyed to the NP about the patient’s poor sleep and bowel movements, and asked the team to pay attention to this issue.
      • On the same day, the team invited the eldest son to the hospital to listen to the explanation of the patient’s illness and reminded him to prepare for the patient’s discharge. After the explanation, the eldest son accepted the arrangements.

[surgical operation]

  • 2023-02-07
    • Surgery
      • Laryngomicrosurgery with laser for hypopharyngeal tumor excision       
    • Finding
      • bulging tumor over bilateral pyriform sinus

[radiotherapy]

[chemotherapy]

==========

2023-03-22

  • The patient is currently self-carrying Betaloc Zok (metoprolol 100mg) for his hypertension. However, the hospital does not have any metoprolol-containing drugs available in stock.
  • Instead, Urosin (atenolol 100mg/tab) is available, which selectively blocks beta 1 receptors and has little to no effect on beta 2 receptors except at high doses.
  • Atenolol 75mg is approximately equivalent to metoprolol 150mg (ref: https://www.whocc.no/atc_ddd_index/?code=C07AB). Therefore, if the intended dose of Betaloc is 1 tablet per day, we recommend taking half a tablet of Urosin per day (0.5# QD).

2023-03-13

  • PharmaCloud database reports that Natrilix (indapamide) has been prescribed at VGHTPE on 2022-12-29 as a 84-day refillable prescription, along with other medications such as Norvasc (amlodipine), Betaloc (metoprolol), and Olmetec (olmesartan) to manage the patient’s hypertension. And this patient developed hyponatremia since 2023-02.

    • 2023-03-13 Na (Sodium) 128 mmol/L
    • 2023-03-06 Na (Sodium) 128 mmol/L
    • 2023-03-01 Na (Sodium) 128 mmol/L
    • 2023-02-27 Na (Sodium) 130 mmol/L
    • 2023-02-20 Na (Sodium) 132 mmol/L
    • 2023-02-16 Na (Sodium) 130 mmol/L
    • 2023-01-30 Na (Sodium) 136 mmol/L
  • Indapamide is a type of diuretic known as a low-ceiling diuretic, which functions by inhibiting the sodium-chloride co-transporter in the kidneys. This leads to an increase in the excretion of both sodium and water from the body.

  • Treatment of diuretic-induced hyponatremia consists of discontinuing the diuretic and administering either isotonic saline or, if the hyponatremia is severe or symptomatic, hypertonic saline. There is a potential risk of overly rapid correction of the hyponatremia with either regimen. Once the diuretic has been cleared and the patient becomes euvolemic, antidiuretic hormone (ADH) release will be appropriately suppressed, resulting in the excretion of a dilute urine, which can lead to rapid excretion of the excess water. Thus, patients with moderate to severe hyponatremia must be monitored carefully during treatment to minimize the risk of osmotic demyelination.

  • It is recommended to monitor serum Na levels at a frequency no less than every 12 hours, ensuring that any changes in serum Na levels do not exceed 4-6mEq/L within a 24-hour period to avoid the development of osmotic demyelination syndrome (ODS). Additionally, it is advised to monitor urine output and neurological symptoms. Other recommended tests include checking serum osmolality, TSH, free T4, ACTH (at 8 am), cortisol (at 8 am), urine osmolality, Na, and Cre.

700887556

230322

[exam findings]

  • 2023-03-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed hot/faint hot spots in both rib cages, and increased activity in the maxilla, sternum, some T- and L-spine, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • No previous study for comparison.
      • Some hot/faint hot spots in both rib cages, and increased activity in the sternum and some T- and L-spine, cancer with bone metastases may be considered, suggesting further evaluation and follow-up with bone scna in 3 months.
      • Suspected benign lesions in the maxilla, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-03-18 CXR
    • Increased infiltration over RLL. May be active infection.
  • 2023-03-16 CXR
    • Enlargement of cardiac silhouette.
    • Linear infiltration over right and left lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - stomach biopsy
    • Nodularity of mucosa, LC side of upper body, biopsy — Compatible with fundic gland polyp
    • Microscopically, the sections show a picture of benign gastric mucosa with parietal and chief cells, compatible with fundic gland polyp.
  • 2023-03-15 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated
    • The sections show a picture of poorly differentiated adenocarcinoma, composed of solid nests and cords of polygonal neoplastic cells in fibrous stroma. Vascular invasion and subtle glandular differentiation are present.
    • IHC shows following features: CK7(+), CK20(-), p40(-), TTF1(-), and CDX2(-). Metastatic carcinoma from either lung or colon is less likely. Suggest clinic correlation.
  • 2023-03-10 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest abd Abdominal CT with and without enhancement revealed:
      • Chest:
        • Tiny nodule at right middle lobe measuring 0.3cm is found. Suggest follow up.
        • Senile fibrotic change is noted at lung fields.
        • Patent airway is found.
        • Non-specific lymph nodes are found in the mediastinum.
        • Bilateral mild pleural effusion is found.
        • Calcified coronary arteries is found.
        • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
      • Visible abdomen:
        • Left renal atrophy is found.
        • The spleen, liver, pancreas and adrenals are intact.
        • Diffuse liver meta up to 6.8cm at S4 is found.
        • There is no evidence of destructive bone lesion.
        • The GB is well distended without soft tissue lesion
        • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Imp:
      • Diffuse liver meta.
        • The primary tumor cannot be estimated in the study.
        • Please correlate with tumor marker and suggest panendoscopy.
      • Bone meta at thoracic spine.
  • 2023-03-08 MRI - T-spine
    • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
    • With and Without-contrast multiplanar spine MRI (including sagittal and axial T1WI, sagittal and axial T2WI and coronal STIR images) revealed
      • normal bone alignment of the spine
      • unremarkable change in the perivertebral regions
      • unremarkable change in the visible cord.
      • unremarkable change in the disc spaces
      • multiple heterogeneous enhancing lesions in the S1, L5, L4, L3, L2, T11, T10, T5 and T3 vertebral bodies with pathological compression fracture at L4 vertebral body
    • IMP:
      • multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
  • 2023-03-07 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Left anterior fascicular block
    • Bifascicular block
  • 2023-03-07 L-spine flex. + ext. (including sacrum)
    • Marked degenerative change of the spine with marginal spur formation. Disc space narrowing at multiple levels. Geographic bone lesions at L2, L3, L4 levels. Suggest further evaluation.
  • 2023-03-06 MRI - L-spine
    • Indication: Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT. The pain became worse in recent days that he needed bed rest. unable to walk.
    • Imaging protocol: 3-4mm slice thickness; sagittal T1, T2 & STIR, axial T1 & T2, and coronal STIR images
    • MRI of lumbar spine without Gadolinium-based contrast enhancement shows:
      • straightening alignment of lumbar spine.
      • marked degenerative change of the spine with marginal spur formation and dehydrated discs at multiple levels.
      • multiple geographic bone lesions of abnormal signal change at anterior T11, L2, L3, L4, L5 vertebral bodies, bilateral L4 pedicles and posterior elements, sacrum (S1) and right iliac bone, suspect bone metastases. Suggest further evluation.
      • L4 compression fracture with curvilinear fracture line, favor pathological compression fracture.
      • severe right L4-5, L5-S1 neuroforaminal narrowing.
      • severe L2-3, L3-4, L4-5 central canal stenosis.
      • no evidence of abnormal signal lesion in visible spinal cord.
      • multiple left renal cysts; left hydronephrosis.
    • Impression:
      • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
      • L4 compression fracture, favor pathological fracture.
      • Degenerative spinal and disc disease.
      • Severe right L4-5, L5-S1 neuroforaminal narrowing.
      • Severe L2-3, L3-4, L4-5 central canal stenosis.
  • 2023-03-05 CT - pelvis - bone
    • History and indication: back pain
    • IMP:
      • Atrophy of left kidney. Bil. renal cysts (up to 2.1cm).
      • Compression fracture of L4.
  • 2023-03-04 L-spine AP + Lat (including sacrum)
    • AP and lateral films of the lumbar spine shows:
      • Compression fracture of T12.
      • Degeneration and spondylosis of L-S spine.

[consultation]

  • 2023-03-13 Ear Nose Throat
    • Q
      • This 68-year-old man patient suffered back psin in 2023/01. Progression back pain in 2023/02.
      • Pelvic CT on 2023/03/04 showed atrophy of left kidney, bilateral renal cysts (up to 2.1cm) and compression fracture of L4.
      • L-spine MRI on 2023/03/06 showed
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone. Suggest further evaluation.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • T-spine MRI on 2023/03/08 showed multiple bone metastasis witohut evidence of significant mass effect on the T-cord and with pathological fracture at L4 vertebral body.
      • Tumor mark with SCC on 2023/03/09 showed increased (SCC:2.0ng/mL).
      • Chest CT on 2023/03/10 showed diffuse liver meta. The primary tumor cannot be estimated in the study and bone meta at thoracic spine.
      • Now, for evaluate R/O head and neck cancer with liver and bone metastases for SCC increased. Thank you.
    • A
      • Local finding:
        • Oral cavity: fibrosis over bilateral buccal mucosa.
        • Oropharynx: fibrotic change over bilateral tonsillar fossa.
        • Neck: no palpable neck mass.
      • Portable nasopharyngoscopy: smooth nasopharynx, oropharynx, hypopharynx; fair vocal cord.
      • Impression: No definitive finding of ENT lesion indicating malignancy in this visit.
  • 2023-03-09 Dermatology
    • Q
      • This time, for bilateral lower limbs skin edema with dull dandruff and pain in 2017.
      • Now, for evaluate bilateral lower limbs, R/O jock itch therapy. Thank you.
    • A
      • The patient had sufferred from dry swelling legs with fissiform scales and stasis change.
      • Under the impression of stasis dermatitis with ichthyosis change.
      • The following sugeetion:
        • wound protection:
          • Biomycin onit 1 tube topical bid use for wound care first.
          • Sinphraderm cream 1 tube topical QN use over dry scales for mositurization.
        • notice further circulation state, avoid peripheral swelling edema state.
  • 2023-03-07 Neurosurgery
    • Q
      • Low back and right hip pain for more than 1 month. Had called at ORT LMD and sciatica was told, and is going to referred to our ORT.
      • The pain became worse in recent days that he needed bed rest
      • unable to walk
      • Past Hx of HTN, DM, lower limbs lymphedema
      • stilck used for Lt knee degeneration
      • 2022/12/17 Cre 1.18 mg/dL
    • A
      • 68 y/o male.
      • Low back and right hip pain for more than 1 month. The pain became worse in recent days so that he needed bed rest and was unable to walk.
      • L-spine MRI:
        • Suspect multiple bone metastases, lumbar spine, sacrum and right iliac bone.
        • L4 compression fracture, favor pathological fracture.
        • Degenerative spinal and disc disease.
        • Severe right L4-5, L5-S1 neuroforaminal narrowing.
        • Severe L2-3, L3-4, L4-5 central canal stenosis.
      • Advice:
        • Enhanced L-spine MRI (and T- and C-spine).

==========

2023-03-22

  • On 2023-03-19, the urinalysis results showed bacteriuria, UTI, occult blood, and leukocyte esterase positivity. Additionally, there was a significant increase in serum creatinine and a decrease in eGFR.
    • 2023-03-18 Creatinine 3.32 mg/dL
    • 2023-03-16 Creatinine 1.61 mg/dL
    • 2023-03-13 Creatinine 1.20 mg/dL
    • 2023-03-09 Creatinine 1.14 mg/dL
    • 2023-03-18 eGFR 19.78
    • 2023-03-16 eGFR 45.59
    • 2023-03-13 eGFR 63.99
    • 2023-03-09 eGFR 67.90
  • Please ensure that the patient is receiving enough fluids to maintain adequate hydration, and that his fluid input and output are being closely monitored? Additionally, it is important to closely monitor for any signs of infection and track the patient’s renal function.

2023-03-20

  • Bone mets were found, but the primary original malignancy has not yet been identified. Investigation is ongoing.
  • The patient’s son said on the phone that the patient had no contact with any family members after the divorce with his mother, so no family members would care, and said he would discuss with other family members whether to come to the hospital to understand his condition.
  • 2023-03-18 Cre 3.32mg/dL, eGFR 19.78, no height or weight data currently available, CrCl cannot be calculated. If eGFR is considered CrCl and the planned levofloxacin dose is 750 mg QD, in case of CrCl < 20 mL/min: 750 mg initial dose, then 500 mg QOD is recommended.

701474112

230322

[exam findings]

  • 2023-03-17 Pathologic Report for PD-L1 (SP142) Assay (Ventana)
    • Sample Number: S2023-4736
      • Tumor type: adenocarcinoma
      • Tumor location: lung
      • Testing assay: SP142 Assay (Ventana)
      • Testing platform: BenchMark XT
      • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
      • Control slide result: Pass,
      • Adequate tumor cells present (>=50 viable tumor cells): Yes
    • Result:
      • Tumor cell (TC) staining assessment: TC category: TC < 1%
      • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
    • Note:
      • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
      • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
  • 2023-03-15 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-03-15 Patho - lung transbronchial biopsy
    • Lung, LLL, CT-guide biopsy — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma.
    • The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2023-03-14 Bone Scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed two hot spots in the middle T-spines and increased activity in the skull, lower T-spines, some L-spines, left S-I joint and inferior aspect of left acetabulum in whole body survey.
    • IMPRESSION:
      • Two hot spots in the middle T-spines and increased activity in the skull. Multiple bone metastases may show this picture.
      • Increased activity in the left S-I joint and inferior aspect of left acetabulum. Bone metastases can not be ruled out.
      • Increased activity in lower T-spines and some L-spines. Degenerative change may show this picture. However, please follow up bone scan to rule out the possibility of bone metastasis.
  • 2023-03-13 Bronchoscopy
    • normal
    • no obvious tumor was found
  • 2023-03-09 CT - chest
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Spiculated mass at left lower lobe measuring 2.7cm is found. Lung cancer is considered. The lession attached to descending aorta and pulmonary artery.
        • Interfissural nodules (n > 10) are found at left upper and lower lobes up to 1.07cm in largest dimension.
        • Mild left pleural effusion is found.
        • Enlarged lymph nodes are found at left hilar and left paratracheal region.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • Imp: left lower lobe lung cancer with lung to ipsilateral lung meta, pleural meta.
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1(M_value) STAGE:____(Stage_value)
  • 2023-03-09 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
    • Finding: The repetitive stimulation study shows borderline decremental response in Trapezius.
    • Conclusion: The findings are possibly suggestive of myasthenia gravis. Please correlate clinically
  • 2023-03-06 MRA - brain
    • Indication: CT showed brain and skull lesion
    • Imaging protocol: 4-5mm slice thickness; sagittal T2, axial T2 & T2 FLAIR, DWI(b=1000)/ADC, coronal T1, axial T1+C, coronal T1+C images, and TOF MRA images
    • Head MRI without/with Gadolinium-based contrast enhancement shows:
      • multiple heterogeneous enhancing brain tumors scattered in bilateral cerebra and cerebella, on the cortex and in subcortical white matter, some associated with vasogenic edema. Larger ones are 1.8cm at left medial temporal lobe, and 2.0cm at right parietal-occipital lobe junction. Brain metastases are favored.
      • multiple enhancing bone tumors involving skull base and calvarial vault, larger ones are 3.9cm at right high parietal skull, and 2.0cm at clivus. Multiple bone metastases are favored.
      • symmetric size of bilateral ventricles.
      • no brain herniation.
      • TOF MRA shows patent and unremarkable intracranial arteries.
    • Impression:
      • Multiple brain and cerebellar metastases.
      • Multiple bone metastases, skull base and calvarial vault.
  • 2023-03-06 CXR
    • Blunting of left CP angle
  • 2023-03-06 CT - brain
    • Indication: SBP200-220mmHg or DBP110-130mmHg
      • noted today with blurred vision ; no recent head injury
      • no vomiting; no fever ; chest discomfort also noted
    • Imaging Protocol: 4mm slice thickness, axial scan and sagittal reconstruction
    • Without-contrast CT of brain shows:
      • White matter edema in right parietal lobe. Suspicious lesion in left medial temporal lobe.
      • Multiple mass lesions in skull, as well as in clivus.
      • Normal size of the ventricles.
      • No midline shift.
    • Impression
      • White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, suspected brain metastasis
      • Multiple skull lesions; DDx: metastasis, multiple myeloma

[consultation]

  • 2023-03-17 Radiation Oncology
    • A
      • A: Adenocarcinoma of the lung, LLL, stage cT4N2M1, with multiple bone and brain metastases.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastases
        • Goal: palliation
        • Treatment target and volume: the metastatic brain tumors and involved skull bone
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions of the metastatic brain tumors and involved skull bone
        • The treatment planning of radiotherapy will be started at 0930, 2023-3-20.
  • 2023-03-08 Neurology
    • Q
      • She presented with sudden blurred vision and diplopia from 2023/03/06 morning after waking up. Dizziness and occasionally headache was also noted. Occasionally headache and progression memory deterioration for years.
    • A
      • Under the impression of multiple brain and cerebellar metastases with unknow primary, the patient was recommanded admission for further examination and treatment. I was consulted for further evaluation.
      • O
        • NE E4V5M6
        • CNs: suspect left gaze diplopia, no EOM abnormality
        • MP full
        • sensation: intact
        • FNF: no dysmetria
        • gait: steady
        • Brain CT revealed: 1. White matter edema in right parietal lobe and suspiciously in left medial temporal lobe, r/o brain metastasis 2. Multiple skull lesions; DDx: metastasis, multiple myeloma
        • Brain MRI/MRA: 1. Multiple brain and cerebellar metastases. 2. Multiple bone metastases, skull base and calvarial vault.
      • impression:
        • suspect diplopia, r/o leptomeningeal carcinomatosis, r/o cranial neuropathy
      • suggestion:
        • treat cancer as your expertise and agree with steroid treatment
        • consider CSF study to rule out cranial neuritis or leptomeningeal carcinomatosis
        • check serum ACHR ab and RST to rule out myasthenia gravis/LES
        • contact me if any questions and thank you for consultation.
  • 2023-03-08 Dermatology
    • Q
      • She presented skin itchy at least 10 years, SLE (skin manifestations) was diagnosis in RenAi Hospital, follow up and medication for 3 years. She had lesions of skin on her head, right calf and buttocks. Due to brain metastasis was found, skin malignancy was suspicious. We need your further evaluation and management. Maybe need to biopsy?
      • She receive cryotherapy for skin lesions at LMD (2023/03/03).
    • A
      • The patient had sufferred from several itchy keraotsis over face, forarm and buttock s/p cryotherapy with poor healing state.
      • Under the impression of irriated seborrheic keratosis with partial destruction.
      • The following sugeetion:
        • Tetracycline onit. 1 tube topical bid use over wound and crust and Betason-N onit 2 tube topical bid use over regional erythematous itchy lesion
        • If some remain itchy keraotsis develop, avoid self-scretch and consider add Rinderon-V cream 1 tube topical bid use.
  • 2023-03-07 Neurosurgery
    • Q
      • MRA: Multiple brain and cerebellar metastases
      • Dizziness and blurred vision
    • A
      • 67 y/o female. Comorbid with SLE.
      • Brain MRI:
        • Multiple brain and cerebellar metastases.
        • Multiple bone metastases, skull base and calvarial vault.
      • Rx:
        • Consult with oncologist for systemic work-up and therapy.

2023-03-08

[assessment]

  • This 67-year-old female with comorbid SLE presented with dizziness and blurred vision. Brain MRI showed multiple brain and cerebellar metastases, as well as multiple bone metastases in the skull base and calvarial vault. The patient is currently receiving care from our oncologist for systemic evaluation and treatment.
  • The medications previously prescribed by Taipei City Hospital for the patient’s systemic connective tissue involvement have been properly added to the active medication list without a reconciliation issue.

700045553

230321

{Metastatic colon adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA, post segmental hepatectomy on 2019-06-05}

[diagnosis] - 2023-03-20 admission note

  • Sigmoid cancer with Metastasis in S7 liver S/P C/T shows progressive disease. Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease. stage IV
  • Viral hepatitis B Anti-HBc positive
  • Type 2 diabetes mellitus without complications

[past history] - 2022-11-25 admission note

  • Type 2 DM
  • Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018.
  • Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 20191226
  • Pig-tail drainage for liver abscess since 2019/06/08.
  • Enterocutaneous fistula since 2019/08/03

[family history]

  • His mother had cervical cancer.

[lab data]

  • 2021-07-30 Anti-HCV Nonreactive
  • 2021-07-30 Anti-HCV Value 0.05 S/CO
  • 2021-07-30 HBsAg Nonreactive
  • 2021-07-30 HBsAg (Value) 0.41 S/CO
  • 2021-07-30 Anti-HBc Reactive
  • 2021-07-30 Anti-HBc-Value 6.63 S/CO
  • 2021-07-30 Anti-HBs 22.86 mIU/mL

[exam findings]

  • 2023-01-27 MRI - T-spine
    • Indication: Mid-back pain and soreness, associated numbness.
    • Findings
      • T1-hypointensity, heterogeneous T2-hypointensity and inhomogeneous enhancement involving both anterior and posterior components of C6, C7, T3, T4 and T5 vertebral body, indicating metastases. Much more severe at T3-5 levels with bony destruction and compression on spinal cord.
      • An enhacning soft tissue mass, about 39 mm at the largest dimension, with irregular maring in right lung field, abutting right main bronchus and right side of T5 vertebrla body, indicating metastasis.
      • No intramedullary lesion.
    • IMP: Bony metastases (C6-7 and T3-5 vertebral bodies) and right lung metastasis.
  • 2023-01-16 CT - Sella
    • Findings
      • An extra-axial tumor (36 mm) at anterior cranial fossa base, can be separated from pituitary fossa by diaphragm sella. Suspected meningioma.
      • After IV contrast administration shows well and homogenous enhancement of the mass or tumor.
    • IMP: Favor a middle frontal base meningioma.
  • 2023-01-16 T-spine AP + Lat.
    • Destructions/metastases, at least, at T3-4-5.
  • 2022-12-13 Patho - liver biopsy needle/wedge
    • Liver, CT-guided biopsy — Adenocarcinoma, metastatic, colonic origin
    • The sections show a picture of adenocarcinoma, moderately differentiated, composed of nests, cords, and single large pleomorphic neoplastic cells in fibrous stroma. Focal glandular differentiation is present. Extensive tumor necrosis is evident.
    • IHC shows: CK7(-), CK20(+) and CDX2(+). The finding is consistent with metastatic colonic adenocarcinoma.
  • 2022-11-28 CT - abdomen
    • Findings
      • Lobulated hepatic tumor at S7/8 of liver up to 5.5cm in largest dimension is found. In comparison with CT dated on 2022-08-10, the lesion enlarged.
      • Diffuse confluent lymphadenopathy at para-aortic and mesenterric region is found. In progression.
      • Mild bilateral pleural effuison is found.
    • Imp:
      • Hepatic meta. In progression.
      • Extensive lymphadenopathy in the abodminal cavity, in enlargement.
  • 2022-09-15 Tc-99m MDP whole body bone scan
    • Prominently increased activity in some upper T-spines. Bone metastases should be considered first.
    • Mildly increased activity in bilateral S-I joints. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, compatible with benign joint lesions.
  • 2022-08-27 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-08-10 CT - abdomen
    • Indication
      • History: D-colon cancer with liver & LNs mets
        • 20180406 CT: Distal D-colon cancer — acute total obstruction
        • 20190520 CT: metastasis in S4/8
        • 20190608 CT: metastasis in S4/8 S/P resection with abscess S/P catheter drainage
        • 20201014 CT: metastasis in S7 S/P C/T with partial response.
        • 20211109 CT: metastasis in S7 1.6 cm.
    • Findings
      • Prior CT identified an ill-defined rim enhancing lesion 4.4 cm in S7 of the liver is noted again, increasing in size to 5.3 cm in the current CT that is c/w liver metastasis S/P C/T with progressive disease.
      • Prior CT identified multiple confluent metastatic lymphadenopathy at para-aortic space and para-cava space are noted again, stable in size that are c/w metastatic nodes S/P C/T with stable disease.
      • S/P surgical resection of S4/8 junction and partial resection of S5/6 of the liver. S/P cholecystectomy. Mild Fatty liver is noted.
      • S/P left hemicolectomy.
      • The spleen shows prominence in size (AP dimension: 11.3 cm).
    • Impression:
      • Metastasis in S7 liver S/P C/T shows progressive disease.
      • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease.
  • 2022-08-04 CXR
    • Cardiomegaly is noted.
    • Right pleural effusion is found.
  • 2022-07-21 CXR
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2022-05-26 CT - abdomen, pelvis
    • Progression of liver/ LNs metastases.
  • 2022-03-12 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-01-15 MRI - nasopharynx
    • Metastastic LAPs at left neck. An extra-axial tumor (37 mm) at anterior cranial fossa and pituitary fossa.
    • Suspected meningioma.
    • D/D: craniopharyngioma, pituitary adenoma, metastasis.
  • 2022-01-14 CT - whole abdomen, pelvis
    • Metastasis in S7 liver S/P C/T shows progressive disease.
    • Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show partial response.
  • 2021-11-10 MRI - nasopharynx
    • multiple enlarged and necrotic lymph nodes in the left lower neck and left supraclavicular fossa.
  • 2021-11-09 CT - whole abdomen, pelvis
    • Hepatic meta at S7, in progression.
    • Extensive paraaortic lymphadenopathy, enlarged.
    • Tiny left upper lobe nodule. Stable.
  • 2021-09-16 CT - whole abdomen, pelvis
    • Progression of liver/LNs metastases.
  • 2021-07-19 Patho - peritoneum biopsy
    • newly developed retroperitoneal LNs, R/I recurrence.
    • malignant neoplasm of descending colon
    • Retroperitoneal lymph node, CT-guide biopsy - Adenocarcinoma, metastatic
    • IHC: CK(+), CK20(-), CDX2(+) and CD31 highlights endothelial cell, compatible with metastatic colonic adenocarcinoma.
  • 2020-10-14 CT - whole abdomen, pelvis
    • A metastasis 2.9 x 2 cm in S7 of the liver S/P C/T with partial response. Follow up is indicated.
  • 2020-08-25 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region, stationary.
    • Stationary of S7 liver tumor.
  • 2020-06-15 MRI - brain
    • A pituitary macroadenoma. No evidence of brain metastasis.
  • 2020-06-13 CT - whole abdomen, pelvis
    • Post-op at the liver with loculated fluid in right subphrenic region with progression. Post-op biloma or associated with recurrenct, suggest tissue study.
    • Stationary of S7 liver tumor.
    • Small bilateral renal stones.
  • 2020-04-01 CT
    • A metastasis 3.9 x 2 cm in S7 of the liver S/P C/T with stable disease.

    • 2019-11-21 Whole body PET scan

      • Three glucose hypermetabolic lesions in the segment 8 of liver, in the segment 7 of liver and in the right upper abdomen just in the inferomedial aspect of the right lobe of liver respectively. Metastatic lesions should be considered.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions and in the soft tissues around bilateral hips. Inflammatory process is more likely.
      • Glucose hypermetabolism in the midline anterior abdominal wall. The nature is to be determined (post-operative change? other nature?).
      • A glucose hypermetabolic lesion the pituitary fossa. The nature is to be determined (some kind of pituitary tumor? other nature?).
    • 2019-11-11 CT - abdomen

      • S/P liver operation. A low attenuation lesion (1.8cm) in S7 of liver without interval change.
    • 2019-08-14 Tc-99m MDP whole body bone scan

      • A faint hot spot in the anterolateral aspect of the right 8th rib, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scna in 3 months for further evaluation.
      • Suspected benign lesions in the left zygomatic bone, inferior angle of the right scapula, bilateral shoulders, and S-I joints.
    • 2019-08-03 MRI - liver, spleen

      • s/p pigtail placement at previous op. region. Some fluid accumulation at previous op. region with tiny air bubble is found. The adjacent liver parenchyma is hyperemic, suspected regional residual abscess formation.
    • 2019-06-06 Surgical pathology Level V

      • pathologic diagnosis
        • Liver, S4-5-8, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Liver, S7, segmental hepatectomy — Metastatic colonic adenocarcinoma
        • Tumor regression grade: Grade 4/5 (cancer cells > fibrosis)
        • Lymph nodes, group 12, lymphadenectomy — Negative (0/3)
      • microscopic examination
        • Diagnosis: Metastatic colonic adenoarcinoma x2
        • Histologic grade: Moderately differentiated
        • Tumor growth pattern: Pushing
        • Tumor pseudocapsule: Present
        • Tumor necrosis: Marked (60%)
        • Parenchymal margin: Uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margins: 0.1 cm (S4-5-8) and 0.1 cm (S7), respectively
        • Vascular invasion: Present
        • Perineural invasion: Not identified
        • Tumor regression grade: Grade 4/5 (residual cancer cells predominate over fibrosis)
        • Lymph nodes, group 12: Negative (0/3) (LN involved/LN examined)
        • Non-neoplastic liver parenchyma: Perivenular congestion, and mild portal lymphocytic infiltration
        • Fatty Change: Moderate (50%)
    • 2019-06-08 CT - abdomen

      • S/P operation. Bil. pleural effusion with adjacent lung collapse.
      • Some air and fluid collection in upper peritoneal cavity and right subphrenic region.
      • Inhomogeneous enhancement of right hepatic lobe.
    • 2019-05-20 CT - abdomen

      • Metastasis 4 cm in size at S4 of the liver is noted and it shows indentation or invasion of the gallbladder wall.
    • 2018-11-16 CT

      • S/P left hemicolectomy. Suggest follow up.
    • 2018-07-07 CT

      • S/P operation. Presence of incisional hernia. Focal fat stranding of abdominal wound.
    • 2018-06-28 Surgical pathology Level III

      • Soft tissue, site?, debridement — Ulcer with granulation tissue
    • 2018-04-26 Surgical pathology Level VI

      • Pathologic diagnosis
        • Descending colon, left hemicolectomy — Adenocarcinoma, moderately differentiated
        • Resection margins: Free
        • Lymph nodes, mesocolic, dissection — Metastatic adenocarcinoma (2/16)
        • Pathology stage: pT4aN1b(cMx); Stage IIIB at least
      • Microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Mesocolic soft tissue
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present
        • Discontinuous extramural tumor extension: Not identified
        • Serosal margin status of colon: Involved
        • Lymph nodes metastasis, mesocolic: Metastatic adenocarcinoma (2/16) (No. Positive / No. Total)
        • Extranodal involvement: Present
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)

[consultation]

  • 2023-02-03 Radiation Oncology
    • A
      • In the past 2 wks, he sufferred from Lt neck enlarging LAPs compression with severe Lt arm and scapular pain. CT-simulation will be arranged on 20230208.
      • Plan to deliver 20 Gy/ 4 fx to the Lt neck LAPs. The dose schedule to the spine mets will be adjusted according to the dose distribution and constraint by then.
      • RT will start around 20230209.
  • 2022-12-14 Radiation Oncology
    • A
      • Paraaortic enlarging LAPs have caused mild lower limbs edema already. Palliative RT is indicated. CT-simulation will be arranged on 20231219.
      • Plan to deliver 40~45 Gy/ 20~25 fx to the paraaortic LAPs. RT will start around 2022/12/21 or 22.
    • 2022-12-12 Radiation Oncology
      • Q
        • for CT guide biopsy of liver
        • This 60-year-old man, a patient of colon cancer with liver mets progression and he was admitted for C/T. The abdominal CT showed hepatic tumor progression. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical history and imaging findings, biopsy is indicated.
    • 2022-09-27 Radiation Oncology
      • A
        • Mr. Hsu, a 60-year-old man with history of Descending colon adenocarcinoma pT4aN1bM0 stage IIIB s/p T-loop colostomy, left hemicolectomy, closure of colostomy and FOLFOX chemotherapy in 2018. Metastatic colonic adenocarcinoma in liver S4-5-8 & S6, pTxN0M1a Stage IVA post segmental hepatectomy on 2019/06/05. RFA for S6/7 metastases at VGHTPE on 2019/12/26. status during palliative C/T with liver metastases and abdominal LAPs progression.
        • The Lt upper back and shoulder pain and soreness has been noted since one month ago. Bone scan on 20220916 revealed prominently increased activity in some upper T-spines. Bone metastases should be considered first.
        • Palliative RT to the upper T-spine metastases is indicated. CT-simulation will be arranged today. Plan to deliver 30 Gy/ 10 fx to the site mentioned above. RT will start around 20220928 or 20220929. Thank you very much.
    • 2022-08-11 Colorectal Surgery
      • Q
        • for suspected fistular
        • This 60-year-old man, a patient of colon cancer with liver mets progression and Metastatic lymphadenopathy in para-aortic space and para-cava space S/P C/T show stable disease S/P C/T. He was admitted due to dyspnea & bak pain on 8/4 22 night abdominal wound poor healing & pus discharge for one week. pus discharge and stool passage via poor healing wound was noted suspected fistular related. We need expertise to evaluate his condition thanks!
      • A
        • The patient was case of colon cancer with liver and LN metastasis
        • Colo-cutaneous fistula was noted
        • PE: Abd: soft; no peritoneal sign; no abdominal pain
        • Imp: Colon cancer s/p op with enterocutaneous fistula
        • Suggestion:
          • Cover with colostomy bag and may contact stoma nurse if needed
          • Keep on palliative chemotherapy
    • 2022-03-15 Ophthalmology
      • Q
        • For left eye reddish for days
        • This 59-year-old man, a patient of colon cancer with liver & lung mets progression S/P C/T. He was admitted for chemotherapy. He compalined of left eye reddish for days. We need expertise to evaluate his condition. thanks!
      • A
        • S
          • For redness, FBS os for 1 week
          • OPHx: trichiasis s/p epilation od 2wk ago
          • PHx: DM, colon cancer with liver & lung mets progression under Erbitux, FOLFIRINOX
          • NKA
        • O
          • BCVA: OD 0.6(0.9X-0.25/-0.50X40) OS 0.3(0.5X0/-0.50X5)
          • PT: 20/18mmHg
          • Pupil: 3mm, light reflex +, no RAPD
          • Eyelash: entropion with trichiasis os
          • Conj: np od, inferior injected os
          • K: clear ou, inferior spks os
          • A/C: deep/clear ou
          • Lens: ns+ ou
          • Fundus: c/d 0.4, one CWS near disc od, one blot hemorrhage and CWS os
        • A:
          • Entropion with corneal abrasion os
          • Mild diabetic retinopathy ou
        • P:
          • Control blood sugar
          • Sinomin 1gtt QID os + Tetracycline oint HS os + tapping inferior eyelid os
          • OPH OPD f/u for entropion and f/u cotton-wool spot at disc os

[surgical operation]

  • 2019-06-05
    • Segmental hepatectomy
    • Secondary liver malignant neoplasm
  • 2018-06-27
    • Colon cancer s/p op with enterocutaneous fistula
  • 2018-06-22
    • Malignant colon neoplasm, desc
    • 8.5 Fr. B. braun port, left cephalic vein, cut-down method.
  • 2018-05-01
    • D-colon cancer obstruction post op
    • Smoe necrotic tissue at colostomy opened wound
    • Debridement and closure and set a penrose drain
  • 2018-04-25
    • D-colon cancer obstruction s/p colostomy
    • D-colon cancer with complete obstruction 744cm
    • Peristoma dense adhesion with omentum and small intestine
  • 2018-04-10
    • D-colon cancer obstruction
    • Severe dilatation of T-colon and short mesentary
    • Asites (+)

[chemotherapy]

  • 2023-03-20 - irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5290mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-03-01 - cetuximab 250mg/m2 100mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5280mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-02-06 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5400mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2023-01-04 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-12-14 - cetuximab 250mg/m2 480mg 2hr + irinotecan 185mg/m2 340mg D5W 250mL 90min + leucovorin 400mg/m2 750mg NS 250mL 2hr + fluorouracil 2800mg/m2 5300mg NS 500mL 46hr (cetuximab + FOLFIRI, Q2WK)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

    • 2022-11-25 - cetuximab 250mg/m2 480mg 2hr + oxaliplatin 60mg/m2 115mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5450mg 46hr (FOLFOXIRI Zhang_ShouYi)

      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg IVD + granisetron 2mg + acetaminophen 500mg PO
    • 2022-11-08 - cetuximab 250mg/m2 490mg 2hr + oxaliplatin 60mg/m2 118mg 2hr + irinotecan 150mg/m2 295mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-10-20 - cetuximab 250mg/m2 485mg 2hr + oxaliplatin 60mg/m2 116mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 775mg 2hr + 5-Fu 2800mg/m2 5430mg 46hr (Zhang_ShouYi)

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 180mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-09-12 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2022-08-26 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5520mg 46hr (Zhang_ShouYi) patient asked to add oxaliplatin back.

    • 2022-08-12 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 350mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-07-21 - cetuximab 250mg/m2 500mg 2hr + irinotecan 180mg/m2 360mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-07-01 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-06-14 - cetuximab 250mg/m2 500mg 2hr + irinotecan 160mg/m2 320mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi) FOLFIRI

    • 2022-05-24 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 120mg 2hr + irinotecan 185mg/m2 370mg 90min + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2022-04-27 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-29 - cetuximab 400mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-03-15 - cetuximab 250mg/m2 500mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-02-10 - cetuximab 400mg/m2 700mg 2hr + oxaliplatin 60mg/m2 100mg 2hr + irinotecan 185mg/m2 360mg 90min + leucovorin 400mg/m2 780mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2022-01-14 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 170mg/m2 330mg 90min + leucovorin 400mg/m2 790mg 2hr + 5-Fu 2800mg/m2 5500mg 46hr (Zhang_ShouYi)

    • 2021-12-22 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 160mg/m2 300mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-12-01 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 290mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2021-11-11 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 2800mg/m2 5345mg 46hr (Zhang_ShouYi) FOLFOXIRI

    • 2021-09-28 ~ 2021-11-09 - Stivarga (regorafenib 40mg/tab) 4# QD D1-21 Q4W

    • 2021-09-03 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5600mg 46hr (Zhang_ShouYi)

    • 2021-08-20 - oxaliplatin 85mg/m2 170mg 2hr + leucovorin 400mg/m2 800mg 2hr + 5-Fu 2800mg/m2 5640mg 46hr (Zhang_ShouYi)

    • 2021-07-29 - oxaliplatin 70mg/m2 140mg 2hr + leucovorin 400mg/m2 805mg 2hr + 5-Fu 2800mg/m2 5660mg 46hr (Zhang_ShouYi)

    • 2020-08-24 - bevacizumab 5mg/kg 200mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-07-27 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5480mg 46hr (Zhang_ShouYi)

    • 2020-06-29 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5460mg 46hr (Zhang_ShouYi)

    • 2020-06-15 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 180mg/m2 350mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-28 - bevacizumab 5mg/kg 300mg 1.5hr + irinotecan 160mg/m2 300mg 1.5hr + leucovorin 400mg/m2 750mg 2hr + 5-Fu 2800mg/m2 5470mg 46hr (Zhang_ShouYi)

    • 2020-05-07 - bevacizumab 300mg 90min + irinotecan 120mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + 5-Fu 400mg/m2 650mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1-2 (Liu_JunHuang)

    • 2020-04-20 - bevacizumab 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 560mg 2hr + 5-Fu 400mg/m2 560mg 15min + 5-Fu 1000mg/m2 1500mg 20hr D1 (Liu_JunHuang)

    • 2020-04-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1 (Liu_JunHuang)

    • 2020-03-16 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-03-02 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-17 - bevacizumab 400mg 90min + irinotecan 280mg 90min + leucovorin 400mg/m2 760mg 2hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-02-03 - irinotecan 270mg 1.5hr + leucovorin 400mg/m2 760mg 0hr + 5-Fu 400mg/m2 760mg 15min + 5-Fu 1000mg/m2 1900mg 20hr D1-2 (Liu_JunHuang)

    • 2020-01-13 - oxaliplatin 85mg/m2 2hr + leucovorin 200mg/m2 380mg 0hr + 5-Fu 400mg/m2 684mg 15min D1-2 + 5-FU 1000 mg 20hr D1-2 (Liu_JunHuang)

    • 2019-12-06 ~ 2019-12-28 - capecitabine

    • 2019-06-12 - FOLFIRI + bevacizumab

    • 2019-05-28 - FOLFIRI + bevacizumab

    • 2019-05-07 - FOLFIRI + bevacizumab

    • 2019-04-20 - FOLFIRI + bevacizumab

    • 2019-04-03 - FOLFIRI + bevacizumab

    • 2019-03-16 - FOLFIRI + bevacizumab

    • 2019-03-02 - FOLFIRI + bevacizumab

    • 2019-02-17 - FOLFIRI + bevacizumab

    • 2019-02-03 - FOLFIRI

    • 2019-01-03 - FOLFIRI

    • 2018-06-08 ~ 2018-06-18: capecitabine

==========

2022-11-28

The control of blood sugar is better than it was during the last hospital stay. As far as the active prescription is concerned, there is no problem.

2022-11-09

The patient continues to have poor blood sugar control despite treatment with acarbose, metformin, and vildagliptin (2 data points over 244 mg/dL on 2022-11-08 and 2022-11-09). SGLT2 inhibitors such as Canaglu (canagliflozin), Forxiga (dapagliflozin) or Jardiance (empagliflozin) might be added to help manage diabetes.

2022-09-13

Although the patient is currently receiving 3 classes of oral antidiabetic medications (metformin, sitagliptin, and dapagliflozin), his blood sugar remains high (381mg/dL on 2022-09-12 17:35, 302mg/dL on 2022-09-13 06:46); HbA1c of 8.4 (2022-08-26 lab), mild diabetic retinopathy has been confirmed (2022-03-15 ophthalmology).

Starting basal insulin (e.g., Toujeo (insulin glargine)) at 0.1 unit/kg/day or 10 units/day is recommended.

2022-07-22

Irinotecan 180 mg/m2 in current regimen is considered a normal dose range for patients with ALT/AST 43/44, BUN 10 (2022-07-21).

There is a history of T2DM in this patient. The most recent HbA1c record dates from 2019, and the AC blood sugar readings have been 271, 327, and 267 since this hospitalization. As there is no hypoglycemic agent in active prescriptions, metformin 500 mg BID is recommended.

2022-03-15

CT and MRI in mid January 2022 showed the disease progressed compared to previous images.

CEA readings since July 2021 at intervals of two to three months showed a peak in November 2021 (1261ng/mL) and a slight fall in February 2022 (886ng/mL), possibly caused by the introduction of FOLFOXIRI from November 2021 (ongoing).

701459963

230321

[diagnosis]

  • Malignant neoplasm of left ovary
  • Left ovary mixed mucinous and aclear cell carcinoma, pT1c3N0M0, stage IC3, post debulking (ATH + BSO + BPLND + artial omentectomy) on 2022/11/18

[past history]

  • Past hx: denied
  • Surgical hx:
    • 2022/11/18 ebulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis
    • 2202/12/07 port implantaion, left cephalic vein

[allergy]

  • NKDA     

[family history]

  • denied family history

[exam findings]

  • 2023-02-18 SONO - abdomen
    • mild fatty liver
    • right renal cyst
  • 2023-02-16 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency, decreased SAP amplitude, slowing sensory conduction velocity in bilateral median nerves. (2) Decreased CMAP amplitude in left median nerve. The F wave study showed no response in left median nerve. The H reflex was within normal limits. The QST study showed abnormal heat and cold sensation in upper and lower limbs.
    • Conclusion
      • The above finding suggest entrapment neuropathy in bilateral median nerves at wrist and small fiber disease. Advise clinical correlation.
  • 2023-02-09 Brainstem auditory evoked potentials, BAEP
    • Findings: Normal waveforms, amplitudes, peak latencies, interpeak intervals following click stimulaion to each ear.
    • Conclusion: This is a normal BAEP study.
  • 2023-02-16 Neurosonology
    • Mild atherosclerosis in left CCA bifurcation and left CCA.
    • Adequate total VA flow volume (234 ml/min).
  • 2023-01-27 MRI - brachial plexus
    • Indication
      • Ovary cancer
      • acute left upper arm pain and left upper limb weakness on 2022/11/21
      • had tenderness point
      • no trauma history
      • 2022/12/15 improving
    • Without- and with-contrast MRI of brachial plexus, including axial, coronal and oblique sagittal T1WI and T2WI (with 3 mm or 4 mm thickness) reveal:
      • Hypertrphic degeneration of C-spine, esp C5-6-7.
      • No abnormality along the course of left brachial plexus.
      • A well-defined non-enhancing cystic lesion infiltrating along muscles at left shoulder joint, including subacromion region, indicating degenerative joint disease.
      • S/P Port-A device at left chest wall.
    • IMP: No evidence of brachial plexus lesion. Cervical spondylosis.
  • 2023-01-27 MRI - C-spine
    • Findings:
      • General bulging disc with central focal protrusion causing mild spinal canal stenosis and bilateral mild neuroformainal narrowing at C4-5.
      • Decreased vertebral body height, end-plate degeneration, general bulging disc with central disc protrusion, posterolateral osteophytes and enlarged facets causing spinal canal stenosis, cord compression and bilateral moderate neuroforaminal narrowing at C5-6-7.
      • No intramedullary abnormality.
      • No abnormal enhancement.
    • IMP: Cervical spondylosis with spinal canal stenosis and neuroforaminal narrowing, esp C5-6-7.
  • 2022-12-09 Nerve Conduction Velocity, NCV
    • Findings
      • The NCV study showed (1) Prolonged distal motor latency in bilateral median nerves. (2) Marked decreased CMAP in left median nerve. (3) Slowing sensory conduction velocity in bilateral median nerve. The F wave study showed prolonged latency in left median nerve. The EMG study showed normal findings in left FDI, left brachioradialis and left biceps brachii muscle. The H reflx was normal.
    • Conclustion
      • The above findings suggest left median neuropathy, left cervical radiculopathy and entrapment neuropathy in right median nerve at wrist. Advise clinical correlation.
  • 2022-12-07 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 24 dB HL; LE 23 dB HL
    • bil normal to moderate SNHL (sensory neural hearing loss)
  • 2022-11-28 MRI - upper arm
    • Partial-thickness intrasubstance tear of supraspinatus tendon
    • Supraspinatus and infraspinatus tendinosis and calcific tendinitis
  • 2022-11-26 Shoulder LT
    • Calcified left rotator cuff tendinitis
  • 2022-11-26 CXR
    • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
    • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch
    • a small nodular opacity over Lt midlung zone?
  • 2022-11-26 Gynecologic ultrasonography
    • ATH + BSO
    • No obvious uterine or ovarian lesion
  • 2022-11-21 Patho - soft tissue tumor, extensive resection
    • Diagnosis:
      • Ovary, left, oophorectomy —- mucinous carcinoma with focal clear cell carcinoma; AJCC 8th edition: pStage IC, pT1c2N0(if cM0), FIGO Stage IC2 or pStage IC, pT1c3N0(if cM0), FIGO Stage IC3; please correlate with the clinical presentation
      • Ovary, right, oophorectomy —- negative for malignancy
      • Fallopian tube, bilateral, salpingectomy —- negative for malignancy
      • Uterus, corpus, total hysterectomy —- negative for malignancy
      • Uterus, cervix, total hysterectomy —- negative for malignancy
      • Uterus, endometrium, total hysterectomy —- negative for malignancy
      • Omentum, omentectomy —- negative for malignancy
      • Lymph node, left iliac, dissection —- negative for malignancy (0/7)
      • Lymph node, left obturator, dissection —- negative for malignancy (0/10)
      • Lymph node, right iliac, dissection —- negative for malignancy (0/6)
      • Lymph node, right obturator, dissection —- negative for malignancy (0/7)
    • Gross description:
      • Procedure (select all that apply): debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND)
      • Specimen Integrity
        • Specimen Integrity of Right Ovary (if applicable): Capsule intact
        • Specimen Integrity of Left Ovary (if applicable): Capsule ruptured
        • Specimen Integrity of Right Fallopian Tube (if applicable): Serosa intact
        • Specimen Integrity of Left Fallopian Tube (if applicable): Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement (required only if applicable): Absent
      • Fallopian Tube Surface Involvement (required only if applicable): Absent
      • Tumor Size
        • F2022-00552
          • Greatest dimension (centimeters): 7.5 cm
          • Additional dimensions (centimeters): 7.3 x 2.8 cm
      • Specimen size:
        • S2022-20527
          • right ovary: 2.3 x 1.8 x 0.3 cm;
          • right tube: 5.6 cm in length and 0.5 cm in diameter;
          • left tube: F2022-00552: 4.6 cm in length and 0.3 cm in diameter;
          • uterus: 8.6 x 5.6 x 4.8 cm, 135 g; Cervix: 3.8 x 3.5 x 2.8 cm; Endometrial cavity: 4.0 x 3.8 x 0.2 cm; Several leiomyomas, measuring up to: 1.1 x 1.0 x 0.8 cm
          • omentum: 14.7 x 10.5 x 2.0 cm
      • Sections are taken and labeled as:
        • F2022-00552: Representative sections are taken and labeled as: FsA1-3, for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: left fallopian tube; X2: adnexal soft tissue; X3-6: left ovary.
        • S2022-20527: A1: cervix; A2-3: endometrium; A4: leiomyoma; A5: right ovary and fallopian tube; A6: left adnexal soft tissue; A7: posterior wall; B1-2: omentum; C1-2: lymph node, left iliac; D1-2: lymph node, left obturator; E1-2: lymph node, right iliac; F: lymph node, right obturator.
    • Microscopic Description:
      • Histologic Type: Mucinous carcinoma with focal clear cell carcinoma; The immunohistochemical stains reveal PAX8(+), WT-1(-), PR(-), Napsin A(focal +), p53(aberrant expression +)
      • Histologic Grade (required for endometrioid, mucinous carcinomas, immature teratomas, and Sertoli-Leydig cell tumors)
        • (Note: Immature teratomas can be graded using a 2-tier or 3-tier system. Endometrioid and mucinous carcinomas are graded via a 3-tier system. Clear cell carcinomas, borderline epithelial neoplasms, all other malignant sex-cord stromal and germ cell tumors are not graded.)
        • WHO Grading System: G2: Moderately differentiated
      • Implants (required for advanced stage serous/seromucinous borderline tumors only): not applicable
      • Other Tissue/ Organ Involvement (select all that apply): Not identified
      • Largest Extrapelvic Peritoneal Focus (required only if applicable): Cannot be determined
      • Peritoneal/Ascitic Fluid: N2022-04283: suspicious
      • Regional Lymph Nodes: left iliac: 0/7; left obturator: 0/10; right iliac: 0/6; right obturator: 0/7
      • Additional Pathologic Findings: Leiomyoma and adenomyosis are seen.
  • 2022-11-18 Body fluid cytology - ascites
    • suspicious for malignancy;
    • few clusters of suspicious cells with high nuclear/cytoplasmic ratio present.
  • 2022-11-18 Frozen section
    • Ovary, left, oophorectomy —- adenocarcinoma
  • 2022-11-17 Colonoscopy
    • Diverticulum, descending colon
    • Internal hemorrhoid
  • 2022-11-17 Panendoscopy
    • Diagnosis
      • Reflux esophagitis LA Classification grade AEsophageal phleboectasia, middle esophagus
      • Superficial gastritis
    • Suggestion
      • No endoscopic evidence of primary malignancy in UGI tract
  • 2022-11-16 ECG
    • Sinus bradycardia
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2022-11-10 Gynecologic ultrasonography
    • suspected pelvis mass: 92 x 47 mm (RI: 0.38)
    • ascites

[surgical operation]

  • 2022-11-18 debulking surgery (total abdominal hysterectomy + bilateral salpingo-oophorectomy + omentectomy + BPLND) + enterolysis

[chemotherapy]

  • 2023-03-20 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-24 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-02-07 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2023-01-18 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-28 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3
  • 2022-12-09 - paclitaxel 175mg/m2 300mg NS 250mL 3hr + carboplatin AUC 4 750mg NS 250mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + palonosetron 250ug + aprepitant 125mg PO D1-3

[note]

First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tube, and peritoneal cancer https://www.uptodate.com/contents/first-line-chemotherapy-for-advanced-stage-iii-or-iv-epithelial-ovarian-fallopian-tube-and-peritoneal-cancer

  • General principles
    • The standard approach to treatment for women requiring first-line chemotherapy for EOC is to use a platinum agent with a taxane. For women with optimally reduced disease (<1 cm of residual disease), there are two options: intravenous (IV) chemotherapy alone or a combination of IV and intraperitoneal (IP) chemotherapy (IV/IP therapy). Women with suboptimally reduced disease (≥1 centimeter of residual disease) are not candidates for IP therapy due to limited penetration into larger tumors. These women should therefore receive IV treatment.
  • Women with optimally cytoreduced disease
    • IV/IP therapy versus IV therapy alone
      • Comparative data
        • For women with optimally cytoreduced disease (no residual or less than 1 cm of residual disease) who have not received neoadjuvant treatment, IV/IP therapy is an appropriate option. Some UpToDate experts prefer IV/IP treatment for optimally cytoreduced disease, while others prefer IV therapy, particularly given that other treatment options including bevacizumab and maintenance therapy with PARP inhibitors are also often included.
      • Preferred IV/IP therapy regimen
        • The most commonly used intravenous/intraperitoneal (IV/IP) regimen comes from GOG 172 and consists of six cycles of
          • IV paclitaxel (135 mg/m2 over 24 hours) on day 1
          • IP cisplatin (100 mg/m2 in a liter of normal saline) on day 2
          • IP paclitaxel (60 mg/m2) on day 8
        • We typically use the above regimen, with the exception of reducing cisplatin to 75 mg/m2, which was the regimen used in GOG 252.
      • Preferred IV therapy regimen
        • For patients with optimally cytoreduced disease in whom intravenous (IV) therapy will be administered, choice of agents and scheduling is the same as for those with suboptimally cytoreduced disease, and is discussed below.
    • Incorporation of HIPEC
      • For patients who undergo neoadjuvant chemotherapy and have an optimal surgical result (ie, residual disease <1 cm), incorporation of HIPEC is discussed separately.
  • Women with suboptimally cytoreduced disease
    • For patients with suboptimally cytoreduced EOC (epithelial ovarian cancer), we suggest IV treatment rather than IV/IP therapy.
    • Choice of agents
      • For women requiring first-line chemotherapy for EOC, the standard IV regimen utilizes platinum and taxane agents. For select patients at higher risk of recurrence (eg, those with pleural effusions or ascites who lack a BRCA mutation), we suggest the addition of bevacizumab, which is administered with chemotherapy and continued as maintenance therapy.
      • Although cisplatin and/or docetaxel are sometimes used in this setting, we prefer carboplatin plus paclitaxel. Our rationale is based on the following:
        • We prefer carboplatin rather than cisplatin because multiple trials have consistently demonstrated that carboplatin produces equivalent response rates and survival outcomes to cisplatin, but is associated with less toxicity.
        • Although both paclitaxel and docetaxel (the most commonly used taxanes for EOC) can be administered along with carboplatin in this setting, we prefer paclitaxel because it is less myelosuppressive than docetaxel. However, a consideration between these two taxanes can be individualized based on their differing toxicities. For paclitaxel, these include a higher risk of neuropathy, myalgias, and weakness compared with docetaxel; for docetaxel, these include a higher risk of neutropenia, hypersensitivity reactions, and nausea and vomiting.
        • We prefer to treat for a maximum of six cycles rather than more because there are no data that treatment beyond six cycles improves outcomes, although further treatment increases the risk of treatment-related toxicities. The administration of further treatment for patients who respond (or do not progress) after six cycles of first-line therapy (ie, maintenance therapy) is covered below.

==========

2023-03-21

  • Some patients with type 1 or type 2 diabetes have a paradoxically high GFR early in their disease course (ie, “glomerular hyperfiltration”). Glomerular hyperfiltration is usually defined as GFR approximately 20 percent or more above that in age-matched, healthy controls without diabetes. In younger individuals, the usual threshold for hyperfiltration is considered 120 to 140 mL/min/1.73m2, whereas in older adults it may be closer to 100 to 120 mL/min/1.73m2. In studies of patients with diabetes that measured GFR, hyperfiltration was associated with greater risks of albuminuria progression and kidney function decline. The kidney protective effects of renin angiotensin system (RAS) and sodium-glucose cotransporter 2 (SGLT2) inhibitors are thought to be mediated, at least in part, by reductions in glomerular hyperfiltration.
    • 2023-03-15 eGFR 155.56
    • 2023-03-09 eGFR 134.22
    • 2023-02-22 eGFR 144.16
    • 2023-02-15 eGFR 151.57
    • 2023-02-07 eGFR 147.78
    • 2023-02-01 eGFR 128.28
    • 2023-01-17 eGFR 144.16
    • 2023-01-12 eGFR 155.56
  • No HbA1c readings or blood glucose levels are accessible in HIS5. It is advised to examine whether the patient has developed type 2 diabetes.

2022-12-29

  • According to the 2022-12-28 lab results, the readings were grossly within the normal range, and no dosage adjustment is necessary.
  • Primarily a distal sensory neuropathy, may occur with paclitaxel. Neuropathy can present as a mixture of paresthesias and dysesthesias, including burning, numbness, tingling, and shooting pains, typically in a stocking-glove distribution. Prior to the chemotherapy, 2022-12-09 nerve conduction velocity test suggested neuropathy, 2022-12-07 pure tone audiometry resulted bilateral normal to moderate sensory neural hearing loss. While severe symptoms are unusual, peripheral neuropathy often leads to subsequent dose reductions in many patients.
  • Carboplatin has also been associated with ototoxicity (1%, UpToDate). Although peripheral neuropathy occurs infrequently, the incidence of peripheral neuropathy is increased in patients >65 years of age and those who have previously received cisplatin treatment (not this case).
  • Please keep an eye out for signs of exacerbated adverse reactions as always.

700035817

230320

{not completed}

He was admitted for hemoptysis with blood clot from oral and nasal cavity for more than a week. History of NPC and CT imaging revealed possible tumor recurrence in Jan 2022.

[exam findings]

  • 2023-03-16 CT - neck
    • Chief Complaints: Tongue swealling and left face redness
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
      • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • S/P tracheostomy.
      • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
  • 2023-03-16 CXR
    • S/P tracheostomy in place.
    • S/P Port-A infusion catheter insertion.
    • Ground glass opacity in bilateral lower lungs.
  • 2023-03-16, 2022-12-28, -12-10 ECG
    • Normal sinus rhythm
    • Left axis deviation
    • Abnormal ECG
  • 2023-01-05 CXR
    • S/p tracheal tube placement with its tip in place.
    • Tortous aorta with calcification is noted.
    • Senile fibrotic change is noted at lung fields.
  • 2022-12-22 CT - abdomen
    • History and indication: Respiratory failure
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Right adrenal nodule (9mm). Hyperplasia of left adrenal gland.
      • Right renal cysts (up to 8mm).
      • Normal appearance of liver, spleen, pancreas.
      • Wall thickening of gallbladder with stone (6mm).
      • Patency of portal vein.
      • Fracture of left femoral neck.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac, coronary arteries.
      • S/P Port-A infusion catheter insertion. S/P tracheostomy in place. S/P foley catheter indwelling.
    • IMP:
      • S/P gastrostomy. Mild small bowel ileus.
      • Bil. pleural effusion with adjacent lung consolidation. Some nodules in bil. lungs.
      • Wall thickening of gallbladder with stone (6mm).
      • Fracture of left femoral neck.
  • 2022-12-22 Patho - colon biopsy
    • Colorectum, hepatic flexure, s/p biopsy(A) — Granulation tissue
    • Colorectum, hepatic flexure, s/p biopsy(B) — Hyperplastic polyp
  • 2022-12-16 CT - abdomen
    • The rectum and sigmoid colon show distension and hard feces retention. please correlate with clinical condition.
    • Chronic cholecystitis is highly suspected.
      • The differential diagnosis include gallbladder cancer.
      • Please correlate with sonography.
    • There are few soft tissue nodules in LLL of the lung.
      • Please correlate with chest CT.
    • Hyperplasia of bilateral adrenal gland are noted.
  • 2022-11-05 ECG
    • Sinus tachycardia
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-08-23 CT - neck
    • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
    • Presence of soft tissue swelling over the region of right face and neck with diffuse fat stranding.
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
    • Suggest clinical correlation and previous films comparison.
  • 2022-05-06 CT - neck
    • Indication: NPC cT4bNx, s/p CCRT + adjuvant PF
    • With and Without contrast Neck CT showed
      • s/p tracheostomy
      • s/p graft stent at the right CCA and right ICA with total occlusion.
      • soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
      • mucosal thickening in the bilateral frontal, bilateral ethmoidal, sphenoidal and bilateral maxillary sinuses. Wall thickening in the walls of the bialteral paranasal sinuses was noted.
      • old insult in the right parietal lobe
    • IMP: soft tissue swelling over right neck, carotid space, and skull base, suspected recurrent tumor with infection?
  • 2022-05-05 CXR
    • S/P tracheostomy
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
  • 2022-04-16 Chest PA/AP view
    • S/P tracheostomy.
    • S/P port-A insertion via right subclavian vein.
    • Right lower lung infiltrates.
    • No cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2022-04-16 KUB
    • Calcifications in the pelvic cavity, could be due to phleboliths.
    • Non-specific bowel gas pattern.
    • Mild lumbar spondylosis.
    • Old fractures at left proximal femur.
  • 2022-01-13 Patho - polyps, inflammatory nasal/sinonasal
    • Labeled as “Granulation tissue at nasopharynx”, biopsy — benign squamous mucosa lined tissue with granulation tissue.
    • Labeled as “Granulation tissue at soft palate, poterior pharyngeal wall”, biopsy — squamous cell carcinoma, granulation tissue and necrotic tissue.
      • IHC stain: p16 (-).
    • Labeled as “Granulation tissue around stoma”, biopsy — necrotic tissue.
  • 2022-01-11 CT - CTA, brain (head, neck)
    • Post graft stent (Viabahn, 8x50mm x2) placement at right ICA-CCA.
    • Total occlusion of right ICA and upper-middle part of CCA.
    • But seems with well blood collateral circulation to right ICA, MCA from left AcomA.
    • Presence of soft tissue swelling over right neck, carotid space, and skull base, recurrent tumor with infection?
    • Old right fronto-temporal insult with brain tissue loss due to ICH.
    • S/P tracheostomy in position.
    • S/P Port-A infusion catheter insertion at right jugular/subclavian region.
  • 2021-04-26 KUB
    • Osteopenia of the bony structure is noted.
    • The psoas shadow is clear.
    • Degenerative change of the bony structure with marginal osteophyte formation is identified.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
    • Suggest clinical correlation
  • 2021-04-18 Sinuses
    • Water’s view of the paranasal sinuses showed
      • obliteration of the bilateral paranasal sinuses
      • no evidence of destructive bone lesions
  • 2021-04-18 Neck soft tissue
    • s/p tracheostomy
    • increased soft tissue thickness in the prevertebral soft tissue
    • s/p stenting at the right neck
  • 2021-04-18 CT - neck
    • s/p tracheostomy.
    • s/p stenting at the right ICA and right CCA with air in the luminal region
    • Diffuse soft tissue densities in nasalpharynx, oropharynx; and bilateral retropharyngeal, right carotid and right masticator spaces with diffuse subcutaneous fatty infiltrates and abscess formation in the right masticator space. Recurrent tumor with abscess, or stent extravasation? Suggest clinical correlation.
    • bilateral CPS.
  • 2020-12-06 CT - abdomen, pelvis
    • PE abdomen: Muscle guarding
    • Without contrast Abdomen CT showed
      • unremarkable change in the solid organs, such as liver, pancreas, spleen, and both kidneys, except multiple GB stones, up to 22mm in the largest one.
      • gastrostomy
    • IMP: GB stones.
  • 2020-12-04 Bronchoscopy
    • Bronchitis
    • Tracheomalasia
    • Profuse purulent bronchorrhea s/p bronchial toilet
    • suspected nasopharyngeal tumor with nearly total obstruction
  • 2020-11-17 Nasopharyngoscopy
    • NPC s/p treatment
    • Trachea granulation
  • 2020-10-28 Whole body PET scan
    • In comparison with the previous study on 2018/12/19, glucose hypermetabolism in the right nasopharyngeal wall disappears, indicating NPC with good response to previous therapy. However, there is a new lesion of glucose hypermetabolism in the left vocal cord in this study, suggesting tumor recurrence with hypopharynx involvement.
    • Glucose hypermetabolism in the left level II cervical lymphh nodes, probably reactive change in response to locoregional inflammation.
    • Glucose hypermetabolism in the right pleura and right axillary lymph nodes, the nature is to be determined (inflammation/ infection process, NPC with distant metastasis, or others ?), suggesting follow-up.
    • Glucose hypermetabolism in the right neck, suggesting s/p tracheostomy with inflammation/infection process.
    • Glucose hypermetabolism in hepatic flexure of colon, bilateral shoulders, and left hip, probably benign in nature.
    • Nasopharyngeal cancer s/p treatment with tumor recurrence, rcT4NxM0-1, stage IVA at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-10-18 CT - neck
    • S/P tracheostomy.
    • S/P vascular stenting in right CCA with intraluminal and perivascualr air densities, suspected infection/inflammation.
    • R/O tumor recurrence in nasalpharynx, oropharynx and carotid and masticator spaces (mainly in right side), with cellulitis? Suggest clinical correlation.
    • Multiple enlarged lymph nodes in neck, mediastinum and right axillary regions.
  • 2020-09-09 CT - CTA, brain (head, neck)
    • Total occlusion from the right proximal CCA to the cavernous ICA with air in the stent graft. suspected inflammatory process.
  • 2020-05-27 CT - abdomen, pelvis
    • findings
      • There is an ill-defined mild poor enhancing lesion measuring 3.4 x 1.4 cm in S4 of the liver (Srs:3, Img:23) that may be abscess? please correlate with clinical condition and sonography.
      • There are several gallstones, the size < 1.8 cm), but no evidence of wall thickening, distension or surrounding fatty stranding.
      • Mild swelling of the pancreatic head is suspected. Please correlate with amylase and lipase level.
      • Left adrenal hyperplasia shows stationary.
      • Hyperdense hard Fecal material in the S-colon and rectum.
      • Status post feeding gastrostomy.
      • There is no focal abnormality in the biliary system, spleen & both kidney.
      • There is no ascites or lymphadenopathy.
      • There is no bowel wall thickening, and no bowel obstruction.
      • There is no evidence of intrinsic or extrinsic bladder mass.
      • The abdominal aorta and IVC are grossly unremarkable.
      • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Liver abscess is suspected. please correlate with clinical condition and sonography.
  • 2020-01-06 Carotid angiography bilat
    • IMP: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
  • 2020-01-05 Embolization (TAE) - neuro
    • Indication: Massive bleeding from the oral cavity
    • Angiography of bilateral ECA shows oozing of the mucosa at right side supplied by branches of rigth ECA and active bleeding is found at left side by left ECA.
    • Embolization was done with fine gelatine sponge from bilateral ECAs till decreased blood flow.
  • 2020-01-05 Carotid angiography bilat
    • Right distal CCA blow-out with one pseudo-aneurysm formation. Suggest covered-stent insertion.
  • 2020-01-05 CT - lung/pleura (chest and upper abdomen) (with and without contrast)
    • Ind: hemoptysis, suspected lung hemorrhage, suspected NPC with tumor bleeding
    • Imp:
      • probably oozing or bleeding at hypopharyngeal region.
      • single nodule at left apical lung. suggest follow up.
      • s/p gastrostomy.
      • s/p tracheal tube placement with its tip in place.
    • 2019-11-25 Abdominal Ultrasonography
      • liver parenchyma disease/ incomplete exam of liver
      • gallstones, GB wall thickening
      • pancreas masked
      • spleen not seen
    • 2019-11-25 Phleborheograph, PRG
      • Venous thrombosis at right internal jugular vein; patent right external jugular vein; patent right subclavian vein.
    • 2019-11-13 CT - sinuses for navigator
      • Increased soft tissue in the bilateral posterior nostrils and the nasopharynx. Nature?
      • CPS
    • 2019-11-05 Nasopharyngolaryngoscopy
      • finding: bi sinus s/p FESS, right choana total synechiae (fibrosis between septum, right inferior T and nasal floor), left NP whitish mass, biopsy done
      • diagnosis
        • NPC s/p treatement
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
    • 2019-10-08 Nasopharyngolaryngoscopy
      • finding: right choana synechiae, left NP mass with whitish exudate coating
      • diagnosis
        • Nasopharyngeal lesion, suspect post-RT necrosis, suspected tumor recurrence
        • suggest debridement/excision of nasopharyngeal lesion + choana-plasy +- FESS for CPS
    • 2019-09-20 Repetitive stimulation test
      • Blink Reflex Studies
      • The repetitive stimulation study at frequency of 2Hz showed no typical decremental responses in the examined muscles.
      • Sympathetic Skin Response (SSR)
    • 2019-09-06 MRA - brain
      • General brain atrophy.
      • Hydrocephalus.
      • Bilateral chronic paranasal sinusitis.
      • Bilateral mastoiditis.
    • 2019-08-30 CT - brain
      • Brain atrophy.
      • Paranasal sinusitis, nasal polyps and mastoiditis.
      • Nasopharyngeal and oropharyngeal lesion. DDX: prolapse of nasal polyps, nasopharyngeal tumor. Suggest ENT check up.
    • 2019-07-26 MRI - nasopharynx
      • post-CCRT change with dissue swelling in the bilateral nasopharynx, oropharynx, amd hypopharyn; and anterior neck. Please f/u 3 months later.
    • 2019-05-24 CT - abdomen
      • Senile fibrotic change is noted at lung fields. Some bronchovascular bundle infiltration at right lower lobe is found.
      • Gallstones with borderline wall thickening but the GB is not distended.
    • 2019-05-15 Myocardial perfusion SPECT with persantin
      • Probably attenuating artifact or mild myocardial ischemia at the inferoseptal wall of LV.
      • No post-stress dilatation of the left ventricle.
    • 2019-05-15 Carotid phonoangiograph, CPA
      • Sonographic diagnosis:
        • Mild to moderate atherosclerosis in Rt CCA.
        • Imcomplete study due to poor temporal windows for transcranial insonation.
        • Partial venous thrombus formation or venous stasis was noted in Rt IVJ with blood flow.
        • Adequate total VA flow volume (126 ml/min), indicating absence of Vertebrobasilar insufficiency.
      • Advise clinical correlation.
    • 2018-12-20 MRI - nasopharynx
      • Image staging(AJCC,8th edition): NPC, T1N1Mx, stage II.
    • 2018-12-19 Whole body PET scan
      • Glucose hypermetabolism in the right nasopharyngeal wall, compatible with the primary lesion of nasopharyngeal cancer.
      • Glucose hypermetabolism in the right level II and III cervical lymph nodes, suggesting cancer with regional lymph node involvement.
      • Mild glucose hypermetabolism in the left level IIa cervical lymphh nodes, reactive change in response to locoregional inflammation may show such a picture.
      • Glucose hypermetabolism in both lobes of the thyroid gland, inflammatory change is more likely. Please correlate with other work-up studies if further evaluation is warranted.
      • Nasopharyngeal cancer, cT1N1M0, stage II (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2018-12-10 Surgical pathology level IV
      • Nasopharynx, left, biopsy — Non-keratinizing squamous cell carcinoma
      • The sections show non-keratinizing squamous cell carcinoma, undifferentiated subtype, composed of sheets and scattered spindle-shaped neoplastic cells in lymphoid stroma.
      • IHC: CK(+), p63(+).

[consultation]

  • 2023-03-17 Ear Nose Throat

    • Q
      • This is a 68 years old man had history of (1) NPC cT4bNx, s/p CCRT + adjuvant PF, with long term ventilator status under hospice care, Diabetes mellitus, Hypertension, Reflux esophagitis and duodenal ulcer, Chronic obstructive pulmonary disease, Hypothyroidism, Right distal common carotid artery pseudoaneurysm status post transcatheter arterial chemoembolization and stent insertion, Old intracerebral hemorrhage, Old myocardial infarction, Right internal jugular vein thrombosis, Enlarged prostate.
      • This time he was admitted due to Tongue swealling and left face redness for 2 days.
      • CT done at ER reported:
        • Known a case of nasopharyngeal cancer S/P treatment. Large lobulated heterogeneous enhancing lesion over nasopharyngeal space with involvement of left parapharyngeal space and nasal cavity, favor malignancy.
        • Presence of thick fluid accumulation and thickened mucoperiosteum in the paranasal sinuses, bilateral.
        • Large amount of loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Lab with leukocytosis and bandemia, admission under the impression of progression of NPC with deep neck infection with abscess formation, cannot rule out tumor necrosis.
      • Emperic treatment with brosym was prescribed. The patient’s family request for further surgical treatment for possible symptom relief.
      • We need your expertise for further evaluation of possibilites of surgical drainge of abscess, thank you!
    • A
      • 68 y/o man
        • NPC s/p treatment
        • Oropharyngeal cancer noted since 2022-01 (biopsy of oropharynx on 2022-01-12: squamous cell carcinoma)
        • No further treatment for oropharyngeal cancer
        • Neck CT on 2022-03-16 revealed loculated fluid collection over oropharyngeal & hypopharyngeal space with involvement of right carotid space, favor abscess formation.
      • Suggest antibiotics teatment
        • I & D not recommended because the CT finding was related to his tumor necrosis with 2nd infection (I&D: Incision and Drainage)
        • I will discuss with his family
  • 2023-03-17 Infectious Disease

    • Q
      • Emperic treatment with brosym was prescribed.
    • A
      • This is a case of oropharyngeal & hypopharyngeal abscess with sepsis.
      • Hx NPC s/p op, C/T, ventilator dependent, DM, HCVD.
      • Antibiotcs with meropenem 1g iv q8h is suggested.
      • Please consider debridement.
      • Collect B/C and pus for culture.
      • Please adjust antibiotic according to culture results and clinical conditions.
    • 2021-12-08 ENT
      • Minimal oozing from tracheal wound
      • Portable fiber through tracheal tube: patent airway, no active bleeding site
      • Local treatment done
      • Suggestion:
        • Curam + Paran for Rt. facial cellulitis
        • ENT OPD f/u if needed
    • 2021-05-06 ENT
      • we had changed the trachea already this night but I could not help him to clean the cerumen because the patuient could noy obey our order and he is too heavy that the nurse was hard to move his head
      • we suggested back yo our OPD for crumen removed
    • 2021-05-03 Family Medicine
      • The patient is a case of NPC. This time, he was admitted due to deep neck infection with abscess formation. Due to poor prognosis, we were consulted for further evaluation.
      • When I visited, the patien lied on bed. I asked the nurse about the family’s decision for hospice care. The nurse said that the patient’s wife still need to take the message to other family members. And they didn’t make decision. As a result, I arranged hospice combine care for the patient.
      • Assessment
        • Indication for hospice combine care : NPC with severe infection
        • ECOG 4
    • 2021-04-19 Radiation Oncology
      • Q
        • This 67 year old man is a case of NPC, old CVA, tracheostomy with vewntilation. He suffer form deep neck infection with abscess formation. We need your expertise for pigtail drainage!
      • A
        • According to the clinical condition and imaging findings, drainage is indicated.
    • 2021-04-18 ENT
      • Impression: Deep neck infection with abscess formation, nasopharyngeal carcinoma.
      • Plan:
        • Surgical intervention at the moment is not appropriate owing to high mortality and morbidity rate.
        • Please arrange admission to INFECTION IPD for broad-spectrum antibiotic treatment.
      • Already told the patient to consider hospice care.
    • 2021-03-30 ENT
      • Local finding via portable fiberoscopy:
        • Bil. nasal mucopus and cannot see N-P well, favor post-RT CPS
        • Rt. auricle swelling and EAC cerumen impaction
        • Diffused redness and swelling of Rt. facial, neck and shoulder skin
      • Imp
        • Favor diffused soft tissue infection, suspected post-R/T caused poor circulation
      • Suggestion
        • Keep current Abx
        • If no improvement or even progression, may consider CT for r/o abscess formation
    • 2020-12-24 Rehabilitation
      • Assessment
        • Acute respiratory failure with ventilator support
        • NPC s/p CCRT with airway stenosis s/p tracheostomy
        • Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding s/p TAE with stent
        • COPD with AE
        • DM
        • HTN
        • old CVA with bedridden status
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
      • Goal: recondition, improve endurance and muscle strength, remove endo tube
    • 2020-10-26 Radiation Oncology
      • Assessment: Non-keratinizing squamous cell carcinoma of the nasopharynx, stage cT1N1M0 (stage II), s/p CCRT.
      • Plan: There is no tissue proven of the suspicious area at the present. ENT further evaluation was suggested.
    • 2020-03-18 Mental Health
      • Psychiatric impression
        • Depressive DISORDER WITH SUICIDE ATTEMPT
        • ADJUSTMENT DISORDER WITH DEPRESSED MOOD,
      • Psychiatric history
        • This 66-year-old male patient was brought to this ER due to self-remove trachia this morning. According to his wife, notable depressed mood and insomnia with initial type since diagnosed with NPC. However, his depression was progressed in recent 3 months since he suffered form hemiparesis due to hemoregic stroke. He also note cooperative for rehabilitation and other treatment. Few and nearly no interpersonal interaction. Previosly, he had self-remove trachia during hospitalization.
        • GIVEN-UP COMPLEX, HELPLESSNESS AND HOPELESSNESS
      • Medical history:
        • Nasopharyngeal, left, non-keratinizing squamous cell carcinoma, cT1N1M0, stage II, with right neck LNs, s/p CCRT and Chemotherapy. Intake form grastostomy
        • Diabetes Mellitus type II.
        • Chronic obstructive pulmonary disease.
        • Right distal common carotid artery pseudoaneurysm status transcatheter arterial chemoembolization and stent on 2020/01/06.
      • Suggestion:
        • prevent suicide, well inform the risk and prevention to his family
        • emotional support
        • correct his medical problem as your expertise
        • may give Mirtapine 1# hs for his depression
        • arrange psychiatric OPD follow up
    • 2020-01-12 General and Gastroenterological Surgery
      • Inform the family members (his wife) of the CT results of the brain, and inform that if the anticoagulant continues to be used, it may aggravate the cerebral hemorrhage, but if the anticoagulant is not used, the stent placed in the aneurysm may be blocked.
    • 2020-01-07 Neurology
      • impression: left hemiplegia, suspect R hemisphere subcortical infarction
      • suggestion:
        • agree with current dual antiplatelet agent therapy if no contraindication such as active bleeding
        • arrange brain MRA (without contrast) for stroke survey (consider contrast enhancement for brain metastasis survey)
    • 2020-01-07 Family Medicine
      • When I visited patient, he lied on the bed and his consicousness was drowsy. Interminttent oozing from oral and trochea were found. Tachycardia was found (HR: 120-130/minute). Breathing sound showed no rhonchi or no wheezing. CT on 20200105 showed tumor local invasion and angiography on 20200106 showed no pneudoaneurym formation. Stent for carotid bleeding was done at that time. Due to NPC with local invasion and persisted bleeding, we will arrange hospice combine care for patient first. If his family prefer to receive palliative care, we will discuss with family about further management or PCU admission issue. If family still want to receive aggressive treatment/management, we will keep current combine care first.
    • 2020-01-07 Infectious Disease
      • Bleeding is the major problem now.
      • Despite there is leukocytosis, no definite infection is found at the present time.
      • Because of repeated embolization, temporary coverage of staphylococci, including MRSA/MRSE possibility, is acceptable.
      • Empirical anti-fungal therapy seems not necessary for him.
      • Please repeat CxR film to see if there is newly-developed pneumonia or not.
    • 2020-01-07 Radiation Oncology
      • We have arranged emergent angiography for this patient 20200106 19:00, which revealed right distal CCA blowout, with active bleeding from pseodoaneurysm. Two stents were placed crossing distal CCA and proximal ICA. No more active bleeding is noted after stenting.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2020-01-07 ENT
      • Local finding: Oozing from oral cavity but cannot see the bleeding origin
      • No epistaxis nor bleeding from tracheostomy
      • s/p 10 pieces Bosmin gauze compression, but may still need TAE again
    • 2020-01-04 ENT
      • Scope: should suspect bleeding from tracheal or lung
        • Yellowish mass over bil. nasopharynx, suspected pus (CPS) or tumor
        • Cannot passed the scope into hypopharynx.
      • However, the patient was using tracheal tube “without” side hole -> less likely from nasal or oral cavity
      • Suggestion: consult chest men for lung CT or bronchoscopy
  • surgical operation

    • 2022-01-12
      • Surgery
        • debride the granulation tissue
        • change gastrostomy tube 20fr for him
      • Finding
        • grandulation tissue around the gastrostomy
    • 2022-01-12
      • Surgery
        • Stomaplasty    
        • Biopsy of oropharynx and nasopharynx mucosal lesion       
      • Finding
        • Granulation around the stoma except inferior part    
        • Yellowish semisolid necrotic substance at soft palate, posterior pharyngeal wall, and bilateral nasopharynx; Diffuse mucosal edema and touch bleeding was noted at above areas  
    • 2020-11-11 excision - granuloma around gastrostomy, easy bleeding(+), pain(+)
    • 2020-04-29 Stomaplasty
      • Surgery
        • Stomaplasty + Nasopharyngeal lesion biopsy
      • Finding
        • Stoma stenosis with granulation formation.
        • Whitish exudate like lesion at bilateral nasopharynx.
    • 2021-04-28
      • Surgery
        • Incision and drainage of right masticator space
      • Finding
        • Much bloody discharge and few pus over right masticator space
    • 2020-04-02
      • Surgery
        • laparoscopic gastrostomy
      • Finding
        • NPC
        • difficulty in NG tube insertion
    • 2020-01-06 Embolization (TAE) - neuro
      • Indication: Right distal CCA blow-out with a large pseudoaneurysm and massive active bleeding.
      • TAE was done with two 8x50 mm stent graft (Viabahn Endoprothesis, overlapped on distal CCA), no more contrast leak after this procedure.
      • Imp: Post stent grafting of the large right CCA pseudoaneurysm.
      • Medication: Plavix and Bockey 1# QD at least 3 month, after 3 month Bockey 1# QD life long.
    • 2019-11-20 Nasopharyngeal necrosis and right choana atresia
    • 2019-08-27 Tracheostomy for respiratory failure
      • neck shortness and stiffness, tracheostomy done with Shily #6
    • 2019-06-10 Jejunostomy - Nasopharyngeal cancer post op, for feeding jejunostomy creation
    • 2017-12-26 R’t soft palate tumor
      • 1.3x2mm granular lesion at right soft palate

==========

2023-03-17

[drug identification]

The medication you are requesting drug identification for is Eltroxin, which contains levothyroxine at a dose of 0.05mg.

This medication is used to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone.

The medication will be sent back to the ward by an in-hospital porter.

2022-05-05

  • Lab data on 2022-05-04 showed PT 10.6 sec, INR 1.02, APTT 40.4 sec, Fibrinogen 474.5 mg/dL, D-dimer 982 ng/mL(FEU).
  • Aspirin, warfarin, vitamin K antagonists, DOACs records found in NHI PharmaCloud.
  • Tranexamic acid 500mg IVD Q8H has been prescribed since 2022-05-05.
  • Hemoptysis no longer appears in the problem list. No issue with current medication.

701252793

230320

[diagnosis] - 2023-03-17 admission note

  • Non-Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck
  • Neoplasm of uncertain behavior of brain, unspecified
  • Other cerebrovascular disease
  • Dizziness and giddiness
  • Other localized visual field defect, unspecified eye
  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Personal history of other infectious and parasitic diseases
  • Chronic obstructive pulmonary disease, unspecified
  • Gout, unspecified

[exam findings]

  • 2023-02-07 MRI - brain
    • No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.
  • 2022-10-12 MRI - brain
    • Clinical information: Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma. Primary NHL (Diffuse large B cell lymphoma) of brain
    • Findings
      • Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm).
      • Prominent peri-tumoral edema over left thalams and temporal lobe.
  • 2022-07-13 Body Fluid Cytology - CSF
    • Negative
    • Smears show some small lymphocytes, plasma cells, and monocytes.
  • 2022-07-12 Whole body PET scan
    • A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
    • Mild glucose hypermetabolism in a focal area in the left anterior upper chest wall. Inflammation may show this picture.
    • Increased FDG accumulaton in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
  • 2022-07-11 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
    • Section shows piece(s) of bone marrow with 60 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There is no malignancy present.
  • 2022-07-09 CXR
    • Atherosclerotic change of aortic arch
  • 2022-07-04 CT - lung/mediastinum/pleura
    • No tumor or LAPs in the neck, chest, and upper abdomen.
  • 2022-07-04 CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2022-06-23 Patho - brain biopsy
    • Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
    • Immunohistochemical stain profiles:
      • CD20(diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-).
      • MUM-1(+), C-MYC(+)
  • 2022-06-23 Frozen Section
    • Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm
  • 2022-06-21 CT - brain for navigator
    • Findings
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt.
      • Mild dilated right lateral ventricle.
    • Impression:
      • intra-axial tumor, d/d lymphoma or high grade glioma.
  • 2022-06-20 MRA - brain
    • Left temporal lobe-basal ganglion tumor with mass effect.
    • D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
  • 2021-04-29 SONO - kidney
    • Right renal stone 0.44 cm
  • 2020-09-21 Bronchodilator Test
    • diagnosis: COPD
    • conclusion: normal spirometry

[consultation]

  • 2022-10-20 Radiation Oncology
    • Q
      • The 56 y/o man has primary brain diffuse large B cell lymphoma, CD20 (diffuse+), CD3 (scant + at T- cells), Bcl-2(+), Bcl-6(+), CD56(-), GFAP(-), Ki-67 index: >90%, cyclin D1(-). Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions).
      • Due to brain lesion in progress, so we need your help for RT assessment. Thanks!
    • A
      • The patient’s history was reviewed and patient was examined.
      • S: For radiotherapy due to CNS lymphomas s/p chemotherapy.
        • PI: The patient has primary brain diffuse large B cell lymphoma, Lugano stage 1E. IELSG score 2 (CSF protein elevated and deep lesions) s/p chemotherapy (2022-07-14 ~ 2022-10-21). Due to brain tumor progression, he was referred for radiotherapy.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Previous RT Hx: (-)
      • O: ECOG: 1
        • PE: meck and bil SCF: neg; no motor dysfunction.
        • CXR (2022-06-20): Clean lung fields based on plain image. Normal shape and size of heart. No abnormal mediastinal interfaces, stripes, and lines. Normal appearance of both hila. Costophrenic angles are preserved. Unremarkable of visible trachea
        • MRI of brain (2022-06-20): Left temporal lobe - basal ganglion tumor with mass effect. D/D: lymphoma, metastases, GBM. Infectious process is unlikely.
        • Operation (2022-06-23): Left periventricular tumor for stereotactic biopsy. [Finding]: 1. An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process.
        • Pathology (S2022-10048, 2022-06-29): Brain, left periventricle lesion, stereotactic biopsy — Diffuse large B cell lymphoma
        • CT scan of lung (2022-7-4): no tumor or LAPs in the neck, chest, and upper abdomen.
        • Pathology (S2022-11023, 2022-07-12): Bone marrow, iliac, biopsy — Negative for malignancy.
        • PET (2022-07-12): A glucose hypermetabolic lesion in the left deep temporal lobe of the cerebrum, compatible with lymphoma.
        • CSF (2022-07-13): negative
        • MRI of brain (2022-10-12): 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), Left temporal lobe-basal ganglion (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe.
      • A: Diffuse large B cell lymphoma of the left temporal lobe-basal ganglion area, Lugano stage 1E, s/p chemotherapy, with gross residual tumor.
      • P: Radiotherapy is indicated for this patient with the following indicators: gross residual tumor
        • Goal: curative
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 3060cGy/17 fractions of the whole brain, and 4500cGy/25 frcations of the CNS lymphoma area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-10-26.
  • 2022-07-20 Nephrology
    • Q
      • The 55 y/o man has primary CNS lymphoma post HD-MTX and Mabtherapy treatment.
      • Due to AKI with elevated P and Mg, but no oliguria or SOB, so we need your help for management. Thanks!
    • A
      • Lab:
        • BUN 96, Cr 1.09 -> 9.71, Na 133, K 3.5, Mg 3.2, P 7.6, Ca 2.3
      • Impression:
        • AKI stage 3 suspect methotrexate induced
        • primary CNS lymphoma post HD-MXT and Mabthera
      • Suggestion
        • check urinalysis
        • check vein gas
        • IV hydration with urinary alkalinzation; could also prescribe furosemide
        • Follow up VBG and urinalysis in the following day
        • check I/O and body weight qd
        • avoid nephrotoxic agents
        • indication of dialysis has been explained to the patient and family.
      • We will follow up the case. Thank you very much for your consultation.
  • 2022-07-11 Ophthalmology
    • Q
      • The 55 y/o man has primary CNS lymphoma with right eye blurred vision, so we need your help for management.
    • A
      • O
        • bv od > os, no floaters ou
        • oph denied
        • BCVA od 0.2(0.4x-1.25/-1.50x175) os 0.2(0.2x-0.75/-2.50x180)
        • PT 20/20
        • k clear ou
        • ac d/cl ou
        • lens clear ou
        • conj np ou
        • f’d c/ d 40% ou, media clear no vitritis ou
      • A
        • no ocular involvement ou currently
      • P
      • suggest control underlying disease+inform the symptoms/ signs and opd f/u afterward
  • 2022-06-20 Neurosurgery
    • Q
      • Stroke symptoms (sudden slurred speech/unilateral limb paresthesia/sudden visual impairment) > symptom onset more than 4.5 hours or relieved, right limb and visual field incoordination for two weeks
    • A
      • A case of 55 y/o male; progressive headache (night pain)/blurred vision/gait disturbance for 2 weeks;
      • Drug hx: nil
      • A brain MRI/MRA showed A well-defined irregular-shaped mass with T1-hypointensity, T2-hyperintensity, diffusion restriction and vivid enhancement involving left deep temporal lobe and basal ganglion, associating with perifocal white matter edema and causing mass efect on laterla ventricles and midline structures. Lymphoma is first considered. D/D: metastases, GBM.
      • P: admit for tumor survey; Stereotactic biopsy indicated; HIV?; Explained;

[surgical operation]

  • 2022-06-23
    • Surgery
      • Left periventricular tumor for stereotactic biopsy
    • Finding
      • An irregular-shaped tumor mass with dense enhancement involving the left deep temporal lobe and adjacent posterior basal ganglion, and with significant perifocal white matter edema and causing mass efect on lateral ventricles and resulting mild midline shift to Rt; intra-axial tumor, d/d lymphoma or high grade glioma; Infectious process
      • 3 strips/ 2 targets were apllied for tumor biopsy;
      • Frozen section: lymphocyte/ vascular structure/ inflammation cell?; Favor malignancy. Perminent report will be followed;
      • Culture also sent.
    • Remark: FROZEN SECTION INITIAL DIAGNOSIS: Brain, periventricular lesion, frozen section — hypercellular round blue cell-type neoplasm

[C/T history]

C1D1 (#1) HD-MTX (8000mg/m2) on 2022/7/14, C1D2 Leucovorin (100 mg/m2) q6h until serum methotrexate <0.05 mmol/L and C1D3 Mabthera (375mg/m2) = 750mg on 2022/7/16. Rolican + HS hydration for AKI correct after HD-MTX. Feburic 80mg/tab (Febuxostat) 1# qod for prevent elevated uric acid.

C1D14 (#2) HD-MTX (due to AKI history, so change to 4000mg/m2) on 22022/8/09, Leucovorin 100mg q6h, Mabthera on 2022/8/11. Colchine and dexamethaxone for gouty arthritis treatment on 2022/8/17.

C2D1 (#3) HD-MTX (4g/m2), Covorin, Mabthera on 2022/8/24-8/26. C2D14(#4) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/12-9/14. C3D1 (#5) HD-MTX (4g/m2), Covorin, Mabthera on 2022/9/26-9/28.

2022/10/13 brain MRI: 1. Known a case of primary brain lymphoma. As compared with prior MRI (2022/06/20), marked shrinkage of left thalamus lesion (from 29mm to 12mm). But marked progression of lateral lesions (abutting left occipital horn) (from 15mm to 31mm). 2. Prominent peri-tumoral edema over left thalams and temporal lobe. C3D15 (#6) HD-MTX (8g/m2), Covorin, Mabthera on 2022/10/21-23.

He received the radiotherapy on 2022/11/2 -2022/12/6 with 3060cGy/17 fractions ofthe whole brain, and 4500cGy/25 fractions of the CNS lymphoma area.

C4D1 (#7) HD-MTX (8g/m2), Covorin,Mabthera on 2023/1/6-8. Followed up MRI of brain was performed on 2023/2/8 revealed No brain infarct was seen. Marked shrinkage of left thalamus and left occipital lesion. Marked regression of peri-tumoral edema.

This time, he was admitted for C4D15 (#8) chemotherapy HD MTX/Covorin/Mabthera on 2023/3/17.

[chemoimmunotherapy]

  • 2023-03-17 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2
  • 2023-01-06 - methotrexate 8000mg/m2 16000mg NS 800mL 6hr D1 + rituximab 375mg/m2 745mg NS 500mL 8hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg + NS 250mL] D2

    • 2022-10-21 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-26 - methotrexate 4000mg/m2 7950mg 6hr D1 + rituximab 375mg/m2 745mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-09-12 - methotrexate 4000mg/m2 7980mg 6hr D1 + rituximab 375mg/m2 748mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-24 - methotrexate 4000mg/m2 7880mg 6hr D1 + rituximab 375mg/m2 740mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-08-09 - methotrexate 4000mg/m2 7900mg 6hr D1 + rituximab 375mg/m2 744mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3
    • 2022-07-14 - methotrexate 8000mg/m2 16000mg 6hr D1 + rituximab 375mg/m2 750mg 8hr D3

      • dexamethasone 4mg D1,3 + diphenhydramine 30mg D1,3 + palonosetron 250ug D1 + acetaminophen 500mg D3

[note]

methotrexate (https://www.uptodate.com/contents/methotrexate-drug-information 2022-07-20)

  • Dosing: Adult
    • Primary CNS lymphoma, newly diagnosed (off-label use):
      • IV:
        • 8 g/m2 over 4 hours (followed by leucovorin rescue) every 14 days until complete response or a maximum of 8 cycles; if complete response, follow with 2 consolidation cycles at the same dose every 14 days (with leucovorin rescue), followed by 11 maintenance cycles of 8 g/m2 every 28 days (with leucovorin rescue) (Batchelor 2003)
      • R-MPV regimen:
        • 3.5 g/m2 over 2 hours on day 2 every 2 weeks (in combination with rituximab, vincristine, procarbazine, and leucovorin [with intra-Ommaya methotrexate 12 mg between days 5 and 12 of each cycle if positive CSF cytology]) for 5 to 7 induction cycles followed by reduced-dose whole brain radiotherapy and then cytarabine (Morris 2013; Shah 2007) or autologous stem cell transplant (Omuro 2015)
      • R-MP regimen (patients >=65 years of age):
        • 3 g/m2 over 4 hours on days 2, 16, and 30 of a 42-day cycle (in combination with rituximab, procarbazine, and leucovorin) for 3 cycles (Fritsch 2017)
      • MT-R regimen:
        • 8 g/m2 once every 2 weeks (adjusted for creatinine clearance and in combination with leucovorin, temozolomide, and rituximab) for 7 doses, then followed by high-dose consolidation chemotherapy (Rubenstein 2013)
        • 3.5 g/m2 on weeks 1, 3, 5, 7, and 9 (in combination with leucovorin, temozolomide, and rituximab), followed by whole-brain radiotherapy and then post-radiation temozolomide (Glass 2016).
  • Dosing: Kidney Impairment: Adult
    • Regimen-specific dosage adjustments:
      • Primary CNS lymphoma, high dose methotrexate (usual methotrexate dose: 8 g/m2 over 4 hours with leucovorin rescue [Gerber 2007]); CrCl is measured or can be calculated using the Cockcroft-Gault equation (Gerber 2007): IV:
        • CrCl >=100 mL/minute: No methotrexate dosage adjustment necessary.
        • CrCl 50 to 99 mL/minute: Calculate dose using percentage reduction of CrCl below 100 mL/minute. Example: If CrCl is 80 mL/minute, adjust dose to 0.8 x 8 g/m2 = 6.4 g/m2.
        • CrCl <50 mL/minute: Avoid methotrexate use.

leucovorin (https://www.uptodate.com/contents/leucovorin-drug-information 2022-07-20)

  • Dosing: Adult
    • Methotrexate-rescue, high-dose methotrexate:
      • Initial: Oral, IM, IV: 15 mg (~10 mg/m2); start 24 hours after beginning methotrexate infusion; continue every 6 hours for 10 doses, until methotrexate level is <0.05 micromolar. Monitor hydration and electrolyte status, as well as urine alkalinization. Adjust dose per institutional protocol or as follows:
        • Normal methotrexate elimination (serum methotrexate level ~10 micromolar at 24 hours after administration, 1 micromolar at 48 hours, and <0.2 micromolar at 72 hours):
          • Oral, IM, IV: 15 mg every 6 hours for 60 hours (10 doses) beginning 24 hours after the start of methotrexate infusion.
        • Delayed late methotrexate elimination (serum methotrexate level remaining >0.2 micromolar at 72 hours and >0.05 micromolar at 96 hours after administration):
          • Continue leucovorin calcium 15 mg (oral, IM, or IV) every 6 hours until methotrexate level is <0.05 micromolar.
        • Delayed early methotrexate elimination and/or acute renal injury (serum methotrexate level >=50 micromolar at 24 hours, or >=5 micromolar at 48 hours, or a doubling of serum creatinine level at 24 hours after methotrexate administration):
          • IV: 150 mg every 3 hours until methotrexate level is <1 micromolar, then 15 mg every 3 hours until methotrexate level is <0.05 micromolar.
    • Methotrexate overdose, inadvertent:
      • Note: Begin as soon as possible after overdose.
      • Oral, IM, IV: 10 mg/m2 every 6 hours until the methotrexate level is <0.01 micromolar. If serum creatinine is increased >50% above baseline 24 hours after methotrexate administration, if 24 hour methotrexate level is >5 micromolar, or if 48 hour methotrexate level is >0.9 micromolar, increase leucovorin dose to 100 mg/m2 IV every 3 hours until the methotrexate level is <0.01 micromolar.
    • Methotrexate overexposure, high-dose methotrexate:
      • Leucovorin nomogram dosing for high-dose methotrexate overexposure (off-label dosing; generalized dosing derived from reference nomogram figures, refer to each reference [Bleyer 1978; Bleyer 1981; Widemann 2006] or institution-specific nomogram for details):
        • At 24 hours:
          • For methotrexate levels of >=100 micromolar at ~24 hours, leucovorin calcium is initially dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 24 hours, leucovorin calcium is initially dosed at 100 mg/m2 IV every 3 or 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 24 hours, leucovorin calcium is initially dosed at 10 mg/m2 IV or orally every 3 or 6 hours.
        • At 48 hours:
          • For methotrexate levels of >=100 micromolar at 48 hours, leucovorin calcium is dosed at 1,000 mg/m2 IV every 6 hours.
          • For methotrexate levels of >=10 to <100 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 48 hours, leucovorin calcium is dosed at 100 mg/m2 IV every 6 hours or 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
        • At 72 hours:
          • For methotrexate levels of ≥10 micromolar at 72 hours, leucovorin calcium is dosed at 100 to 1,000 mg/m2 IV every 3 to 6 hours.
          • For methotrexate levels of ~1 to 10 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally to 100 mg/m2 IV every 3 hours.
          • For methotrexate levels of ~0.1 to 1 micromolar at 72 hours, leucovorin calcium is dosed at 10 mg/m2 IV or orally every 3 to 6 hours.
        • If serum creatinine is increased >50% above baseline, increase the standard leucovorin calcium dose to 100 mg/m2 IV every 3 hours, then adjust according to methotrexate levels above.
        • Follow methotrexate levels daily, leucovorin calcium may be discontinued when methotrexate level is <0.1 micromolar.
        • Some regimens use the following equation when calculating the leucovorin calcium dose (if the methotrexate plasma concentration is >5 micromolar) (Ramsey 2018):
          • Plasma methotrexate concentration (micromolar) x body weight (kg)
  • Warnings/Precautions
    • Disease-related concerns:
      • Anemias: Leucovorin is inappropriate treatment for pernicious anemia and other megaloblastic anemias secondary to a lack of vitamin B12; a hematologic remission may occur while neurologic manifestations progress.
      • Renal impairment: Leucovorin is excreted renally; the risk for toxicities may be increased in patients with renal impairment.
    • Concurrent drug therapy issues:
      • Fluorouracil: Leucovorin may increase the toxicity of 5-fluorouracil; deaths from severe enterocolitis, diarrhea, and dehydration have been reported (in elderly patients); granulocytopenia and fever have also been reported.
      • Sulfamethoxazole-trimethoprim: The combination of leucovorin and sulfamethoxazole-trimethoprim for the acute treatment of Pneumocystis jirovecii pneumonia in patients with HIV infection has been reported to cause increased rates of treatment failure.
    • Other warnings and precautions:
      • Folic acid antagonist overdose: When used for the treatment of accidental folic acid antagonist overdose, administer as soon as possible.
      • Methanol toxicity: Leucovorin is the reduced form of folic acid; leucovorin is rapidly converted to tetrahydrofolic acid derivatives, which are the storage forms of folate in the body. Because leucovorin does not require metabolic reduction, it is the preferred form of folate in the treatment of methanol toxicity. Administration during methanol toxicity is especially important in patients with chronic alcohol use disorder as these patients may have chronic folate deficiency. Clinicians should note that leucovorin is an adjunctive therapy and should never be used as the sole intervention in the management of methanol toxicity (AACT [Barceloux 2002]).
      • Methotrexate overdose: When used for the treatment of a methotrexate overdose, administer IV leucovorin as soon as possible. Monitoring of the serum methotrexate concentration is essential to determine the optimal dose/duration of leucovorin; however, do not wait for the results of a methotrexate level before initiating leucovorin. It is important to adjust the leucovorin dose once a methotrexate level is known. The dose may need to be increased or administration prolonged in situations in which methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.
      • Methotrexate rescue therapy: Methotrexate serum concentrations should be monitored to determine dose and duration of leucovorin therapy. Dose may need to be increased or administration prolonged in situations where methotrexate excretion may be delayed (eg, ascites, pleural effusion, renal insufficiency, inadequate hydration). Never administer leucovorin intrathecally.

==========

2023-03-20

  • The patient’s height is 175cm, weight is 80kg, and his lab results from 2023-03-20 showed serum Cre 1.38mg/dL, eGFR 56.65, and CrCl 63~68mL/min.
  • The recommended dosing for methotrexate in adult patients with CNS lymphoma whose CrCl is 50 to 99 mL/minute is to calculate the dose using the percentage reduction of CrCl below 100 mL/minute. For example, if CrCl is 65 mL/minute, the dose should be adjusted to 0.65 x 8 g/m2 = 5.2 g/m2.

2023-02-20

  • The patient’s serum creatinine levels have decreased to nearly the upper limit of normal.
    • 2023-02-02 Creatinine 1.30 mg/dL
    • 2023-01-20 Creatinine 1.54 mg/dL
    • 2023-01-16 Creatinine 1.41 mg/dL
    • 2023-01-13 Creatinine 1.95 mg/dL
    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL

2023-01-10

  • Methotrexate induced acute renal failure is typically nonoliguric and is reversible in almost all cases. Plasma creatinine levels usually peak within the first week and return toward baseline levels within 1 to 3 weeks. The patient’s renal function is decreasing at a much slower rate over time, which is a positive sign that creatinine almost reaches its peak level.

    • 2023-01-10 Creatinine 2.09 mg/dL
    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-10 eGFR 35.09
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-10 BUN 27 mg/dL
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • The likelihood of MTX-induced renal dysfunction in patients receiving high dose MTX can be minimized (but not eliminated) by hydration both to maintain a high urine flow and to lower the concentration of MTX in the tubular fluid and by alkalinization of the urine to a pH above 7.0. Raising the urine pH from 5.0 to 7.0 increases the solubility of MTX 10-fold.

  • It is customary to begin the MTX infusion only after the urine pH is >= 7.0 and to maintain it in this range until plasma MTX levels have declined to less than 0.1 microM.

  • Urinary alkalinization is most easily accomplished by adding ampules of sodium bicarbonate to each liter of IV fluid hydration. This accomplishes both fluid hydration and urinary alkalinization. A typical choice is IV D5W with 100 to 150 mEq of sodium bicarbonate per liter, administered by continuous infusion at 125 to 150 mL/hour. A cation concentration of 80.5 mEq/L is roughly equivalent to one-half normal saline. The amount of bicarbonate in each liter and the IV fluid composition can then be modified according to the urine pH and serum sodium.

  • An alternative oral protocol for sodium bicarbonate can be started with 3000 mg (300mg/tab * 10 tablets) Q6H, and can be escalated the frequency to Q4H as needed; once the urine pH is greater than 7, the 24 hour daily dose can then be lowered and divided into four doses, every six hours.

2023-01-09

  • Lab data indicated that the patient’s renal function is deterioating

    • 2023-01-09 Creatinine 2.02 mg/dL
    • 2023-01-08 Creatinine 1.99 mg/dL
    • 2023-01-07 Creatinine 1.36 mg/dL
    • 2023-01-06 Creatinine 1.01 mg/dL
    • 2023-01-09 eGFR 36.50
    • 2023-01-08 eGFR 37.13
    • 2023-01-07 eGFR 57.61
    • 2023-01-06 eGFR 81.22
    • 2023-01-09 BUN 27 mg/dL
    • 2023-01-08 BUN 26 mg/dL
    • 2023-01-07 BUN 21 mg/dL
    • 2023-01-06 BUN 17 mg/dL
  • In this male patient, who is 56 y/o, Cre 2.02 mg/dL and weighs 82 kg, the estimated CrCl is 47 mL/min. The self-carried Baraclude (entecavir) for patients with CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours. QODAC is preferred.

  • Methotrexate is greater 80% excreted as the unchanged drug and is primarily excreted in the urine. Leucovorin 100mg IVD Q6H has been administered since 2023-01-08 06:05.

  • Serum MTX levels are declining at an apparent rate.

    • 2023-01-08 22:39 3.549 umol/L
    • 2023-01-07 22:36 17.473 umol/L
      • ref Toxic:
        • 24 hr > 10 umol/L
        • 48 hr > 1 umol/L
        • 72 hr > 0.1 umol/L
  • If the patient is still able to urinate normally, furosemide may be an option for helping the excretion of methotrexate. For patients with an eGFR greater than 30 mL/minute/1.73m2, furosemide does not require dosage adjustment.

2022-07-20

  • The dosage of leucovorin 200mg Q6H used immediately following methotrexate has been adjusted to 400mg Q6H as of 2022-07-20. Leucovorin is excreted renally, however there are no dosage adjustments provided in manufacturer’s labeling for kidney impairment patients.
  • Items in the active prescription that should be addressed if kidney function is altered.
    • Keppra (levetiracetam)
      • The manufacturer’s labeling recommends estimating CrCl using the Cockcroft-Gault formula adjusted for BSA as follows: CrCl (mL/minute/1.73 m2) = CrCl (mL/minute)/BSA (m2) x 1.73.
        • CrCl 80 to 130 mL/minute/1.73 m2: 500 mg to 1.5 g every 12 hours.
        • CrCl 50 to <80 mL/minute/1.73 m2: 500 mg to 1 g every 12 hours.
        • CrCl 30 to <50 mL/minute/1.73 m2: 250 to 750 mg every 12 hours.
        • CrCl 15 to <30 mL/minute/1.73 m2: 250 to 500 mg every 12 hours.
        • CrCl <15 mL/minute/1.73 m2: 250 to 500 mg every 24 hours (expert opinion).
    • Baraclude (entecavir)
      • Daily-dosage regimen preferred.
        • CrCl >=50 mL/minute: No dosage adjustment necessary.
        • CrCl 30 to <50 mL/minute: Administer 50% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 48 hours.
        • CrCl 10 to <30 mL/minute: Administer 30% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 72 hours.
        • CrCl <10 mL/minute: Administer 10% of usual indication-specific dose daily. Alternatively, administer the usual indication-specific dose every 7 days.
    • Furosemide
      • eGFR >30 mL/minute/1.73 m2: No dosage adjustment necessary.
      • eGFR <=30 mL/minute/1.73 m2: Higher doses may be required to achieve desired diuretic response due to decreased secretion into the tubular fluid. However, single doses >160 to 200 mg IV (or oral equivalent) are unlikely to result in additional diuretic effect (Brater 2011).
  • CrCl is 10 mL/min and eGFR is 7 mL/min for this patient based on Cockcroft-Gault formula, CKD-EPI equation and 2022-02-20 updated lab data.

701469357

230320

[lab data]

2023-03-17 Anti-HBc Nonreactive
2023-03-17 Anti-HBc-Value 0.18 S/CO
2023-03-17 Anti-HCV Nonreactive
2023-03-17 Anti-HCV Value 0.17 S/CO
2023-02-03 Anti-HCV Nonreactive
2023-02-03 Anti-HCV Value 0.10 S/CO
2023-02-03 HBsAg Nonreactive
2023-02-03 HBsAg (Value) 0.49 S/CO
2023-02-03 Anti-HBs 1.12 mIU/mL
2023-02-02 MTBC PCR NOT DETECTED
2023-02-02 MTBC PCR Value <11.8 CFU/ml

[exam findings]

  • 2023-03-12 CT - abdomen
    • Clinical history: 51 y/o male patient with cough, headache, chills, fever since this morning, mild nausea, loose stool
    • With and without contrast enhancement CT of abdomen - whole:
      • S/P feeding jejunostomy.
      • Thickening wall at the middle/distal third esophagus, c/w esophageal cancer, with ulceration at left lateral wall with adjacent lung consolidation.
      • Left pleural effusion.
      • There are enlarged lymph nodes in bilateral SCF, pretracheal, subcarina, around GE junction, r/o metastatic lymph nodes.
      • Left renal cyst, 0.8cm.
      • Unremarkable change of the liver, spleen, pancreas and right kidney.
    • Impression:
      • S/P feeding jejunostomy.
      • Esophageal cancer with ulceration and adjacent left lung consolidations, left pleural effusion.
      • Multiple metastatic lymph nodes in lower neck, mediastinum and upper abdomen.
  • 2023-03-12 CXR
    • S/P port-A insertion via left subclavian vein.
    • Increased bilateral lung markings.
    • No cardiomegaly.
    • Thoracic spondylosis.
  • 2023-02-17 Patho - gingival/oral mucosa biopsy
    • Diagnosis:
      • Uvula, wide excision (S2023-2822A) with frozen section (F2023-65) — poorly differentiated carcinoma and sarcomatoid carcinoma.
      • Hypopharyngeal tumor, wide excision (S2023-2822B) — squamous cell carcinoma in situ (CIS), < 1 mm from unspecified margin.
      • Uvula: pT1 pNx (if cM 0); pStage: I.
      • Hypopharynx: pTis pNx (if cM0); pStage: 0.
    • Macroscopic examination
      • Surgical Procedure(s): uvula: wide excision with frozen section. Hypopharynx: wide excision.
      • Specimen Type:
        • Main location: S2023-2822A: uvula; B: hypopharynx.
        • Other part(s) included: F2023-00065A: posterior margin; B: anterior margin.
        • Lymph node dissection: no.
      • Specimen Integrity: intact
    • Microscopic examination
      • Histologic Type: 01: uvular tumor: poorly differentiated carcinoma and sarcomatoid carcinoma. 02. hypopharyngeal tumor: carcinoma in situ (CIS).
      • Histologic Grade: 01: uvular tumor: G3: Poorly differentiated
      • Microscopic Tumor Extension: (specify) submucosa.
      • Margins (obtained from the main resection specimen):
        • Margins uninvolved by invasive carcinoma, uvular tumor:
          • Distance from closest margin: gin and posterior margin. 4 mm. Anterior margin and posterior margin. NOTE: This distance does not include the size of frozen section specimens.
        • Margins uninvolved by squamous cell carcinoma in situ (left hypopharynx)
          • Distance from closest margin: 1 mm. Unspecified margin
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: no lymph node submitted.
  • 2023-02-11 MRI - larynx
    • p16(+) Oropharnx
      • Impression (Imaging stage): T: 0(T_value) N: 2c(N_value) M: 0(M_value) STAGE: IVA(Stage_value)
  • 2023-02-08 Nasopharyngoscopy
    • whitish lesion over posterior side of uvula, smooth NPx, granular lesion over left hypopharynx
  • 2023-02-04 MRI - brain
    • MRI of the brain in multiplanar projections, multisequences imaging acquisition without and with IV Gd-DTPA administration shows:
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2023-02-04 Pure Tone Audiometry
    • PTA:
      • Reliability FAIR
      • Average RE 38 dB HL, LE 43 dB HL
      • Bil normal to moderatly severe SNHL
  • 2023-02-03 Whole body PET scan
    • Glucose hypermetabolism involving the middle to lower portions of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in a left upper paratracheal lymph node, some bilateral supraclavicular lymph nodes and a lymph node in the upper abdomen near EG junction. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in a focal area in the middle lobe of right lung. Inflammation may show this picture. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • Glucose hypermetabolism in the uvula, hypopharynx, nasopharynx, bilateral parotid glands, some bilateral upper neck lymph nodes, soft palate and bilateral tonsils. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Increased activity in the lower T-spines and L4-5 spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
  • 2023-02-02 Patho - larynx biopsy
    • Labeled as “hypopharynx”, biopsy — squamous cell carcinoma in situ (CIS).
  • 2023-02-02 Patho - nasopharyngeal/oropharyngeal biopsy
    • Labeled as “uvula”, bronchoscopic biopsy — Sarcomatoid carcinoma.
    • Section shows diffuse infiltration of spindle shaped neoplastic cells.
    • IHC stain: Vimentin (diffuse +), CK (focal +), p16 (-).
  • 2023-02-01 Patho - esophageal biopsy
    • Soft palate, left, biopsy — Squamous cell carcinoma in situ
  • 2023-02-01 Cardiopulmonary Exercise Testing
    • summary:
      • low exercise capacity ( VO2 75%, WR 76%)
      • low stroke volume response during exercise
      • normal HR response slope
      • normal ventilatory function ( FVC 102%, FEV1 94%)
      • No SpO2 desaturation during exercise
      • Poor expiratory muscle strength (MIP 77%, MEP 51%)
      • Health-related quality of life, CAT= 0, good
    • suggestions:
      • treat underlying condition
      • for low stroke volume response, suggest to intake adequate fluid, may survey cardiac function
      • arrange pulmonary rehab with exercise training after operation
      • low risk for operation
  • 2023-01-30 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2023-01-30 Patho - esophageal biopsy
    • Esophagus, 30 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated (G2)
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
  • 2023-01-28 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Highly suspected esophageal cancer, M-L/3, s/p biopsy
      • Incomplete study
    • Suggestion
      • Admission for parenteral nutrition and staging.
      • Watch out for refeeding syndrome.

[radiotherapy]

[chemotherapy]

  • 2023-03-16 - cisplatin 80mg/m2 130mg NS 500mL 4hr + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-2 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

701473264

230316

[drug interaction]

  • Histamine H2 Receptor Antagonists may decrease the absorption of dasatinib. Dasatinib prescribing information states histamine H2 receptor antagonists (H2RAs) should not be coadministered with dasatinib due to the risk of reduced dasatinib concentrations and efficacy. Given the longer-term acid suppression achieved with H2-antagonist or proton pump inhibitor therapy, the manufacturer suggests the use of antacids (with 2-hour dose separation) if acid-reducing therapy is required. The likely mechanism for this apparent interaction is impaired absorption of dasatinib, which does appear to display pH-sensitive solubility, due to the increase in gastric pH caused by a H2-receptor antagonist.

  • Currently, the patient is prescribed Sprycel (dasatinib) and Ulstop (famotidine) with a QD and BID frequency, respectively. These medications are being administered at the same time of 09:00. To prevent any potential drug interactions, it is recommended to shift the administration time of one of the medications to a time that does not overlap with the other medication.

700180610

230315

[exam findings]

  • 2023-02-20 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (76 - 29) / 76 = 61.84%
      • M-mode (Teichholz) = 61
    • Adequate LV systolic function with normal resting wall motion
    • Trivial MR and trivial TR
    • Preserved RV systolic function
  • 2023-02-01 whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
  • 2023-01-30 Her-2/neu in situ hybridization
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION: BREAST
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number: S2023-1401
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
    • RESULT OF HER2/NEU IN SITU HYBRIDIZATION : LYMPH NODE
      • Negative: There is NO amplification of HER2 detected
      • METHOD AND DETAILS:
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 gene copy signal per cell: 1.8
        • Average number of CEP17 gene copy signal per cell: 2
        • HER2/CEP17 ratio: 0.9
        • Heterogeneous signals: Absent
        • Origin slide and block number:S2023-1402
        • Specimen: Formalin-fixed paraffin embedded breast tumor
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hydridization: CISH (Ventana HER2 dual ISH DNA probe cocktail assay, Roche compancy)
      • INTERPRETATION CRITERIA (ASCO/CAP scoring criteria 2018)
        • Amplified:
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number >=4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=6.0 signals/cell
        • Not amplified:
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number <4.0
          • HER2/CEP17 ratio <2.0 with an average HER2 gene copy number >=4.0 and <6.0 signals/cell
          • HER2/CEP17 ratio >=2.0 with an average HER2 gene copy number <4.0
  • 2023-01-30 Patho - breast biopsy (no need margin)
    • Breast, right, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 Patho - lymphnode biopsy
    • Lymph node, right axillary, core biopsy — Invasive carcinoma, no special type, NST.
    • Section shows fragments of lymph node tissue with irregular neoplastic ducts infiltration.
    • IHC stains (using block: S2023-1401): ER (+, 95%, strong intensity), PR(-, 0%), Her2/neu: equivocal (score=2+), Ki-67(50%), E-cadherin (+). An additional report of Her2 DISH will be followed.
  • 2023-01-30 CT - chest
    • Indication: Unspecified lump in breast
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images, and oblique sagittal reconstructed images of the Rt breast shows:
      • chest wall: a large Rt breast solid soft-tissue tumor (93mm in longest axial dimension) with surrounding linear opacities (lymphatic drainage) and skin involvement, and many metastatic lymph nodes at Rt axilla.
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
      • Visible abdominal contents: a low density focus (24mm) in the uterus, cystic lesion or necrotic myeoma.
        • mltiple stones with collapsed gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. no ascites..
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast cancer with Rt axillary LNs metastasis T4N1
  • 2023-01-20 SONO - breast
    • Findings
      • Parenchymal pattem
        • Loosely (inhomogeneously) sonodense
      • Focal sonographic lesion
        • right breast huge tumor, with skin involvement, heteogenous, > 10cm, favor malignancy
        • LAP(+)
    • Diagnosis
      • Highly suspicious of malignancy,with sonographic positive axillary LAP
    • Treatment
      • Core-needle biopsy
    • Suggestion and Plan
      • Regular OPD follow-up
      • BI-RADS 5 - Highly Suggestive of Malignancy (>95% malignant) Appropriate Action Should Be Taken

[chemotherapy]

  • 2023-03-14 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-02-20 - doxorubicin 60mg/m2 100mg NS 100mL 10min + cyclophosphamide 600mg/m2 1000mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

Granocyte (lenograstim 250ug/vial) CGRAN01 - 2023-03-02 ~ 2023-03-04 - 250ug QD SC - IPD 2023-03-02

[assessment]

  • On 2023-01-30, the Her-2/neu in situ hybridization results indicated a negative status for both breast and lymph nodes.
  • On 2023-03-02, a grade 4 neutropenia event was observed in the patient with a WBC count of 930/uL and Neutrophil count of 18%. Following the administration of three consecutive days of lenograstim since that day, no further episodes of neutropenia have been observed up to the present time.
  • Please prescribe Baraclude (entecavir) 0.5mg tablets, one tablet daily, for the patient’s underlying hepatitis B virus infection.

700541242

230315

{Malignant neoplasm of body of stomach; gastric antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy}

[diagnosis] - 2023-02-04 discharge note

  • Gastric  antrum, pT4aN0M1, stage IV status post radical subtotal gastrectomy with lymph node dissection and B-II gastrojejunostomy
  • Hepatits B, anti-HBC:positive

[past history]

  • Hypertension
  • right shoulder s/p operation 7+ years ago at NTUH                                        

[allergy]

  • NKDA                             

[family history]

  • Denied family history of cancer and mental diseases.
  • No members of the family with diabetes.  

[exam findings]

  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at left brachiocephalic vein
    • Emphysematous change over both lungs.
    • Osteopenia of the bony structure is noted.
  • 2023-01-25 CT - abdomen
    • s/p subtotal gastrectomy.
    • Minimal ascites in the abdominal cavity is found.
  • 2023-01-25 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Abnormal ECG
  • 2023-01-02 CT - abdomen
    • History and indication: gastric cancer wt peritoneal seeing, pT4aN0M1, stage IV
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction.
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P gastric operation.
      • Bronchiectasis at RML, RLL and LLL.
      • Retroversion of uterus.
      • Atherosclerosis of aorta.
    • IMP:
      • S/P gastric operation. No evidence of tumor recurrence.
      • Bronchiectasis at RML, RLL and LLL.
    • 2023-01-02 CXR
      • Borderline cardiomegaly
      • Scoliosis of the T-spine with convex to right side.
    • 2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30 Body fluid cytology - ascites and others
      • Negative
    • 2022-08-01, -07-29, -07-27, -07-26, -07-24 CXR
      • Ground glass opacities in bil. lungs.
    • 2022-07-24 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Suboptimal study due to much blood and blood clot were noted upon entering stomach.
        • Post subtotal gastrectomy with Billroth II anastomosis
        • Suspicious gastrojejunal anastomosis site ulcers, Forrest calssification IIa and Ib, s/p hemostasis with submucosal epinephrine injection and clipping
      • Suggestion
        • NPO
        • High dose PPI use
        • suggest second-look endoscopy
    • 2022-07-20 CXR
      • Pneumoperitoneum.
      • Right catheterization to SVC in position.
      • Left catheterization to SVC in position.
      • S/P NG tube indwelling.
      • Ground glass opacity in bilateral lower lungs and RUL.
      • Blunted bilateral costophrenic angles.
    • 2022-07-19 Patho - stomach subtotal/total
      • pathologic diagnosis
        • Stomach, subtotal gastrectomy — Poorly cohesive carcinoma, signet-ring cell type
        • Margins, bilateral cutting ends, subtotal gastrectomy — Free of tumor invasion
        • Lymph nodes, D2 LN dissection — Negative for malignancy (0/47)
        • Omentum, subtotal gastrectomy — Metastatic carcinoma
        • AJCC Pathologic staging — pT4aN0M1, stage IV
      • microscopic examination
        • Histologic type: Poorly cohesive carcinoma, signet-ring cell type (Lauren classification: diffuse type)
        • Histologic grade: Poorly differentiation (G3)
        • Depth of tumor invasion: Tumor invades the serosa
        • Margins: All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin: 2 mm from radial margin
        • Perineural invasion: Present
        • Lymphovascular space invasion: Absent
        • Regional lymph nodes: Negative for malignancy (0/47)
          • 0/7 (LN 1), 0/7 (LN 3), 0/1 (LN 4), 0/3 (LN 5), 0/3 (LN 6), 0/26 (LN 7, 8, 9, 11p, 12a), 0 (LN14v) (Number of LN involved/Number of LN examined)
        • Duodenum: Involved by carcinoma
        • Omentum: Metastatic carcinoma
        • Additional pathologic findings: Reactive gastropathy
        • Pathologic Staging: pT4aN0M1 (stage IV)
        • IHC (S2022-10770): HER2 (negative, score=1+)
        • Ascites Cytology: Negative
    • 2022-07-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (91.5 - 28.5) / 91.5 = 68.85%
        • Normal chamber size
        • Adequate LV and RV systolic function
        • AV sclerosis with trivial AR, trivial MR, TR and PR
        • No regional wall motion abnormalities
    • 2022-07-08 Double contrast upper GI series
      • Findings
        • Normal appearance of the esophagus.
        • There is no evidence of abnormal mucosal pattern at the stomach.
        • Intact EG junction.
        • The gastric angle is intact.
        • Decreased peristasis with poorly opacified gastric pylorous.
      • Imp:
        • Decreased peristasis with poorly opacified gastric pylorous.
    • 2022-07-07 MRI - upper abdomen
      • Suboptimal study due to motion.
      • Hepatic hemangioma. S4/8
      • Enhanced mucosa at gastric pylorous is found. Nature?
    • 2022-07-07 Patho - stomach biopsy
      • Stomach, pyloric ring, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by individual tumor cells infiltratiion. Immunohistochemistry of CK(+) and Her2 (-, Dako score 1+) for tumor. Besides, mild intestinal metaplasia is also noted.
    • 2022-07-06 SONO - abdomen
      • Diagnosis: Hepatic hemangima, right lobe
    • 2022-07-06 Esophagogastroduodenoscopy, EGD
      • Esophagus: Confluent mucosal breaks more than 75% with fagile mucosa and superficial ulcers were noted from EC junctiob to 25cm below the incisors.
      • Stomach: Upon entry, much food debris was noted in stomach. Mucosal swelling was noted at pylori ring, causing pylori stricture that the scope could not pass through. Biopsy *6 was performed the pylori ring.
      • Duodenum: Not checked
      • Diagnosis
        • Incomplete study
        • Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related
        • Pylori stricture, s/p biopsy
      • Suggestion
        • Please pursue pathology report
    • 2022-07-05 CT - abdomen
      • Addendum Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a(T_value) N:N1(N_value) M:M0(M_value) STAGE:III(Stage_value)
    • 2022-07-05 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider inferior ischemia
      • ST & T wave abnormality, consider anterolateral ischemia
      • Prolonged QT

[consultation]

  • 2022-07-13 General and Gastrointestinal Surgery
    • Q
      • This 69 years old female has the history of hypertension
      • This time, she came to ER for persisit vomit with dizzness in recently 2 weeks, she ver been to LMD but invain. She denied fever or chills, dyspnea or chest pain , abdomen pain, tarry or bloody stool passage recently. She also denied TOCC history.
      • At ER, physical exammination revealed abdomen soft without tenderness and acitve bowel sound. Lab data showed impaird renal function, hyponatremia hypokalemia and the Non-contrast CT of abdomen-pelvis revealed: Bronchiectasis at RML, RLL and LLL. Distention of stomach and dilatation of esophagus. Retroversion of uterus. Initial NG was placed at ER and coffee ground was noted and gastric juice showed OB 3+. KCAL fluid was given to correct hypokalemia. Under the impresion of Vomit, hypokalemia, she was admitted to GI wrd for further management.
      • EGD was perfromed and reported Incomplete study Reflux esophagitis, LA D, with ulcers formation, suspected vomiting related Pylori stricture, s/p biopsy. The pathology reported Poorly cohesive carcinoma with signet-ring cell differentiation. we need your expertise. Thanks~
    • A
      • please arrange heat echo for pre-op survey
      • TPN for nutrition support
      • we will take over for this case
      • further operation will arrange on next week

[surgical operation]

  • 2022-07-18 Radical subtotal gastrectomy and B-II gastrojejunostomy
    • Tumor visible at antrum at lesser curvature of antrum
    • Ring-like tumor about 3cm width at pyloric antrum
    • cT4aN1M0

[chemoimmunotherapy]

  • 2023-02-21 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 470mg NS 250mL 2hr + fluorouracil 2000mg/m2 2350mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-02 - oxaliplatin 60mg/m2 70mg D5W 250mL 2hr + leucovorin 400mg/m2 450mg NS 250mL 2hr + fluorouracil 2000mg/m2 2300mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL

    • 2023-01-09 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-22 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2400mg/m2 2840mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-12-08 - oxaliplatin 70mg/m2 80mg 2hr + leucovorin 400mg/m2 450mg 2hr + fluorouracil 2400mg/m2 2760mg 46hr

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-17 - oxaliplatin 40mg/m2 47mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2360mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-25 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 470mg 2hr + fluorouracil 2000mg/m2 2370mg 46hr + [docetaxel 30mg/2 35mg IP 1hr + cisplatin 30mg/m2 35mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-09-13 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-30 - oxaliplatin 40mg/m2 50mg 2hr + leucovorin 400mg/m2 490mg 2hr + fluorouracil 2000mg/m2 2470mg 46hr + [docetaxel 30mg/2 37mg IP 1hr + cisplatin 30mg/m2 37mg IP 1hr + gentamicin 40mg IP 1hr + sodium bicarbonate 2800mg IP 1hr]

      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-08-08 - mitomycin-C 15mg/m2 20mg 2hr D2-3 + [fluorouracil 500mg/m2 645mg IP 1hr D1-5 + gentamicin 40mg IP 1hr D1-5 + sodium bicarbonate 2800mg IP 1hr D1-5]

==========

2023-03-15

  • According to available lab data since 2022-07-05 in HIS5, the patient has experienced frequent occurrences of hyponatremia, hypopotassemia, hypokalemia, and hypomagnesemia. However, during the same time frame, there have been few instances of hyper- or hypophosphatemia.

  • The patient began receiving FOLFOX treatment in August 2022, and the use of carboplatin in this treatment regimen can be associated with hyponatremia, hypokalemia, hypomagnesemia, and hypocalcemia.

  • It is recommended to continue monitoring the patient’s electrolyte levels and prescribe supplements as needed. If it becomes challenging to maintain a balance of electrolytes through supplementation, it may be necessary to consider reducing the dose of carboplatin or switching to a different regimen.

2023-02-22

  • A low serum magnesium level of 1.6mg/dL (2023-02-21) has been observed, and the patient has been prescribed MgSO4 injections and MgO tablets appropriately.
  • Apart from hypomanesia, the patient’s other laboratory readings were within normal limits, and their vital signs have remained stable throughout this hospitalization.

2023-01-10

  • There has been a frequent low level of magnesium in the patient’s blood for months, this hospital currently has only magnesium oxide tablets available for oral administration, so it is recommended to continue prescribing MgO when he is discharged.
  • MgO should be taken with food and at least 240mL of water (absorption: oral up to 30%). Patients might be educated that whole grains, legumes, and dark-green leafy vegetables are dietary sources of magnesium.

2022-12-09

  • As multiple body fluid (primarily ascites) cytological studies (2022-11-18, -11-17, -10-27, -10-26, -10-04, -09-14, -09-13, -09-01, -08-30) did not reveal evidence of malignancy, intraperitoneal chemotherapy was discontinued while systemic FOLFOX is continued.

  • The lab serum magnesium levels indicated a frequent deficiency of serum magnesium in this patient.

    • 2022-12-08 Mg (Magnesium) 1.4 mg/dL
    • 2022-11-16 Mg (Magnesium) 1.7 mg/dL
    • 2022-10-17 Mg (Magnesium) 2.0 mg/dL
    • 2022-10-14 Mg (Magnesium) 1.5 mg/dL
    • 2022-10-11 Mg (Magnesium) 1.8 mg/dL
    • 2022-10-03 Mg (Magnesium) 1.8 mg/dL
  • For the magnesium sulfate prescription will expire on the weekend, a lab data renewal may assist in determining whether the magnesium supplement should continue to be administered.

2022-10-26

  • Body weight has decreased by almost 10 kg in the last 3 months (33.1kg 2022-10-25 <- 42.8kg 2022-07-27 gastrectomized), and a low albumin level (3.2 g/dL 2022-10-25) could indicate malnutrition. Long-term survival may be adversely affected by malnutrition after gastrectomy for gastric cancer (ref: Impact of Malnutrition After Gastrectomy for Gastric Cancer on Long-Term Survival. Ann Surg Oncol. 2018;25(4):974-983. doi:10.1245/s10434-018-6342-8)

  • It is advisable to begin strict nutritional follow-up as soon as possible after surgery in order to prevent a sharp weight loss in the early postoperative phase when most of the dietary problems arise.

  • Vitamin B12 injections might be required, as well as multivitamins and minerals.

  • As this patient’s weight is approximately equivalent to that of a ten-year-old child, the dosage might need to be adjusted accordingly.

2022-09-13

  • Metoclopramide might enhance the CNS depressant effect of lorazepam. The patient should be monitored for signs of increased CNS depressant effects (e.g. somnolence, drowsiness).

700909334

230315

[diagnosis]

  • Malignant neoplasm of overlapping sites of corpus uteri
  • Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV with obstructive Lt lung collapse; ECOG = 3.
  • Secondary malignant neoplasm of retroperitoneum and peritoneum
  • Thalassemia, unspecified
  • Gastrointestinal hemorrhage, unspecified
  • Allergy, unspecified, initial encounter
  • Dysthymic disorder
  • Insomnia due to other mental disorder
  • Constipation, unspecified
  • Chronic viral hepatitis B without delta-agent

[past history]

  • uterus leiomyosarcoma with bone meta, liver and lung metastases s/p OP, pazopanib target therapy with progression and chemotherapy (cisplatin and ifosphamide).
  • Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105~0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110~1224) at Tri-service General Hospital, under current radiation therapy.
  • Gastro-esophageal reflux disease with esophagitis, LA grade D
  • Thalassemia
  • Positive infection of COVID-19 on 2022/05/16

[exam findings]

  • 2023-03-09 CT - brain
    • Clinical information: This 62 y/o female patient has the history of metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilateral salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence
    • Cranial CT scans from the vertex to the mid-maxillary level were performed with i.v. contrast injection.
    • Impression:
      • One enhancing nodular lesion (7mm) over right parietal lobe, favor a metastatic lesion.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2023-02-08 CTA - chest
    • Indication: Malignant neoplasm of overlapping site
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and coronal slab MIP PA images shows:
    • Comparison was made with previous CT dated on 2022/12/08
      • Lungs: extensive heterogeneous consolidation with air-bronchograms at left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases.
      • Mediastinum and hila: enlarged LNs in the Rt hilum and intrapulominary LLL.
      • Aorta: normal caliber of thoracic aorta.
      • Central pulmonary arteries: normal caliber and well opacification
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt effusion extending to major fissure, Rt pleural metastasis and thickening.
      • Chest wall and visible lower neck: unremarkable.
      • Visible abdominal-pelvic contents:
        • multiple large metastatic hepatic tumors, small metastatic tumors at left kidney and Rt adrenal gland, and a large metastatic tumor at RUQ of abdomial cavity. a large tumor at pelvic cavity involving adjacent organs.
        • small ascites is visible.
    • Impression: Leiomyosarcoma of uterus with multiple sites of metastases, in progression as compared with the previous CT on 2022/12/08
  • 2023-02-08 CXR
    • Extensive heterogeneous consolidation in left perihilar lung region and multiple randomly distributed pulmonary nodules of varying sizes due to metastases
    • Port-A catheter inserted into superior RA via left subclavian vein.
    • Diffuse hepatomegaly.
    • Normal heart size.
  • 2023-02-02 CXR
    • There are multiple nodular opacity projecting in both lung that are c/w metastases after correlate with CT.
    • S/P metalic autosuture at left lower lung.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
  • 2023-01-25 CXR
    • Cardiomegaly is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Mass like lesion at left upper lobe with nodular lesions at both lungs is found.
  • 2023-01-04
    • A nodular opacity projecting in the left upper lung is suspected. Please correlate with CT.
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
    • S/P metalic autosuture at left lower lung.
  • 2022-12-13
    • Multiple nodules at bil. lungs.
    • Patch density at LUL.
  • 2022-12-08 CT - chest
    • Indication: Leiomyosarcoma s/p C/T
    • Chest and Abdominal CT with and without enhancement revealed:
      • Chest:
        • S/p port-A placement with its tip at Superior vena cava.
        • Nodular lesions at both lungs up to 3.6cm at right lower lobe is found. In comparison with CT dated on 2021-09-21, the lesion enlarged.
        • Left hilar infiltration is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • s/p ATH and BSO.
        • Soft tissue nodule at right pelvic side wall up to 4.6cm in largest dimension. In progression.
        • Soft tissue mass near uncinate process of the pancreas is found. The lesion enlarged.
        • Low density lesions at both lobes of liver up to 6.4cm in largest dimension is found. In enlargement.
        • The urinary bladder is well distended without soft tissue lesion.
        • Right adrenal enlargment up to 3.09cm is found. In progression. Suggest clinical correlation
    • Imp:
      • s/p ATH and BSO.
      • Residual tumor at pelvis about 4.6cm with liver, lung, right adrenal and uncinate process meta. In progression.
  • 2022-11-15 CXR
    • Progression of left pleural effusion as compare with CXR on 2022-09-21. Suggest clinical correlation.
    • S/P port-A insertion via left subclavian vein.
    • Multiple lung tumors, suspected lung metastasis, progression.
  • 2022-09-21 CT - abdomen
    • History: uterine leiomyosarcoma
      • 20220330 CT from TSGH: a heterogeneous mass 14 cm in the RUQ of abdomen,surround by C-loop of duodenum. Suspected metastasis.
      • 20220524 CC:UGI bleeding, gastroscopy:One 2cm ulcerative mass covering with fresh blood just distal to papilla. Patho:metastatic uterus leiomyosarcoma,
      • 20220623 CT:R/O metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • Indication: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG 2. s/p palliative RT on 2022/06/07.
    • MD CT (64 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • Prior CT identified a metastasis measuring 3.3 cm in S6 of the liver is noted again, mild decreasing in size to 3 cm.
        • However, There are two newly-developed poor enhancing masses measuring 4.3 cm in S4/5/8 and 1.2 cm in S7 of the liver that are c/w newly-developed metastases.
      • Prior CT identified multiple metastases on both lower lung are noted again, mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
      • S/P hysterectomy.
      • There is mild left pleural effusion.
      • There is a poor enhancing lesion measuring 1.2 cm in left kidney middle pole, nature? Please correlate with sonography.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, spleen & right kidney.
        • There is no ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Two newly-developed liver metastases in S4/5/8 and S7.
      • Multiple lung metastases show mild increasing in size.
      • Prior CT identified metastasis in between the pancreatic head and duodenum is noted again, marked decreasing in size.
  • 2022-09-21, -08-15 CXR
    • Multiple lung tumors, suspected lung metastasis.
    • Regression of left pleural effusion as compare with CXR on 2022-08-15, -07-19.
  • 2022-07-19 CXR
    • Total white-out of left lung and mediastinum shift to left side is noted that may be left lung collapse?
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • There are few nodular opacity projecting in both lung hat may be metastases. Please correlate with CT.
  • 2022-06-28 Abdomen Decubitus LT
    • Left Pleura effusion and left lung volume decrease.
  • 2022-06-28 CXR
    • Left pleural effusion.
    • Deviation of trachea.
    • Multiple nodules at right lung.
  • 2022-06-23 CT - abdomen
    • History and indication: metastatic uterus leiomyosarcoma
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Multiple nodules in right lung.
      • A poor enhancing tumor (3.3cm) at S6 of liver.
      • Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
    • IMP:
      • S/P hysterectomy.
      • Left pleural effusion with adjacent lung collapse. Lung and liver metastases. Suspected metastases at pancreatic head and duodenum with duodeno-colon fistula.
  • 2022-05-24 Patho - stomach biopsy
    • Duodenum, just distal to papilla, biopsy (A) — Leiomyosarcoma.
    • IHC stains: desmin (+), CD117 (-), CD34 (-), dog-1 (-), CK (-), melan-A (-), Ki-67: 90%.
    • Section shows 1 piece(s) of benign duodenal tissue and 1 piece of neoplastic spindle cell tumor with markedly enlaged and hyperchromatic nuclei.
  • 2022-05-24 Colonoscopy
    • No active bleeder nor blood clot was noted during this exam, but few tarry stool residual was noted
    • Diverticula, cecum and ascending colon
    • Mild internal hemorrhoid
  • 2022-05-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcerative tumor, 2nd portion, s/p biopsy (A)
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric polyps, body, s/p biopsy (B)
      • Gastric erosion, middle body, PW site, s/p biopsy (C)
    • Suggestion
      • Suggest Abdominal CT with contrast (if not contraindicated) to DDx the duodenal lesion.
      • Keep high dose PPI therapy for 3-5 days
      • If acitive bleeding, consider angiography for embolization and surgical intervention. Endoscopic treatment is NOT suitable for such bleeding lesion.
      • Pursue the result of pathology report
  • 2022-04-13 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA grade D
      • Superficial gastritis
      • Incomplete study
    • Suggestion
      • Consider temporary NG tube for decompression
      • PPI use for severe reflux esophagitis
      • Consider 2nd look endoscopy if active bleeding or persistent tarry stool
  • 2022-04-11 ECG
    • Sinus tachycardia
    • Right atrial enlargement
    • Rightward axis
    • Pulmonary disease pattern
    • Abnormal ECG
  • 2022-04-11 Abdomen -Standing (Diaphragm)
    • There are few nodular opacity projecting in both lung that may be metastases. Please correlate with CT.
  • 2021-03-23 CT (performed at another hospital?)
    • There are several small nodules (maximal size: about 1.7 cm) in all lobes (im:87) showing no change in size in comparison with the prior study obtained on 2020-12-02, lung metastasis is suspected. Suggest get tissue diagnosis
    • Multiple hypodense lesions in the spleen. Suggest correlate with abdomen CT study

[consultation]

  • 2023-01-05 Oral and Maxillofacial Surgery
    • Q
      • This is a 62-year-old female who has the underlying disease of the following below: 1. Metastatic uterus leiomyosarcoma, FIGO stage IB, AJCC T1bN0M0 status post staging laparotomy with extrafascial hysterectomy + bilaterla salpingo-oophorectomy + bilateral pelvic and para-aortic LNs dissection + omentectomy + peritoneal washing on 2016/09/26 with vaginal reccurence, status post transvaginal tumor excision on 2017/12/25 status post 6 courses of adjuvant chemotherapy with Paclitaxel plus Carboplatin (20180105-0430) with lung metastases and bone metastases, status post 5 courses of chemotherapy with Cisplatin, Ifosfamide and Mensna (20211110-1224) at Tri-service General Hospital, under current radiation therapy. 2. Gastro-esophageal reflux disease with esophagitis, LA grade D 3. Thalassemia 4. Positive infection of COVID-19 on 2022/05/16.
      • For throbbing pain in upper left tooth, we need your further evaluation and management. (throbbing pain consists of recurring achy pains, may also experience pounding, beating, or pulsing pain.)
    • A
      • deep caries of tooth 26 was noticed.
      • But due to unstable hemodynamic status, Hb = 3.1 g/dL, blood transfusion was performed at ward
      • we suggested symtpom relief/pain relief (NSAID if no contraindicated/gastric ulceration)
  • 2022-07-01 Radiation Oncology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB, patient asks for RT for treamtent.
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis s/p to RUQ tumor from 2022-04-27 to 2022-06-07 with duodeno-tumor fistula and intermittent tumor bleeding; left pleural effusion with adjacent lung collapse, due to tumor obstruction of left main bronchus; ECOG = 2.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: Metastatic tumor at left main bronchus.
          • Technique: VMAT & IGRT (OBI).
          • Dose & Fractionation: 2400cGy/6 fractions.
          • Expected benefits: about 60-70% chance to open the left bronchus, improve breathing, and last for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction. Possible toxicity (malaise, radiation esophagitis and pneumonitis) is told. CT simulation is arranged on 2022-07-04 15:30pm. Treatment will be started on next Tuesday or Wednesday if feasible.
        • Hospice care is also suggested. It has been recommended that family members be prepared for the best and the worst. Infection, bleeding, and other metastases may pose a threat at any time to the patient. Get to know the wisdom of letting go at the right time and adapt anticipatory grief accordingly.
  • 2022-06-30 Family Medicine
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. This time she has left lung collapse with SOB and abdomen CT with duodeno-colon fistula, can’t do the surgical intervention. Due to terminal stage, so we need your help for share care. Thank you.
    • A
      • When I visited, the patient lied on bed and her caregiver stood by her. She still wanted to receive palliative radiotherapy. After discussion, I decided to arrange hospice combine care for this patient.
      • Current condition: 62 y/o metastatic uterus leiomyosarcoma
      • Indication for hospice combine care: metastatic uterus leiomyosarcoma
  • 2022-06-28 General and Gastroenterological Surgery
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula. So we need your help for surgical indication management. Thank you.
    • A
      • S: Gastroenterological SurgeryDue to UGI bleeding, surgical intervention is consulted.
      • O:
        • vital signs: stable, no fever
        • HEENT: pale conjunctiva, OU
        • abdomen: soft, ovoid, normal bowel sound, RUQand epigastric tenderness, no rebounding pain
        • lab data: see chart
      • A: uterus leiomyosarcoma with multiple metastases,suspect duodeno-colon fistula and UGI bleeding
      • P:
        • Please arrange panendoscopy and colonoscopy for bleeding source and duodeno-colon fistula and possible hemostasis
        • Please use high dose PPI and keep blood transfusion if onging GI bleeding
        • If UGI bleeding is not well control after medication, blood trasfusion, and GI scope hemostasis, TAE is preferred than operation in stage IV case.
  • 2022-06-27 Gastroenterology
    • Q
      • The 62 y/o female has metastatic uterus leiomyosarcoma with liver, multiple lung, omentum, pelvis, left kidney metastasis, stage IV. Due to abdomen CT showed metastases at pancreatic head and duodenum with duodeno-colon fistula and stool ob 4+ with anemia Hb: 6.6d/dL. So we need your help. Thanks!
    • A
      • EGD on 20220524 showed a duodenal ulcerative tumor in 2nd portion, which was compatible with the CT finding
      • But the colonoscopy at the same time did not showed evidence of fistula
      • CT scan (20220623) reported a large tumor located between duodenum and pancreatic head region with suspicious duodeno-colonic fistula. Though, intraperitoneal free air accumulated below liver could not be ruled out.
      • Imp: Duodenal or pancreatic head tumor (suspected metastasis) with duodeno-colonic OR duodeno-peritoneal fistula
      • Suggestion:
        • Consult GS for surgical indication
        • Keep on PPI for the sign of UGI bleeding due to the duodenal tumor
  • 2022-04-25 Radiation Oncology
    • A
      • Diagnosis: Metastatic uterus leiomyosarcoma, 14-cm tumor at RUQ with compression and invasion of duodenum, complicated with UGI bleeding, and liver, multiple lung, omentum, pelvis, left kidney metastasis; ECOG = 3.
      • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan may be designed as the following one:
          • Target & Volume: RUQ tumor.
          • Technique: VMAT.
          • Dose & Fractionation: 2500-3000cGy/10-12 fractions.
          • Expected benefit: about 30-40% chance to improve tumor bleeding and obstruction, lasting for about 1-2 months.
      • Plan: Palliative R/T is suggested for tumor obstruction and bleeding. Possible toxicity (malaise, vomiting, radiation gastritis and enteritis) is told. CT simulation is arranged on 20220426 16:00pm. Treatment will be started on Wednesday if feasible.
        • It is recommended that the patient’s spouse and children make an appointment with me to listen to the explanation of the condition and discuss the treatment goals; it is recommended to continue to arrange the hospice ward.

[radiotherapy]

s/p palliative RT on 2022/06/07 (RUQ tumor), 2022/07/18 (left hilum), 2022/08/05 (left hilum), 2022/10/21 (liver, SBRT), 2023/01/02 (LUL).

  • 2023-01-03 ~ 2023-01-19 - 2500cGy/10 fractions (15 MV photon) to duodenal tumor
  • 2022-12-12 ~ 2023-01-02 - 4500cGy/15 fractions (6 MV photon) to LUQ tumors
  • 2022-10-11, -13, -17, -19, -21 - 5000cGy/5 fractions (15 MV photon) to liver tumors over right lobe
  • 2022-08-01 ~ 2022-08-16 - 4200cGy/12 fraction (6 MV photon) to L main bronchus tumor & other 2 tumors
  • 2022-07-05 ~ 2022-07-18 - 2400cGy/6 fractions (6 MV photon) to left main bronchus tumor
  • 2022-04-27 ~ -05-06, -05-15 ~ -06-01, -06,07 - 3000cGy/15 fractions (15MV photon) to RUQ tumor

[immunotherapy]

  • 2023-03-14 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-20 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-02-03 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2023-01-09 - nivolumab 3mg/kg 100mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL
  • 2022-12-19 - nivolumab 3mg/kg 200mg NS 100mL 30min
    • diphenhydramine 30mg + NS 250mL

==========

2023-03-15

  • Based on the available data, this patient’s HGB level has consistently remained below the lower limit of normal and requires blood transfusions to prevent it from dropping further.
    • 2023-03-13 HGB 6.4 g/dL
    • 2023-03-08 HGB 7.4 g/dL
    • 2023-03-02 HGB 8.2 g/dL
    • 2023-02-15 HGB 8.0 g/dL
    • 2023-02-08 HGB 9.3 g/dL
    • 2023-02-02 HGB 8.7 g/dL
    • 2023-01-31 HGB 10.1 g/dL
    • 2023-01-25 HGB 7.7 g/dL
    • 2023-01-25 HGB 6.6 g/dL
    • 2023-01-17 HGB 8.5 g/dL
    • 2023-01-09 HGB 8.9 g/dL
    • 2023-01-07 HGB 7.9 g/dL
    • 2023-01-04 HGB 3.1 g/dL
    • 2022-12-18 HGB 10.5 g/dL
    • 2022-12-15 HGB 4.9 g/dL
    • 2022-12-13 HGB 8.8 g/dL
    • 2022-12-07 HGB 6.5 g/dL
    • 2022-11-15 HGB 6.1 g/dL
    • 2022-10-18 HGB 6.4 g/dL
    • 2022-09-20 HGB 7.2 g/dL
    • 2022-08-30 HGB 7.9 g/dL
    • 2022-08-16 HGB 6.9 g/dL
    • 2022-07-19 HGB 11.3 g/dL
    • 2022-07-10 HGB 9.1 g/dL
    • 2022-07-06 HGB 7.1 g/dL
    • 2022-06-28 HGB 8.4 g/dL
    • 2022-06-26 HGB 6.6 g/dL
    • 2022-06-23 HGB 8.9 g/dL
    • 2022-06-21 HGB 8.9 g/dL
    • 2022-06-15 HGB 6.8 g/dL
    • 2022-06-07 HGB 8.8 g/dL
    • 2022-05-30 HGB 10.0 g/dL
    • 2022-05-27 HGB 9.3 g/dL
    • 2022-05-26 HGB 9.4 g/dL
    • 2022-05-25 HGB 5.1 g/dL
    • 2022-05-23 HGB 9.6 g/dL
    • 2022-05-22 HGB 5.8 g/dL
    • 2022-05-21 HGB 9.6 g/dL
    • 2022-05-17 HGB 10.8 g/dL
    • 2022-05-12 HGB 9.4 g/dL
    • 2022-05-05 HGB 8.0 g/dL
    • 2022-04-27 HGB 10.0 g/dL
    • 2022-04-25 HGB 10.3 g/dL
    • 2022-04-24 HGB 8.3 g/dL
    • 2022-04-24 HGB 9.7 g/dL
    • 2022-04-18 HGB 7.9 g/dL
    • 2022-04-14 HGB 8.0 g/dL
    • 2022-04-12 HGB 6.8 g/dL
    • 2022-04-08 HGB 11.4 g/dL
    • 2021-05-04 HGB 10.4 g/dL
    • 2020-09-09 HGB 10.0 g/dL
  • This patient has received nivolumab immunotherapy 5 times since 2022-12-19 and has undergone multiple rounds of radiotherapy between late April 2022 and late January 2023. It is unlikely that anemia can be solely attributed to nivolumab, as hematologic immune-related adverse events from nivolumab occur less frequently and the exact mechanism of anemia is unknown. However, they are typically non-dose-related. The anemia in this patient may also be caused by other factors, such as the multiple rounds of radiotherapy she has undergone.

2023-03-14

  • Advanced uterine leiomyosarcoma (ULMS) remains an incurable disease in most cases, and despite new drug approvals, improvements in overall survival have been modest at best. Microsatellite instability and/or high tumor mutational burden are distinctly uncommon in uterine LMS, perhaps explaining the lack of activity of immunotherapy agents observed in phase II trials in LMS.

    • ref:
      • Immunotherapy with single agent nivolumab for advanced leiomyosarcoma of the uterus: Results of a phase 2 study. Cancer. 2017;123(17):3285-3290. doi:10.1002/cncr.30738
      • Pembrolizumab in advanced soft-tissue sarcoma and bone sarcoma (SARC028): a multicentre, two-cohort, single-arm, open-label, phase 2 trial [published correction appears in Lancet Oncol. 2017 Dec;18(12 ):e711] [published correction appears in Lancet Oncol. 2018 Jan;19(1):e8]. Lancet Oncol. 2017;18(11):1493-1501. doi:10.1016/S1470-2045(17)30624-1
  • Based on the available lab data in HIS5 since 2020-09-09, the patient’s HGB level has never reached the lower limit of normal. In 2023, the patient has received her 7th blood transfusion during this hospitalization.

  • There is no medication reconciliation issue found in the patient.

2023-02-21

  • 2023-02-08 CT showed disease progression compared to 2022-12-08 CT.
  • The patient has had a relatively low blood pressure of around 100/70 and a slightly elevated resting heart rate of around 90 during her hospital stay. Adequate hydration may be beneficial in this situation.

2023-02-03

  • Tramectedin is an alkylating agent approved for the treatment of unresectable or metastatic soft tissue sarcomas (liposarcomas or leiomyosarcomas). It is a temporary purchase item in this hospital and could be a subsequent option if nivolumab becomes less effective. For patients previously treated unresectable/metastatic liposarcoma or leiomyosarcoma: IV 1.5 mg/m2 as a continuous infusion over 24 hours once every 3 weeks; continue until disease progression or unacceptable toxicity.
    • ref:
      • Efficacy and Safety of Trabectedin or Dacarbazine for Metastatic Liposarcoma or Leiomyosarcoma After Failure of Conventional Chemotherapy: Results of a Phase III Randomized Multicenter Clinical Trial. J Clin Oncol. 2016;34(8):786-793. doi:10.1200/JCO.2015.62.4734
      • Doxorubicin alone versus doxorubicin with trabectedin followed by trabectedin alone as first-line therapy for metastatic or unresectable leiomyosarcoma (LMS-04): a randomised, multicentre, open-label phase 3 trial. Lancet Oncol. 2022;23(8):1044-1054. doi:10.1016/S1470-2045(22)00380-1
      • The Role of Trabectedin in Soft Tissue Sarcoma. Front Pharmacol. 2022;13:777872. Published 2022 Feb 23. doi:10.3389/fphar.2022.777872

2022-04-15

[tube feeding]

  • All the oral drugs can be administered with a nasogastric tube.
  • The coadministration of fentanyl, diphenhydramine, and estazolam may enhance the CNS depressant effect, please observe for signs of slowed or difficult breathing, and/or sedation.

701388511

230315

{not completed}

{angioimmunoblastic T cell lymphoma, high grade with neck, inguinal, retroperitoneal LN metastases and generalized skin rashes, Lugano stage III, PS:0}

[lab data]

  • PSA
    • 2022-08-08 PSA 8.100 ng/mL
    • 2022-07-15 PSA 7.360 ng/mL

[exam findings]

  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, right, needle biopsy — Prostatic adenocarcinoma (Gleason score = 7 = 4 +3 ) involving 3 of 6 strips of prostatic tissue by the number of involved strips or 50 % by the involved volume of the specimen.
    • The neoplastic glands are 34betaE12 (-) and AMACR (+) with IHC stain.
    • Histologic Type: Prostatic adenocarcinoma
    • Histologic Grade: Gleason score = 7 = 4 + 3
    • Tumor Quantitation: For needle biopsy: Proportion of prostatic tissue involved by tumor: 3 of 6 strips of prostatic tissue by the number of strips or 50 % by the volume of the specimen.
  • 2022-08-08 Patho - prostate needle biopsy
    • Prostate, left, PSA = 7.360, needle biopsy — stromal and glandular hyperplasia with multiple foci of chronic inflammation. All prostatic glands are 34betaE12 (+) and AMACR (-) with IHC stains.
  • 2022-06-10 SONO - neck
    • Some LNs in bil. neck.
  • 2022-05-12 PET scan (at Cardinal Tien Hospital)
    • Malignant lymphoma with bilateral sides of neck LNs, submental LNs, mediastinal LNs, bilateral axillary LNs, hepatoduodenal ligament LNs, retroperitoneal LNs, bilateral iliac chain LNs and bilateral inguinal LNs involvement.
  • 2022-05-11 Patho - neck (at Cardinal Tien Hospital)
    • high grade lymphoma, favor T-cell lymphoma, angioimmunoblastic T cell lymphoma is compatible.
    • CD3:(+/diffuse), BCL:(+/diffuse), CD20(-), CD10(+), CD4(+), CD21(+) for follicular dendritic cells, CD8(+), EBV(-), MIB-1: highly increasing proliferative index for tumor cells.
  • 2022-05-05 SONO - abdomen (at Cardinal Tien Hospital)
    • fatty liver, hepatic cyst, GB wall thickening, Intra abdominal LN, renal cyst and splenomegaly.
  • 2022-04-28 CT - neck (at Cardinal Tien Hospital)
    • extensive lymphadenopathy at bilateral neck, upper mediastinum on 2022/4/28.
  • Initial presentation
    • body weight loss 10kg in one month and neck lymphadenopathy

[chemoimmunotherapy]

  • 2022-08-14 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-25 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-07-04 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5
  • 2022-06-10 - cyclophosphamide 750mg/m2 1600mg 30min + doxorubicin 50mg/m2 100mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-5

[family meeting minutes]

  • In the family meeting, the attending physician Dr. Gao explained the process and precautions of autoPBSCT to the patient and his family members (sister and brother-in-law). The patient expressed his willingness to fully cooperate. However, the patient has been married before and his only daughter is currently studying in the United States and is unaware of her father’s medical condition.

  • The patient’s family support may be insufficient before and after the scheduled transplantation. The nursing station will assist in coordinating caregiver arrangements. The attending physician reminded the patient to inform his daughter about his condition, and the patient indicated his understanding.

701313188

230314

[diagnosis] - 2023-03-13 admission note

  • Diffuse large B-cell lymphoma, extranodal and solid organ sites
  • Localized swelling, mass and lump, neck
  • Chronic sinusitis, unspecified
  • Temporomandibular joint disorder, unspecified

[past history]

Medical history: HTN, Chronic rhinosinusitis

Operation history: - glaucoma - s/p Parotidectomy, left、submandibular gland tumor excision, left - s/p Port-A insertion, L’t after L’t cephalic vein exploration         

[allergy]

  • NKDA     

[family history]

Denied family history

[exam findings]

  • 2023-02-17 SONO - abdomen
    • Liver cysts
    • Gallbladder adenomyomatosis
    • Splenomegaly
  • 2023-02-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (131 - 54) / 131 = 58.78%
      • 2D (M-simpson) = 59
    • Mildly dilated LV with mild hypokinesia of inferior wall, mid-to-apical posterior wall; preserved LV systolic function.
    • Normal RV systolic function.
    • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Aortic valve sclerosis; midl MR; trivial TR.
    • Mildly dilated aoartic root and proximal ascending aorta (35 mm)
  • 2023-02-14 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Negative for malignancy.
  • 2023-02-10 CXR
    • Solitary pulmonary nodule at RUL.
  • 2023-02-09 Whole body PET scan
    • Glucose hypermetabolism in a left posterior upper neck lymh node and in the right submandibular gland. Lymphoma should be watched out.
    • Glucose hypermetabolism in a focal area in the region about left aspect of soft palate and in the region about right posterior gingiva. The nature is to be determined (inflammation? lymphoma?). Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in the left parotid and left submandibular areas. Post-operative inflammation may show this picture.
    • Mild glucose hypermetabolism in some bilateral neck level II lymph nodes, in a focal area in the left anterior upper chest and in a focal area in the lower lobe of left lung. Inflammatory process is more likely.
    • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulation may show this picture.
  • 2023-01-27 Patho - salivary gland resection
    • DIAGNOSIS:
      • A: Salivary gland, left parotid, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • B: Salivary gland, left parotid, inferior pole of deep lobe, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • C: Salivary gland, left parotid, superior pole of deep lobe, parotidectomy — Negative for malignancy
      • D: Salivary gland, left parotid, superior margin, parotidectomy — Diffuse large B-cell lymphoma, non-GCB type
      • E: Salivary gland, left submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F: Lymph node, left, level Ib, dissection — Diffuse large B-cell lymphoma, non-GCB type
      • G: Salivary gland, left residual submandibular gland, excision — Diffuse large B-cell lymphoma, non-GCB type
      • F2023-00041
        • Parotid gland, left, biopsy — Diffuse large B-cell lymphoma, non-GCB type
    • GROSS DESCRIPTION:
      • A: Specimen submitted in formalin consists of a piece of left parotid gland weighing 28.0 gm and measuring 4.7 x 4.7 x 2.5 cm. On cut, there is a gray, solid tumor measuring 4.0 x 3.0 x 1.7 cm. The tumor is involving the anterior, superior, inner resection margins, and 1.2 cm, 0.7 cm, and 0.1 cm away from the posterior, inferior, and outer resection margins. The parenchyma elsewhere is unremarkable. Representative sections are taken and labeled as A1-6: tumor (A1: superior: ink black, outer: ink green, inner: ink yellow; A2: inferior: ink black, outer: ink green, inner: ink yellow; A3: anterior; A4: posterior).
      • B: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 1.8 x 1.0 x 0.3 cm. All for section in a cassette B.
      • C: Specimen submitted in formalin consists of 3 pieces of tan, irregular tissue measuring up to 0.8 x 0.6 x 0.2 cm. All for section in a cassette C.
      • D: Specimen submitted in formalin consists of a piece of tan, irregular tissue measuring 1.4 x 0.8 x 0.6 cm. All for section in a cassette D.
      • E: Specimen submitted in formalin consists of a piece of left submandibular gland tissue measuring 5.0 x 3.0 x 2.4 cm. On cut, there is a gray, solid tumor measuring 3.7 x 3.0 x 2.4 cm. The tumor is involving the peripheral resection margin. Representative sections are taken and labeled as: E1-2: the same level.
      • F: Specimen submitted in formalin consists of 4 level Ib lymph nodes, measuring up to 1.1 x 0.7 x 0.5 cm. All for section in a cassette F.
      • G: Specimen submitted in formalin consists of a piece of left residular submandibular gland tissue measuring 1.8 x 1.4 x 0.6 cm. On cut, there is a gray, solid tumor almost involving the whole specimen. The tumor is involving the peripheral resection margin. The specimen is bisected and all for section in a cassette G.
      • F2023-00041
        • Specimen submitted in fresh consists of a piece of tan, irregular tissue measuring 0.7 x 0.3 x 0.2 cm. All for section in a cassette for frozen examination.
    • MICROSCOPIC DESCRIPTION:
      • A: Sections show salivary gland with diffusely infiltration of large lymphoid cells. The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(-), CD10(-), MUM1(+), Cyclin D1(-), and c-MYC(-). The Ki-67 is about 20-30%. The results are consistent with diffuse large B-cell lymphoma, non-GCB type.
      • B: Section shows salivary gland with infiltration of large lymphoid cells.
      • C: Section shows salivary gland without infiltration of large lymphoid cells.
      • D: Section shows salivary gland with infiltration of large lymphoid cells.
      • E: Sections show salivary gland with diffusely infiltration of large lymphoid cells.
      • F: Section shows 4 lymph nodes with infiltration of large lymphoid cells.
      • G: Section shows salivary gland with diffusely infiltration of large lymphoid cells.
      • F2023-00041
        • Section shows salivary gland with diffusely infiltration of large lymphoid cells and marked crushed artifact.
  • 2022-12-20 CT - neck
    • CT scans of the neck from the level of hard palate to the level of infraclavicular region using a 64-sliced multi-detector row volumetric CT after intravenous injection of 100 c.c. iodinated contrast agent.
    • Coronal reformation was performed. The slice thickness is 5 mm.
    • Findings:
      • One well-defined nodular lesion (3.6cm) within left parotid gland, showing homogeneous enhancement. May be a benign mixed tumor. Suggest tissue proof.
      • The oral cavity shows no evidence of focal lesion.
      • The mouth floor and submandibular regions are normal. No focal lesion is identified.
      • Relative hypertrophy of left submandibular gland.
      • The thyroid appears normal in size and enhancement.
      • Effacement of left pyriform sinus.
  • 2022-12-19 Nasopharyngoscopy
    • Findings: synechia between R middle T and septum; bilateral middle T polypoid change with clear to whitish mucus; smooth nasopharynx, oropharynx, hypopharynx.
    • Diagnosis/Conclusion: chronic rhinosinusitis

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 50mg BID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-02-16 - rituximab 375mg/m2 646mg NS 500mL 8hr D1 + [cyclophosphamide 750mg/m2 1292mg NS 250mL 30min + liposome doxorubicin 30mg/m2 52mg D5W 250mL 1hr + vincristine 1.4mg/m2 2mg NS 50mL 10min] D2 + prednisolone 60mg/m2 20# as 7#, 7#, 6# TID PO D2-6 (R-CDOP)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2

[assessment]

  • The patient’s underlying hypertension is well controlled with Exforge (amlodipine 5mg + valsartan 160mg) currently and there were no medication reconciliation issues.

701328032

230314

[diagnosis] - 20221219 admission note

  • Malignant neoplasm of stomach, unspecified
  • Mixed hyperlipidemia
  • Chronic gastric ulcer without hemorrhage or perforation
  • Ulcer of esophagus without bleeding

[exam findings]

  • 2022-12-22 Body fluid cytology - ascites
    • atypia
  • 2022-12-14 CXR
    • Atherosclerosis of the aorta.
  • 2022-11-14 CXR
    • Ground glass opacity in bilateral lower lungs.
    • Left pleural effusion.
  • 2022-11-11 Patho - gallbladder (benigh lesion)
    • Gallbladder, laparoscopic cholecystectomy — acute cholecystitis, compatible with cholelithiasis
  • 2022-11-11 Patho - stomach biopsy
    • Diagnosis:
      • Stomach, antrum, partial gastrectomy — Poorly differentiated adenocarcinoma
      • Lymph node 1, dissection — Metastatic adenocarcinoma ( 1 / 5 )
      • Lymph node 3, dissection — Metastatic adenocarcinoma ( 2 / 2 )
      • Lymph node 4, dissection — Metastatic adenocarcinoma ( 3 / 7 )
      • Lymph node 5, dissection — Metastatic adenocarcinoma ( 1 / 1 )
      • Lymph node 6, dissection — Metastatic adenocarcinoma ( 3 / 6 )
      • Lymph node, unspecified, dissection — Metastatic adenocarcinoma ( 2 / 7 )
      • Lymph node 14, dissection — Negative for malignancy ( 0 / 1 )
      • Omentum, omentectomy — Negative for malignancy
      • AJCC 8th edition pathology stage:pT4aN3a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Partial gastrectomy, distal
      • Tumor Site: Antrum
      • Tumor Size: 5.5x 4.2 cm
      • Gross configuration - For advanced carcinoma (Borrmann classification): Type III: Ulcerated with poorly defined infiltrative margins
      • Sections are taken and labeled as: F2022-530FS:margin, A1:D-margin, A2-12:tumor, B:LN1, C:LN3, D:LN4, E:LN5, F:LN6, G1-2:lymph node, H:LN14, I:omentum
    • Microscopic Description:
      • Histologic Type
        • Adenocarcinoma
        • Lauren classification of adenocarcinoma: Intestinal type
      • Histologic Grade: G3: Poorly differentiated
      • Tumor Extension: Tumor invades the serosa (visceral peritoneum)
      • Margins
        • Proximal margin: uninvolved by invasive carcinoma
        • Distal margin: uninvolved by invasive carcinoma
        • Radial margin: involved by invasive carcinoma
      • Lymphovascular Invasion: present
      • Perineural Invasion: present
      • Regional Lymph Nodes
        • Number of lymph nodes examined/involved: 12 / 29
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
          • m (multiple primary tumors) r (recurrent) y (posttreatment)
        • Primary Tumor (pT)
          • pT4a: Tumor invades the serosa (visceral peritoneum)
        • Regional Lymph Nodes (pN)
          • pN3a: Metastasis in seven to 15 regional lymph nodes
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case)
          • Not applicable
      • Additional Pathologic Findings
        • None identified
        • Intestinal metaplasia
      • Ancillary Studies : None
      • Comment(s): None
  • 2022-11-05 CT - chest
    • A nodule at RML. Emphysema at bil. lungs.
    • Gastric antral cancer with outlet obstruction and regional LAP.
    • Left adrenal tumor (1.7cm).
    • Gallbladder stones (up to 1.3cm).
    • A calcified spot (6mm) at right subphrenic region.
  • 2022-11-01 Flow Vlume Test
    • mild obstructive impairment
  • 2022-10-31 Patho - stomach biopsy
    • Stomach, antrum, biopsy — Adenocarcinoma, moderately differentiated
    • The secvtions show a picture of adenocarcinoma, moderately differentiated, composed of cuboidal neoplastic cells, arranged in tubular and papillary patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
  • 2022-10-31 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Advanced gastric cancer with obstruction, Borrmann type III, antrum, s/p biopsy*3
      • Reflux esophagitis LA grade D
      • Incomplete study
    • Suggestion
      • NG decompression
      • Follow up pathology result
  • 2022-10-28 ECG
    • Normal sinus rhythm
    • Right bundle branch block
    • Abnormal ECG
  • 2022-10-26 CT - abdomen
    • History: hunger epigastric pain for months, being told to have one huge ulcer at antrum, tissue proved adenocarcinoma (2022-10-04) refer to GS Dr.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the gastric antrum, measuring 1.5 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are five enlarged nodes in the gastrohepatic ligament and hepatoduodenal ligament that may be metastatic nodes (N2).
      • There are several gallstones (< 1.5 cm) and mild wall thickening of the gallbladder.
      • There is a calcification 7 mm at S8 of the liver dome that is c/w old granuloma.
      • There is a mass lesion in left adrenal gland, measuring 1.8 cm in size, -2 HU at non-enhanced CT and 42 HU at portal venous phase images.
        • Adenoma of left adrenal gland is highly suspected.
        • Follow up is indicated.
      • Abdominal aorta shows atherosclerosis andectasia 2.2 cm.
      • A renal cyst measuring 0.8 cm in left upper pole is noted. Please correlate with sonography.
      • There is a small soft tissue nodule in RML of the lung, measuring 3 mm in size at lung window setting (Srs:302 Img:7).
        • Follow up chest CT 6 months later is indicated.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2 (N_value) M:M0 (M_value) STAGE:III(Stage_value)

[surgical operation]

  • 2022-11-10
    • Surgery
      • radical subtotal gastrectomy with D2 dissection
      • HIPEC with Oxalip (300mg/M2) at 42 degree C 60 mins
    • Finding
      • distal gastric cancer with multiple LN alpable
      • peritoneal seeding+
      • serosa++

[chemotherapy]

  • 2023-03-13 - oxaliplatin 75mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2400mg 3880mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-17 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-02-03 - oxaliplatin 75mg/m2 115mg D5W 250mL 2hr + leucovorin 400mg/m2 625mg NS 250mL 2hr + fluorouracil 2400mg 3770mg NS 500mL 46hr (FOLFOX Q2W)
    • dexamathasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-20 - oxaliplatin 60mg/m2 90mg D5W 250mL 2hr + leucovorin 400mg/m2 645mg NS 250mL 2hr + fluorouracil 2000mg 3200mg NS 500mL 46hr + [docetaxel 30mg/m2 20mg + cisplatin 30mg/m2 20mg + gentamicin 20mg + sodium bicarbonate 1400mg] IP 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-10 - oxaliplatin 300mg/m2 510mg IP 1hr (HIPEC)

==========

2023-01-04

Based on the available lab data, serum Ca levels are stably lower than the normal range. If PTH secretion is insufficient to act on kidney, bone, and intestines, hypocalcemia may occur (hypoparathyroidism). No PTH lab data available. As the serum albumin concentration is also below normal, the low calcium level could also be due to a reduction in serum albumin levels.

Even when potassium supplements are taken intermittently, serum K readings remain below normal range since December 2022. An acute increase in hematopoietic cell production is associated with potassium uptake by the new cells and this may lead to hypokalemia. Administration of vitamin B12 or folic acid to treat a megaloblastic anemia or use of granulocyte-macrophage colony-stimulating factor (GM-CSF) to treat neutropenia are the most common scenarios in which this occurs.

2022-12-20

  • Cancer multidisciplinary team meeting (2022-12-06) concluded the treatment for the case: arrange further CCRT and keep IP C/T.
  • This patient is admitted for mFOLFOX chemotherapy as arranged. Based on lab data (2022-12-19), the chemotherapy was not contraindicated.
  • There were low levels of albumin (3.1g/dL 2022-12-19) and prealbumin (13.85mg/dL 2022-11-21). They might indicate a short-term impairment in energy intake and the effectiveness of nutritional support.
  • As a diagnosis item, mixed hyperlipidemia is listed, however no associated medication is prescribed, and recent lab data show that triglyceride levels have returned to normal.
    • 2022-11-21 Triglyceride (TG) 109 mg/dL
    • 2022-11-14 Triglyceride (TG) 111 mg/dL
    • 2022-11-08 Triglyceride (TG) 156 mg/dL

700978784

230313

[diagnosis] - 2023-03-12 admission note

  • Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma]
  • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
  • Type 2 diabetes mellitus with diabetic nephropathy

[edu opinion] - 2023-03-12 admission note

History - Orbital lymphoma more commonly presents in the middle-age and the elderly. - Slowly progressing, and typically painless.

Signs - Conj: the typical lesion is salmon or flesh-pink color - Orbit, eyelid: when palpable, the masses are firm. - Lacrimal gland: an “S-shaped” mass due to the lateral location of the lacrimal gland - Proptosis - Ptosis and decreased levator function may indicate superior orbital and levator muscle involvement, and motility should also be measured if the patient complains of diplopia. - Signs are more commonly unilateral

Symptoms - Many lesions are asymptomatic but depending on the location of the mass, patients can complaint of exophthalmos, pain or diplopia, as well of conjunctival, eyelid, orbital or lacrimal gland mass.

Differential diagnosis - Benign lymphoproliferative lesions - Lymphoid hyperplasia - Systemic lymphoma - Metastasis - Amelanotic melanoma - Epithelial tumors - Inflammatory and infectious lesions - Orbital pseudotumor - Cavernous hemangioma    

[past history]

  • DM
  • Hyperlipidemia
  • Mucosa‐associated lymphoid tissue (MALT) lymphoma over kidney and urinary system s/p radiotherapy 

[allergy]

  • NKDA

[exam findings]

  • 2023-03-09 2D transthoracic echocardiography

(145 - 47) / 145 - M-mode (Teichholz) = 68 - Prominent concentric LV hypertrophy and mild RV hypertrophy with indeterminated LV filling pressure and impaired RV relaxation; moderately dilated LA. - Dilated LV with normal LV and RV systolic function. - Aortic valve sclerosis and mild aortic root calcification; mild MR; mild PR.

  • 2023-03-07, 2022-12-20 ECG
    • Normal sinus rhythm
    • Moderate voltage criteria for LVH, may be normal variant
  • 2023-02-21 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, iliac creast, biopsy — Free from lymphoma involvement
    • Immunohistochemical stains:
      • MPO: positive for myeloid series
      • CD71: positive for erythroid series
      • CD61: positive for megakaryocytes
      • CD34 and CD117: positive for blast
      • CD20: positive for B-cell
      • CD3: positive for T-cell
  • 2023-02-17 Patho - colon biopsy
    • Polypoid colonic lesion, cecum, biopsy — Non-specific chronic colitis
  • 2023-02-17 SONO - nephrology
    • Chronic renal parenchymal disease, mild to moderate degree
    • Right renal cysts
  • 2023-01-27 CT - chest
    • Indication:
      • Unspecified B-cell lymphoma, lymph nodes of head, face, and neck
      • Type 2 diabetes mellitus with diabetic nephropathy
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 2.5 mm lung window,5 mm soft-tissue window slice thickness)
    • Chest CT without IV contrast ehnancement shows:
      • Chest:
        • Minimal interstitial infiltration over both lungs is found.
        • Patent airway is found.
        • There is no evidence of destructive bone lesion.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Mild left hydronephrosis and hydroureter is found.
        • Right renal stone is found.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
    • IMp: Minimal interstitial infiltration over both lungs
  • 2023-01-20 Patho - stomach biopsy
    • Stomach, low body and antrum, biopsy— chronic gastritis with intestinal metaplasia and Helicobacter infection
    • Stomach, cardia, biopsy— inflammatory polyp with Helicobacter infection
  • 2023-01-18 Whole body PET scan
    • Glucose hypermetabolism in the left orbital fossa (Deauville score 5), compatible with lymphoma with tumor recurrence.
    • Glucose hypermetabolism in bilateral mediastinal and bilateral pulmonary hilar lymph nodes (Deauville score 4-5), tumor recurrence should be considered, suggesting biopsy for further investigation.
    • Glucose hypermetabolism in a lymph node in the right retromolar region (Deauville score 4) and in the gastric region (Deauville score 4), the nature is to be determined (reactive or recurrent nodes, or other nature ?), suggesting follow-up.
    • Increased FDG uptake in the rectal region, the nature is to be determined also, suggesting colon fibroscopy exam. for investigation.
    • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
    • B-cell lymphoma s/p treatment with tumor recurrence, rc-stage II at least, by this F-18 FDG PET scan.
  • 2023-01-02 Patho - soft tissue nontumor/mass/lipoma/debridement
    • PATHOLOGIC DIAGNOSIS
      • Orbital, left, biopsy — Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Small B-cell lymphoma, compatible with extranodal marginal zone lymphoma, composed of small to medium-sized, slightly irregular nuceli with abundant pale cytoplasm and monocytoid appearance
      • Pathologic Extent of Tumor: To adjacent adipose tissue
      • Additional Pathologic Findings: None identified
      • Immunophenotyping: CD3(-), CD20(+), CD5(-), CD23(focal+), CD43(-), Cyclin D1(-)
  • 2022-12-20 Nasopharyngoscopy
    • polyp over right middle meatus, mucopus over right inferor meatus and left chona, polyp over nasopharynx, fair vocal fold movement
  • 2022-12-14 CT - orbits
    • With and Without contrast CT of the bilateral orbital cavities showed
      • An irregular-margined soft tissue lesion, about 38.7mm, with attachment to the anterior aspect of the left IR muscle. Mild enhancement was noted.
      • The anterior and lateral bony walls of right maxillary sinus were thickened.
      • The mucosal thickening in the bilateral ethmoidal, sphenoidal and right maxillary sinuses with destruction of the medial wall of the right maxillary sinus. Some calcified spots within the right maxillary sinus were noted.
    • IMP:
      • Suspected inflammatory tumor in the left orbital cavity or hemangioma (less likely).
      • Suspected infectious process or tumor in the right maxillary sinus.
  • 2022-12-14 Nasopharyngoscopy
    • smooth nasopharynx, oropharynx, hypopharynx
    • nasal polyp over right middle meatus, no obvious mucopus noticed
    • post-nasal dripping over nasopharynx
  • 2018-10-31 SONO - abdomen
    • Diagnosis
      • Fatty liver,mild to moderate
      • Suspected renal cysts,bil
      • Pancreas not shown
      • Suboptiaml examination of liver due to Poor echo window
    • Suggestion
      • OPD follow up
      • Follow liver function test and AFP
      • Small liver lesion may be masked by bowel gas, especially liver dome

[consultation]

  • 2022-12-14 Ear Nose Throat
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S
        • Left eye pain and periorbital swelling for 2 months
        • Phx: type 2 DM, dyslipidemia, gout
        • no visual loss, diplopia, facial pain, epistaxis, foul smelling, epistaxis, nasal obstruction, rhinorrhea
      • O
        • Local finding: bilteral pale and boggy inferior turbinates
        • Scope:
          • smooth nasopharynx, oropharynx, hypopharynx
          • nasal polyp over right middle meatus, no obvious mucopus noticed
          • post-nasal dripping over nasopharynx
        • CT: sinusitis over bilateral sphenoid sinus and right maxillary sinus, mass lesion over left infra-orbital region
      • A
        • Impression: Right maxillary sinusitis
      • P
        • Nasonex for right side sinusitis
        • Survey and management of right eye lesion as ophthalmalogist suggested
        • ENT OPD f/u a week later
        • Well education
        • if diplopia, visual loss noticed, back to ER soon
  • 2022-12-14 Ophthalmology
    • Q
      • Pain noted around left eye, no blurring of vision
      • Redness +, Swelling +, Local Heat +
      • Past History: DM, HTN
      • Surgical history: Denied
      • Drug allergy: Denied
    • A
      • S: left periorbital swelling for 1-2 month, no BV, no diplopia, no pain
        • PHx: DM, hyperlipidemia, ophx denied, nka
      • O
        • WBC 6740, CRP 0.8
        • BCVA OD 0.6x-1.75/-2.25x75 OS 0.6x-3.0/-1.0x100
        • PT: 15/18 mmHg
        • pupil: 3mm+/+, 3mm+/+, no rapd
        • palpation : no tenderness
        • Hertel exophthalmometer: 12>–120–<16
        • EOM: mild limitation at lower left gaze os
        • conj: mild chemosis os
        • K: cl ou
        • AC: deep and clear ou
        • LenS: NS + ou
        • F’d: no infiltration, no whitish nor lelvated lesion, no vessel compromise , macula ok, no break ou
      • A: orbital tumor with proptosis, os cause to be determied, lymphoma?
      • P:
        • please consult ENT for sinus lesion
        • explain to the patient, the lesion might be benign or malignant, further survey is needed
        • inform the risk of disesae progression and IOP elevation, if difficulty on opening eye and progressive pain, come back to ER asap
        • opd f/u on W2

[chemoimmunotherapy]

  • 2023-03-13 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2
  • 2023-02-21 - rituximab 375mg/m2 674mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL D2 + prednisolone 60mg/m2 50mg BID D2-6
    • [dexamethasone 4mg + diphenhydramine 30mg + acetaminophen 500mg PO + NS 250mL] D1 + [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D2

[assessment]

  • On 2023-03-12, a self-paid G-CSF filgrastin 150ug SC was administered due to leukopenia (WBC count of 2.73K/uL, marked with asterisks in the following table) observed on the same day. The event occurred approximately 3 weeks since the patient’s first R-CHOP treatment started on 2023-02-21. This is longer than the usual 1-2 week timeframe for WBC nadir after chemotherapy. However, it cannot be entirely ruled out that there may be other unidentified factors that are affecting the patient’s WBC count.
    • 2023-03-13 WBC 7.91 x10^3/uL
    • 2023-03-12 WBC 2.73 x10^3/uL *
    • 2023-03-03 WBC 4.72 x10^3/uL
    • 2023-02-19 WBC 3.89 x10^3/uL
    • 2023-02-03 WBC 6.99 x10^3/uL
    • 2023-01-12 WBC 9.84 x10^3/uL

701455299

230310

[exam findings]

  • 2022-12-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (82 - 26) / 82 = 68.29%
      • M-mode (Teichholz) = 68.4
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
  • 2022-11-14 Patho - breast simple/partial mastectomy
    • Diagnosis:
      • Breast, right, partial mastectomy — Invasive carcinoma of no special type, grade 2
      • Skin, right breast, partial mastectomy — Negative for malignancy
      • Lymph node, SLN, right axilla, SLNB — Negative for malignancy (0/2)
      • AJCC 8th edition pathology stage:pT1cN0(if cM0); Anatomic stage IA; AJCC prognostic stage IA
    • Gross Description
      • Procedure
        • Partial mastectomy
      • Lymph node sampling (if lymph nodes are present in the specimen)
        • Sentinel lymph node(s)
      • Specimen laterality
        • Right
      • Sections are taken and labeled as:
        • F2022-533FSA1-2: margins,
        • F2022-533FSB: SLN,
        • F2022-533A1-8: tumor and skin,
    • Microscopic Description
      • For Invasive Carcinoma
        • Histologic type: Invasive carcinoma of no special type
        • Size of invasive carcinoma (mm): 15 mm
        • Histologic grade (Nottingham histologic score): grade II (score7)
        • Extent of tumor (required only if the structures are present and involved)
        • Skin involvement: Absent
        • Chest wall invasion deeper than pectoralis muscle: Absent
      • For Ductal Carcinoma In Situ
        • Tumor size (mm): 6 mm
        • Nuclear grade: 2
        • Architectural pattern: Comedo and Non-comedo
        • Tumor necrosis: Present
      • Margins:
        • Negative, Closest margin (7 mm from closest margin)
      • Nodal status: Negative
      • No. examined: 2
      • No. macrometastases (>2 mm): 0
      • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells):0
      • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
      • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
        • In the Breast: N/A
        • In the Lymph nodes: N/A
      • Immunohistochemical Study: Reference: S2022-17911
  • 2022-11-11 Frozen Section
    • Margin, right breast, frozen section — Free
    • SLN, axilla, right, frozen section — Negative for malignancy (0/2)
  • 2022-11-11 Lymphoscintigraphy
    • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • IMPRESSION: Probably a sentinel lymph node at the right axillary region.
  • 2022-10-25 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed some faint hot spots in bilateral rib cages and increased activity in the maxilla, lower T-spine, some L-spines, bilateral shoulders, sternoclavicular junctions and hips in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower T-spine and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, sternoclavicular junctions and hips, compatible with benign joint lesions.
  • 2022-10-24 CT - chest
    • Indication: Malignant neoplasm of unspecified site of right female breast, Unspecified lump in breast
    • MDCT (256-detector rows, GE Revolution, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images and axial slab MIP images, and oblique coronal reconstructed images of the Rt breast shows:
      • Lungs: normal appearance of bilateral lungs.
      • Mediastinum and hila: no enlarged LN or mass.
        • the trachea and main bronchi are normallly identified without endobronchial lesion.
      • Vessels:
        • the vascular markings and great vessels in the lung, hila, and mediastinum are normal in distribution and appearance.
      • Heart: normal in size of cardiac chambers.
      • Pleura: unremarkable.
        • Chest wall and visible lower neck: an enhancing nodular lesion with mild lobulated contour (15mm in longest dimension) in inferior central aspect of Rt breast. multiple low density ovalm or round shaped lesions within the breast too measuring up to 3.1cm. no enlarged LNs in axilla.
      • Visible abdominal-pelvic contents: diffuse wal thickening of distal half body and fundal part with sessile luminal nodular lesions of the gall bladder.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, kidneys, uterus, U-bladder, and small and large bowels.
        • no enlarged lymph node. no ascites.
      • Visualized bones: unremarkable.
    • Impression:
      • Rt breast tumor (15mm) and multiple cysts.
      • Gall tumor.
  • 2022-10-17 Patho - breast biopsy (no need margin)
    • DIAGNOSIS:
      • A. Breast, right, nipple, core biopsy — Fibroadenoma
      • B. Breast, right, 6 o’clock, core biopsy — Invasive carcinoma, no special type, NST.
        • IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
    • MICROSCOPIC DESCRIPTION:
      • A. Section shows fragments of breast tissue with fibroadenoma.
      • B. Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
  • 2022-10-17 SONO - breast
    • Treatment: core needle biopsy
    • Suggestion and Plan:
      • Right breast 6’region tumor, suspected malignancy, suggest biopsy.
      • Right nipple region cystic tumor, suspected intraductal papilloma, suggest biopsy.
      • Multiple bilateral breast cysts.
    • BI-RADS:
      • Category 4c: highly suspicious abnormality-biopsy should be considered.
  • 2022-10-17 Mammography
    • Indication: breast lump was noted during regular healthy examination.
    • No previous mammography is available for comparison.
    • Mammography of bilateral breasts with craniocaudal (CC) and mediolateral oblique (MLO) views shows:
      • Composition: The breast tissue is heterogeneously dense, and this may decrease the sensitivity of mammography.
      • Multiple oval nodules with obscured margin at bilateral breasts, suggest ultrasound correlation.
      • An irregular mass shadow at right lower central breast, 6’ region, superimposed with microcalcifications and associated with mild architectural distortion. Suggest ultrasound correlation and may consider biopsy.
      • No enlarged axillary lymph nodes.
    • Final assessment:
      • BI-RADS category 0, Need additional imaging evaluation.
      • Suggest ultrasound correlation for bilateral breast masses, especially right 6’ region mass.

[consultation]

  • 2022-11-11 Rehabilitation
    • Q
      • This 43 y.o lady denied systemic disease, op history on contraceptive for 10 years. 5 months before admission, noted solid tumor on 7 o’clock of right breast. Futher investigation was done. Right breast biopsy showed invasive carcinoma no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • 2022/10/17 Mamography : BI-RADS category 0, Need additional imaging evaluation.
        • 2022/10/17 Breast sono : 1. Right breast 6’region tumor, r/o malignancy, suggest biopsy. 2. Right nipple region cystic tumor, r/o intraductal papilloma, suggest biopsy.3. Multiple bilateral breast cysts.
        • 2022/10/24 Chest + Abd CT : Rt breast tumor (15mm) and multiple cysts. Gall tumor.
        • 2022/10/25 Bone scan : Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • She is admitted for partial masmectomy + SLND possible ALND.
      • We need your expertse opinion and set up rehabilitation program for post masmectomy and axillary lymph node dissection.
    • A
      • Physical examination
        • 2022/11/10 14:15 T/P/R: 36.5 degree celsius / 66bpm / 17bpm BP:118/56mmHg
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Hand and arm circumference (R/L,cm):
          • Elbow joint above 5cm 23/23.5
          • Elbow joint below 5cm 21/21
      • Imp
        • Breast, right Invasive carcinoma, no special type, NST. IHC stains: ER (+, 90%, strong intensity), PR(+, 5%, strong intensity), Her2/neu: negative(score=0), Ki-67(10 %), p53 (15-20%).
        • Unspecified lump in breast
      • OP: right partial masmectomy + SLND possible ALND on 2022/11/11.
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation (passive ROM, massage, therapeutic exercise) and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications

[surgical operation]

  • 2022-11-11
    • Surgery
      • partial mastectomy and SLNB
    • Finding
      • right 6/1 tumor, about 1.5cm in diameter, frozen: margin free
      • SLNB: negative of malignancy, 0/2
    • Procedure
      • Under ETGA, we harvested the SLNB under gamma-detecter assisted. The frozen section showed negative of malignancy. Then we performed wide excision for right breast tumor. Then frozen section of margin showed negative of malignancy. After one J-vac drain was left, then we closed the wound layer by layers.

[chemotherapy]

  • 2023-02-20 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-30 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2023-01-03 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3
  • 2022-12-12 - fluorouracil 500mg/m2 790mg NS 100mL 30min + epirubicin 90mg/m2 140mg NS 100mL 30min + cyclophosphamide 500mg/m2 790mg NS 500mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg PO D1-3

==========

2023-03-10

  • Currently, there are no observed leukopenia symptoms. However, the time serial data of the WBC count showed a downtrend, with the nadir (marked with an asterisk in the following table) indicating a obvious decrease in accordance with the treatment cycle. To avoid over-suppressing the recovery of WBC, it may be beneficial to consider reducing the dose of epirubicin.
    • 2023-03-08 WBC 7.12 x10^3/uL
    • 2023-03-02 WBC 0.79 x10^3/uL *
    • 2023-02-16 WBC 7.56 x10^3/uL
    • 2023-02-09 WBC 1.13 x10^3/uL *
    • 2023-01-30 WBC 5.90 x10^3/uL
    • 2023-01-12 WBC 2.27 x10^3/uL *
    • 2023-01-03 WBC 5.95 x10^3/uL
    • 2022-12-20 WBC 2.23 x10^3/uL *
    • 2022-12-12 WBC 4.79 x10^3/uL
    • 2022-10-22 WBC 5.16 x10^3/uL

2023-02-20

  • The WBC count reached its lowest point approximately 7-10 days after the previous chemotherapy treatment in this patient, as indicated by the time relationship between the chemotherapy dates and the lab data recorded at this hospital.

  • Epirubicin can cause neutropenia (in 54% to 80% of patients; with grades 3/4 in 11% to 67%; nadir occurring at 10 to 14 days and recovery by day 21) and leukopenia (in 50% to 80% of patients; with grades 3/4 in 2% to 59%). ref: UpToDate

  • The prophylactic administration of G-CSF after chemotherapy may be considered around one week after treatment. Another option to consider is to moderately reduce the dose of epirubicin.

  • Cyclophosphamide use may lead to hemorrhagic cystitis, which can cause pyelitis, ureteral disease (ureteritis), and hematuria. Therefore, please closely monitor for any signs of these possible adverse reactions. Mesna can be used for the prevention of cyclophosphamide-induced hemorrhagic cystitis in cancer patients. Patients who have difficulty emptying their bladders are at a higher risk of developing bladder toxicity. If there is a clinical concern, a bladder ultrasound should be performed, and if there is a high post-void residual, the use of mesna is also appropriate for such patients.

701443048

230309

[exam findings]

  • 2023-01-09, 2022-12-13, -12-06, -11-22 CXR
    • Increased infiltration over RLL. May be active infection.
    • S/P port-A catheter insertion.
    • S/P tracheostomy.
    • S/P N-G tube insertion.
  • 2022-11-03 Patho - colon biopsy
    • Distal transverse colon, biopsy — Ulcer
  • 2022-11-01 PD-L1 IHC 28-8
    • PD-L1 Immunostaining Result
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percentage of 28-8 expressing tumor cells (%TC): 0%
  • 2022-10-21 MRI - nasopharynx
    • Indication: Malignant neoplasm of tongue, unspecified
    • Findings
      • invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm.
      • enlarged lymph nodes in the bilateral submandibular spaces
      • a nodular lesion about 25mm in the left thyroid gland.
    • IMP: invasive oral cavity cancer, in progression.
  • 2022-10-18 Patho - colon biopsy
    • Large intestine, descending, biopsy —- ulcer with non-specific colitis
  • 2022-10-06 Nasopharyngoscopy
    • Granulation over mouth floor, left gingival sulcus, left tonsillar fossa, tongue base (almost contacted lingual side of epiglottis), bulging of R posterior phayrngeal wall, cystic formation? over R AE fold, fair vocal cord movement
  • 2022-10-05 CT - abdomen
    • History: Recurrent squamous cell carcinoma of tongue, cT4aN0M0, stage IVA
    • Findings:
      • There is distension with fluid and gas collection of the entire colon. please correlate with clinical condition.
      • A renal cyst measuring 1.5 cm in right middle pole is noted.
      • There minimal effusion in right posterior basal CP angle.
  • 2022-10-03 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, suspected buried bumper syndrome
      • Bilious substance in stomach
      • Oral cancer
    • Suggestion
      • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
      • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
  • 2022-09-12 ECG
    • Sinus tachycardia
    • ST & T wave abnormality, consider inferior ischemia
    • ST & T wave abnormality, consider anterolateral ischemia
  • 2022-08-12 Patho - gingival/oral mucosa biopsy
    • Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma.
    • IHC stains: p16 (-), CK5/6 (+), p40 (+).
  • 2022-08-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed hot areas in the mandible, and increased activity in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints, in whole body survey.
    • IMPRESSION:
      • Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?), suggesting further evaluation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in the skull base, bilateral sternoclavicular junctions, shoulders, and S-I joints.
  • 2022-08-09 MRI - nasopharynx
    • Oropharyngeal Cancer (p16-) Staging Form
    • For Oropharyngeal Carcinoma (p16-)
        1. PRIMARY TUMOR:
        • T4 : Moderately advanced or very advanced local disease
          • T4a : Moderately advanced local disease: Tumor invades the larynx, extrinsic muscle of tongue, medial pterygoid, hard palate, or mandible
        1. REGIONAL LYMPH NODES:
        • N1 : Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE(−)
        1. DISTANT METASTASIS:
        • M0 : No distant metastasis (in this study)
    • AJCC 8th edition Staging status: T4aN1M0
  • 2022-08-08 SONO - abdomen
    • incomplete exam of liver
    • pancreas obscured

[consultation]

  • 2023-03-09 Family Medicine
    • Q
      • For hospice care for pain control and and aromatherapy and lymphatic massage
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022 (The treatment process has been listed in detail in the progress note). ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance and swelling of face were noted. We need your help for combined hospice care for pain control and and aromatherapy and lymphatic massage, Thanks !!
    • A
      • 41 y/o gentleman advanced tongue cancer
      • pain control now
        • Fentanyl 2 large Q3D, Oxynorm (5) 2# q4H, MXL (60) 1# Q12H
      • VAS 5~ 7
      • may add lyrica for neuropathic pain
      • adjust morphine as required
      • Our sahre care would follow up.
  • 2023-03-07 Nephrology
    • Q
      • For severe hyponatremia and unbalance electrolye
      • Because of severe hyponatremia, we need your help, Thanks!!
    • A
      • We visited the patient at the bedside and evaluated his condition. His consciousness was clear, speech was coherent, no respiratory distress, no convulsions and no focal neurological symptoms were noted, and his four limbs were not edematous. He denied having drunk excessive free water or urinated in larger amount than usual.
      • His blood test showed a steep decline in serum Na levels over the course of hospitalization, but we require more data to determine the nature of hyponatremia.
        • 2023-03-06 Na (Sodium) 109 mmol/L
        • 2023-02-27 Na (Sodium) 126 mmol/L
        • 2023-02-24 Na (Sodium) 129 mmol/L
        • 2023-02-20 Na (Sodium) 132 mmol/L
      • Our advices are as follows
        • Adequate hydration with isotonic saline, and avoid 3% hypertonic saline unless patient exhibit severe neurological symptoms
        • Monitor serum Na at least Q12H, changes in serum Na levels should not exceed 4-6mEq/L within 24 hours or osmotic demyelination syndrome (ODS) may develop
        • Monitor urine output amount and neurological symptoms
        • Check serum osmolality, TSH, fT4, ACTH (8am), Cortisol (8am)
        • Check urine osmolality, Na, Cre
      • Please feel free to contact us should you require further assistance.
  • 2023-02-27 Ear, Nose, and Throat
    • Q
      • For nasal bleeding management.
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa.
      • MRI revealed tumor had involved to posterior pharyngeal walls. We need your help for nasal bleeding management. Thanks.
    • A
      • S
        • L nasal bleeding even after bosmin gauze compression
        • a case of Recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA with cuffed-tracheostomy (Rota)
      • O
        • Left anterior nasal bleeding
        • trismus and oropharynx invisible, but no blood noticed from oral cavity
        • scope can not be performed due to active bleeding even under bosmin gauze
        • no more bleeding after merocel packing over left common meatus
      • A
        • Left epistaxis
      • P
        • no more bleeding after merocel packing over left common meatus
        • suggest abx usage for merocel insertion
        • may contact us for merocel removal 5-7 days later
  • 2023-02-21 Infectious Disease
    • Q
      • For severe leukocytosis
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. immunotherapy with OPDIVO and CCRT at our hospital since 08/16/2022. ECOG: 3. However, anemia, hypoalbuminemia and mild electrolyte imbalance were noted.
      • Because of severe leukocytosis (CRP:12.19, WBC: 17680) and sputum culture revealed Pseudomonas aeruginosa 2+ and Achromobacter xylosoxidans 2+, we need your help, Thanks !!
  • 2023-01-12 Cardiology
    • Q
      • For severe hypertension
      • This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy. Immunotherapy with OPDIVO and CCRT at our hospital since 2022-08-16. ECOG: 3. However, Anemia . hypoalbuminemia and mild electrolyte imbalance were noted . Because of severe hypertension recently, we need your help, Thanks !!
    • A
      • S
        • This 41 y/o male patient is a case of squamaous cell tongue cancer s/p OP and C/T with recurence. He was admitted for palliative chemotherapy. He also had previous history of bronchial asthma and no longer attack in the previous 2 years. High BP was recorded after hospitalization. Now we are consulted for adjusting anti-HTN medications.
      • O
        • BP: 160190/80110+ mmHg, HR:80~110 BPM
        • Current anti-HTN medications: olmetec 1# BID use
        • 20221024 EKG: sinus tachycardia
        • 20230111 BUN/CR:12/0.55, ALT:8, K:3.1
      • Suggestion:
        • Please add adapin (nifedipine 30mg) 1# QD and nebilet (nebivolol 5mg) 1/2 # QD for better BP and HR control.
        • If elevated BP is still recorded 3~5 days later, then push up adapin to 1 # BID, and push up nebilet to 1# QD if no bronchial asthma happens after nebilet treatment.
        • Change olmetec to micardis (telmisartan) 1# QD if above treatment is unsatisfactory for BP control.
  • 2022-11-22 Radiation Oncology
    • Q
      • For radiation therapy
      • This is a 41-year-old male Fillipino patient , he had squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino. However, recurrent squamous cell carcinoma of tongue and was admitted for palliative chemotherapy and imunotherapy.
        • Anti-neoplastic therapy:
          • Palliative chemotherapy with #3 Erbitux 400mg/M^2 + #2a 90% TPF (Taxotere 36mg/M^2, Cisplatin 36mg/M^2, 5-Fu 900mg/M^2, Leucovorin 90mg/M^2) on 2022/09/07 - 2022/09/09.
          • Palliative chemotherapy with #4 Erbitux 400mg/M^2 + #2b 60% TPF (Taxotere 24mg/M^2, Cisplatin 24mg/M^2, 5-Fu 600mg/M^2, Leucovorin 60mg/M^2) on 2022/09/30 - 2022/10/02.
          • Palliative chemotherapy with #5 Erbitux 250mg/M^2 + #3a 70% Taxotere 28mg/M^2 on 2022/11/01.
          • Palliative chemotherapy with #6 Erbitux 250mg/M^2 + #3b 70% Taxotere 28mg/M^2 on 2022/11/11.
          • Immunotherapy with #1 OPDIVO 160mg on 2022/11/07. 2022/11/22.
    • A
      • S: For palliative radiotherapy due to recurrent left tongue cancer.
      • O
        • PI: This is a 41-year-old male Fillipino patient, he had squamous cell carcinoma of left oral tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Philippines. Because of recurrent squamous cell carcinoma of tongue, he was admitted for palliative chemotherapy and immunotherapy.
          • Previous RT Hx (2021-11-15 ~ 2021-12-31, St. Luke’s Medical Center, Phippines): 6000cGy/30 fractions of the (GTVp+0.1cm+ entire tongue, base of tongue, alveolar ridge, epiglottis, bilateral retrostyloid, level IB, II, III, IV, V, and modified level VI and left level IA nodes, + margins), 7000cGy/35 fractions of the [(GTVp(heterogenous enhancing mass, left hemitongue extending to the right side) + margin), + prechemotherapy level IIA, bilateral; level IB, right]+ margin] + margin.
        • ECOG: 3
        • PE: oral cavity: protruding tumor mass over anterior tongue border and low gum; poor hearing function; on oxygen inhalation.
        • MRI (2022-08-09): stage T4a(5.3cm, right tongue base; left tonsillar fossa, oropharyngeal wall), N1(right level I, single lymphadenopathy)M0.
        • Bone scan (2022-08-10): Hot areas in the mandible, the nature is to be determined (dental problem, cancer with local bone involvement, or other nature ?)
        • Pathology (S2022-13232, 2022-08-16): Labeled as “left lower gingiva”, incisiaonal biopsy — squamous cell carcinoma. IHC stains: p16 (-), CK5/6 (+), p40 (+).
        • CXR (2022-10-07): No cardiomegaly. No active lung lesion. Normal bony contour. S/P port-A catheter insertion.
        • MRI (2022-10-21): 1. invasive tumors with heteorogeneous enhancement in the bilateral oropharynx, posterior tongue, oral tongue, mouth floor, left buccogingical mucosa, the mendible, left pterygoid plates, lower lip with the largest axis, about 111mm. 2. enlarged lymph nodes in the bilateral submandibular spaces. 3. a nodular lesion about 25mm in the left thyroid gland. Imp: invasive oral cavity cancer, in progression.
      • A:
        • Squamous cell carcinoma of left oral tongue, stage cT3N0M0, stage III, s/p partial glossectomy on 2015/07.
        • Squamous cell carcinoma of left oral tongue, stage cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy and definitive radiotherapy in Philippines, with progression, s/p palliative chemotherapy and immunotherapy.
      • P: Palliative radiotherapy is indicated for this patient with the following indicators: tumor progression
        • Goal: pallaition
        • Treatment target and volume: tumor over left oral tongue to low gum and peripheral involved area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 3000cGy/15 fractions
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be arranged.
  • 2022-10-28 Thoracic Surgery
    • Q
      • This 41-year-old Philippine male patient was a case of recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVa. MRI revealed tumor had involved to oropharyngeal walls. However, he had suddened onset severe dyspnea and stridor were found. Acute respiratry failure were highly suspected, we need your for tracheotomy tube insertion. Thanks !!
    • A
      • The patient had buccal ca. s/p CCRT with fibrotic neck
      • Progressive dyspnea noted since last night
      • Tracheostomy may be considered but very high risk of life threatening
      • Consult ANE Dr for evaluation
      • Prepare ICU bed
  • 2022-10-12 Dermatology
    • Q
      • However, patient complained of itching skin lesion suspected fungal infection in right inguinal was noted for a while. We need your expertise and further management. Thanks !!
    • A
      • The patient had sufferred from erythematous to blackwish palques over bilateral inguinal area with staellite active borders.
      • Under the impression of intertrigo eczema with seocndary candidiasis infesation.
      • The following sugeetion:
        • Zalain (sertaconazole) 1 tube topical bid use over large area of invloved area
        • Please keep the affected area dry and clean, add Mycomb (nystatin, triamcinolone, neomycin, gramicidin) 1 tube topical bid use on the active scaling lesions of bilateral inguinal area.
  • 2022-10-03 Gastroenterology
    • Q
      • However, blood stool since 2022-10-02 was noted. Anemia (Hb: 7.9) and tachycardia this morning. Because of suspected GI bleeding. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • The 41-year-old man has left tongue cancer, cT3N0M0, stage III, s/p glossectomy and chemotherapy at Philippines. Due to further treatment of recurrent left tongue cancer, he transfered to Taiwan for further management. He just received chemotherapy, finished on 2022-09-30 but bloody stool with tarry was noted. Therefore, we are consulted for further management.
      • O
        • PE
          • conscious: clear
          • chest: smooth breath pattern under room air
          • abdomen: soft and flat
          • extremity: warm
        • Lab
          • Hb: 10.8 -> 7.9
          • Plt: 515k -> 542k
        • 20221003 EGD
          • Diagnosis:
            • Reflux esophagitis LA Classification grade A
            • Superficial gastritis
            • PEG insertion site (wound) at AW of lower body, without presence of the PEG tube, r/o buried bumper syndrome
            • Bilious substance in stomach
            • Oral cancer
          • Suggestion:
            • No bloody substance or active bleeder in UGI tract. Please survey other bleeding source, such as LGI bleeding.
            • Consider CT scan to confirm the location of the PEG. Remove the PEG tube and then revision should be done If buried bumber syndrome or migration of PEG is confirmed.
      • Impression
        • Tarry stool with blood clot, lessly like Upper GI tract bleeding by 20221003 EGD, need to rule out Lower GI tract bleeding
      • Suggestion
        • Due to the patient unable oral intake and dysfunction PEG, please use Ducolax 2PC BID + Cleanse enema, then arrange Colonscopy
        • If massive bleeding again or unstable hemodynamic status, please arrange CTA or TAE
        • Due to PEG dysfunction, after bleeding subsided, discuss with GS for further management.
  • 2022-09-28 Infectious Disease
    • Q
      • This 40-year-old male Fillipino patient who sufferred from recurrent squamous cell carcinoma of tongue, cT4aN1M0, stage IVA and under process in palliative chemotherapy treatment. Leukocytopenia, anemia, hypoalbumin and electrolyte imbalance were noted during this chemotherapy course.
      • Current problem: his central line culture showed GNB, we need your further evaluation and suggestion. Thanks !!
    • A
      • S: The patient’s condition was as your description.
      • O: 2022-09-25 B/C: GNB
      • Suggestion:
        • Antibiotics with finibax 500mg iv q8h for GNB sepsis is suggested.
        • DC tapimycin
        • Please remove or exchange the CVP
        • Check CXR
  • 2022-09-07 Metabolism and Endocrinology
    • Q
      • However, his thyroid function showed T3 46.195ng/dl, T4 4.076, free T4 1.388 and TSH 1.3. We need your further evaluation and suggestion. Thanks !!
    • A
      • S
        • This 40-year-old male, with past history of squamous cell carcinoma of left tongue, cT3N0M0, stage III, status post partial glossectomy on 2015/07. SCC of left tongue, cT4aN0M0, stage IVA s/p neoadjuvant chemotherapy with 3 cycles of TPF on 2021/08 - 2021/10 and definitive radiotherapy in Fillipino, was admitted due to recurrent squamous cell carcinoma of tongue and for palliative chemotherapy. We were consulted for abnormal TFT.
      • O
        • HR: 119
        • Possible related medication: Thyroxine 50 mcg 1# QDAC for 2 months until now (according to his family)
        • AST/ALT: 50/85
        • BUN/Cr: 13/24
        • Na: 137, K: 3.7
        • TSH/FT4: 1.300/1.388
        • T3: 46.195
        • ATPO, ATG, TSH receptor Ab: unavailable
        • ACTH/Cortisol: unavailable
        • ECG: sinus tachycardia (8/8)
      • A
        • Sick euthyroid syndrome
        • R/I radiation related primary hypothyroidism
      • Suggestions
        • Keep thyroxine 50 mcg 1# QDAC as before
        • Check ATPO, ATG in the next lab
        • Recheck TSH/FT4 2 weeks later or Meta OPD follow, including thyroid ultrasound
        • Contact us if needed. I’d like to follow up this patient.
  • 2022-08-12 Gastroenterology
    • Q
      • However, his Anti-HCV (+) and value showed 1.20 were noted. We need your further evaluation and suggestion. Thanks !!
    • A
      • check Bil(D), a-Fetoprotein, HCV RNA PCR (quantitative)
      • Well explained to the patient low incidence of HCV reactivation during or after chemotherapy according to previous reports
      • GI OPD f/u for treatment

[chemoimmunotherapy]

  • 2023-03-09 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-21 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-16 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-02-09 - docetaxel 32mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-31 - pembrolizumab 200mg NS 100mL 1hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-30 - methotrexate 30mg/m2 50mg NS 100mL 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2023-01-03 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-28 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-20 - cetuximab 250mg/m2 420mg 1hr + cisplatin 40mg/m2 70mg in saline 0.9% 500mL 2hr (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-09 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-12-06 - cetuximab 250mg/m2 400mg 1hr + docetaxel 40mg/m2 60mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-24 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-22 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg + granisetron 1mg
  • 2022-11-10 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 45mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-11-07 - nivolumab 3mg/kg 160mg in saline 0.9% 100mL 1hr
    •                 diphenhydramine 30mg 
  • 2022-11-01 - cetuximab 250mg/m2 400mg 1hr + docetaxel 28mg/m2 48mg in saline 0.9% 100mL 1hr
    • dexamethasone 4mg + granisetron 1mg
  • 2022-09-30 - cetuximab 250mg/m2 400mg 1hr + docetaxel 24mg/m2 40mg in NS 100mL 1hr + cisplatin 24mg/m2 40mg in NS 300mL 3hr + [leucovorin 60mg/m2 100mg + fluorouracil 600mg/m2 1000mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-09-07 - cetuximab 250mg/m2 400mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-23 - cetuximab 250mg/m2 440mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-08-16 - cetuximab 400mg/m2 700mg 1hr + docetaxel 36mg/m2 60mg in NS 150mL 1hr + cisplatin 36mg/m2 60mg in NS 300mL 3hr + [leucovorin 90mg/m2 160mg + fluorouracil 900mg/m2 1600mg] in NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg

==========

2023-03-09

[assessment - appetite stimulant]

  • The patient reached his lowest recorded weight of 52.6kg on 2023-01-13, before slightly increasing to 54.6kg on 2023-02-24. The patient is currently receiving nutrition through a nasogastric tube and it is recommended to provide sufficient calories, protein, and other nutrients.

  • Previously in another pharmacist note, megestrol was recommended as an appetite stimulant, but if the patient cannot tolerate it and there is still a need for an appetite stimulant, Pilian (cyproheptadine 4mg/tab) might be also considered as an off-label alternative for decreased appetite due to chronic disease. The recommended dosage for Pilian is an initial 2mg four times per day for one week, followed by 4mg four times per day.

    • ref:
      • Cyproheptadine is an effective appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2004;38(2):129-134. doi:10.1002/ppul.20043
      • Long-term trial of cyproheptadine as an appetite stimulant in cystic fibrosis. Pediatr Pulmonol. 2005;40(3):251-256. doi:10.1002/ppul.20265
  • Quetiapine might then be considered as a last resort to increase weight, but it comes with the cost of dyslipidemia.

[assessment - pain control]

  • MXL (morphine 60mg/cap) 1# Q12H, fentanyl transdermal patch 50ug/h 2# Q3D, OxyNorm (oxycodone 5mg/cap) 2# Q4H have been properly prescirbed to deal with the backgroud pain.

  • NG tube OxyNorm administration: pour the small granules out of the OxyNorm capsules, dissolve them in drinking water, and pass them through the feeding tube.

  • If the patient still experiences breakthrough pain with a high VAS score, the addition of PRN morphine might be considered.

2023-02-10

  • HGB 11.3 g/dL 2023-02-09 <- 6.5 g/dL 2023-02-06, in this case, anemia has been mitigated.

  • Platin- and taxel-based treatments have been administered to the patient.

    • Cisplatin-induced neuropathy was more similar to neuropathy in patients receiving oxaliplatin than in those receiving paclitaxel. The cisplatin and oxaliplatin groups exhibited the coasting phenomenon and more prominent upper extremity symptoms than lower extremity symptoms during chemotherapy administration weeks. In contrast, paclitaxel-treated patients did not, on average, exhibit the coasting phenomenon; additionally, lower extremity symptoms were more prominent during the weeks when paclitaxel was administered. ref: Cisplatin-associated neuropathy characteristics compared with those associated with other neurotoxic chemotherapy agents (Alliance A151724) [published correction appears in Support Care Cancer. 2021 Nov;29(11):7129-7130]. Support Care Cancer. 2021;29(2):833-840. https://doi.org/10.1007/s00520-020-05543-5
    • Cisplatin-induced peripheral neuropathy (CIPN) is a frequent serious dose-dependent adverse event that can determine dosage limitations for cancer treatment. CIPN severity correlates with the amount of platinum detected in sensory neurons of the dorsal root ganglia (DRG). After cisplatin-induced DNA damage, p21 appears as the most relevant downstream factor of the DDR in DRG sensory neurons in vivo, which survive in a nonfunctional senescence-like state. ref: Cisplatin-induced peripheral neuropathy is associated with neuronal senescence-like response. Neuro Oncol. 2021;23(1):88-99. https://doi.org/10.1093/neuonc/noaa151
  • 2020 ASCO guidelines suggest that clinicians may offer duloxetine to patients with chemotherapy-induced peripheral neuropathy, and 2020 joint ESMO/EONS/EANO guidelines recommend duloxetine for treatment of neuropathic pain in this setting. ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. J Clin Oncol 2020; 38:3325. https://doi.org/10.1200/jco.20.01399

    • Duloxetine for adult patients with chemotherapy-induced peripheral neuropathy: Oral initial 30 mg once daily for 1 week, then 60 mg once daily. Ref: Effect of duloxetine on pain, function, and quality of life among patients with chemotherapy-induced painful peripheral neuropathy: a randomized clinical trial. JAMA. 2013;309(13):1359-67. doi:10.1001/jama.2013.2813 https://doi.org/10.1001/jama.2013.2813
    • There is Cymbalta (duloxetine 30mg/cap) available in the stock. According to the patient’s lab results of 2023-02-09, his liver and kidney function have not deteriated, so no dose adjustment is required. Cymbalta 1# QD is recommended to mitigate his neuropathy.
  • The platinum agents cisplatin and carboplatin are used both as single agents and to form the backbone for most combination regimens to treat metastatic and recurrent head and neck cancers. Although carboplatin is often considered to be less systemically effective than cisplatin in head and neck cancer, there is little direct evidence. Carboplatin may be preferred in some cases since it is associated with less neurotoxicity, nephrotoxicity, ototoxicity, and nausea and vomiting compared with cisplatin, although carboplatin causes more myelosuppression.

    • Compared to TPF (docetaxel, cisplatin, fluorouracil) induction chemotherapy, CT (carboplatin, paclitaxel) induction chemotherapy had at least similar if not better LRC and PFS in patients while having less renal toxicity. Thus, CT induction chemotherapy may benefit patients with locally advanced HNSCC by facilitating adequate chemoradiation regimens that enhanced disease control. ref: Comparison of carboplatin-paclitaxel to docetaxel-cisplatin-5-flurouracil induction chemotherapy followed by concurrent chemoradiation for locally advanced head and neck cancer. Oral Oncol. 2014;50(1):52-58. https://doi.org/10.1016/j.oraloncology.2013.08.007

[duplicate note]

  • As the note has already been responded to, please disregard this duplicate note generated by the system.

2023-01-30

  • Since the patient has lost more than 10kg of body weight over the past 5 months (64.4kg 2022-09-17 -> 52.6kg 2023-01-13), possibly as a result of tumor-induced cachexia, it is recommended that the patient consume more and/or receive more intensive nutritional support. The addition of some appetizers, such as megestrol, might be beneficial.

  • Metoclopramide has been prescribed. The use of Emend (aprepitant) for antiemetic effect might be considered if nausea and/or vomiting is observed.

701472893

230309

[exam findings]

  • 2023-03-01 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with myeloproliverative neoplasm and see description
    • The sections show normocellular marrow (30%). The M/E ratio about 2:1 in MPO and CD71 immunostains. Increased numbers of small to enlarged CD61+ megakaryocytes with occasional hyperchromatic nuclei, arragned in loose clusters are present. No left shift of myeloid series and erythroid precursors. A few CD34+ and/or CD117+ immature cells in interstitium, account for <3% of nucleated cells can be found. Loose network of reticulin with many intersections (MF-1) in reticulin stain. The finding is compatible with myeloproliferative neoplasm. The differential diagnosis including prefibrotic/early primary myelofibrosis and essential thrombocythemia. Suggest bone marrow smear evaluation, genetic study and clinic correlation.
  • 2023-03-01 CT - brain
    • Indication: Thrombocythemia with dizziness, R/O CVA
    • IMP: No evidence of intracranial lesion.
  • 2023-02-24 CT - abdomen
    • CC: abdominal pain, diarrhea once and vomit > 3 times since last night
      • no fever, headache (+), no family had similar symptom
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformatted isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple hyperdense lesions in the stomach, duodenum, and small intestine that may be food materials.
        • please correlate with clinical condition.
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas. In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
        • Please correlate with GYN. sonography.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidneys.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There are two poor enhancing lesion 2 cm and 1.8 cm in the uterus that may be myomas.
      • In addition, there is a cystic lesion 2.1 cm in left adnexa that may be left ovarian cyst.
      • Please correlate with GYN. sonography.

[consultation]

  • 2023-02-08 Ear Nose Throat
    • Q
      • This 43-year-old woman patient is a case of Thrombocythemia with dizziness. Now, for evaluate ear examine of dizziness. Thank you.
    • A
      • S:
        • intermittent Vertigo for 1 month
        • when lying down and getting up from the bed in the morning and at night?
        • Duration: 50 mins
        • First attack: this time
        • Headache(+) for 1 month
        • Tinnitus(-), Hearing loss(-), aural fullness(-)
        • N/V and abdominal pain since last Thursday, improved now nausea or vomiting now, but still intermittent vertigo and headache
        • PHx: denied
        • Allergy: denied
      • O:
        • Ear drums: intact
        • No spontaneous, positional , positioning nystagmus
        • Finger nose finger : ok
        • Romberg test : ok
        • Tandem gait : ok
        • Dix-Hallpike test: Bil negative
        • Supine roll test: Bil negative
      • A: Vertigo, cause?
        • central origin can’t be ruled out
      • P:
        • Please rule out central lesion due to thrombocythemia
        • Brain image study: had arranged
        • Treat thrombocythemia as your expertise
        • may consider diphenidol and nicametate citrate
        • ENT/Neuro OPD f/u

700378861

230306

[exam findings]

  • 2023-03-01 SONO - chest
    • Pleural effusion, minimal, bilatera
    • Consolidation, LLL and RLL
  • 2023-02-27, -02-25, -02-23, -02-20, -02-17 CXR
    • S/P nasogastric tube insertion
    • S/P CVP line insertion from left jugular vein and the tip located at SVC.
    • Atherosclerotic change of aortic arch
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear and nodular infiltration over both lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Borderline cardiomegaly
  • 2023-02-23 KUB
    • Fecal material store in the colon.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-22 CT - brain
    • Indication: Myelodysplastic Syndrome
    • IMP: No evidence of intracranial lesion.
  • 2023-02-22 SONO - abdomen
    • GB wall thickening, possibly secondary to hepatitis or ascites
    • Parenchymal renal disease
    • Left renal cyst
    • Ascites
    • Pleural effusion
    • suboptimal echo window
  • 2023-02-17 MRI - L-spine
    • Indication: Myelodysplastic Syndrome. bilateral lower limbs weakness
    • Impression:
      • Degenerative spinal and disc disease.
      • Favor intramuscular hematomas in right psoas muscle.
  • 2023-02-08 SONO - chest
    • Symptoms:
      • Internal jugular vein narrowing or thrombosis.
      • Peripheral vein narrowing
    • Indication:
      • Risky in bleeding, thrombosis, vessel narrowing.
    • Clinical Diagnosis
      • COVID-19 pneumonia with ARDS.
      • MDS with severe pancytopenia
    • Echo Diagnosis
      • Right side
        • Internal jugular vein and common carotid artery confirmed by echo probe compression, Doppler velocity detection.
        • Internal jugular vein compress: lumen narrowing, velocity increasing.
        • Internal jugular vein lumen narrowing and velocity increase during inspiration.
        • Cross-sectional probe: lumen area: 0.66cm in diameter
        • Thrombosis: No
  • 2023-02-02 CT - abdomen
    • History and indication: SOB
    • IMP: Ground glass opacities at bil. lungs. Some LNs at mediastinum. Pericardial and pleural effusion.
  • 2023-01-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • diverticulum : the second portion of duodenum
    • Suggestion
      • PPI therapy
      • OPD follow-up
  • 2021-09-30 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1)
      • MICROSCOPIC EXAMINATION
        • The sections show normocellular marrow (25%). M/E ratio = 2:1 in CD71 amd MPO stains. The megakaryocytes are not remarkable.
        • Slightly increased CD138+ mature plasma cells (5%) in interstitium.
        • Increased CD34+ blasts, account for 9% of marrow cells. Only few CD117+ immuture cells. the finding is compatible with myelodysplastic syndrome with excess blasts (MDS-EB-1). Suggest further bone marrow smear evaluation and clinic correlation.
  • 2019-08-12 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (119 - 37) / 119 = 68.91%
      • LVEF = 69
      • M-mode (Teichholz) = 69
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Mild MR; mild TR; mild PR.
    • No vegetation was found by TTE.
    • Flat IVC, consider hypovolemia.
  • 2019-08-11 CT - abdomen
    • Indication: Suspected liver abscess.
    • Impression:
      • No intraabdominal abscess
      • Left renal cyst
      • Prominent pancreatic tail

[consultation]

  • 2023-02-24 Nephrology
    • Q
      • For Hyernatremia evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 20230202, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed Hyernatremia, Na (blood): 160 -> 163 -> 171 mmol/L, Na (urine): 32 mmol/L, K (blood): 2.5 -> 3.2 mmol/L, K (urine): 18.8 mmol/L, Osmolality (blood): 340mOsn/kg, Osmolality (urine): 236mOsm/kg, Urine SG: 1.006, U/O: 2807.3+ lossml/day(2023/02/20), 1560ml/day(2023/02/21), so we need your help for Hyernatremia evaluation, thanks a lot!!
    • A
      • Patient seen with history reviewed. We are consulted for hyernatremia.
      • pitting edema 2+
      • Lab
        • 2023-02-22 Na(Urine) 46 mmol/L
        • 2023-02-22 Urine osmolarity 281 mOsm/Kg
        • 2023-02-22 Na (Sodium) 171 mmol/L
        • 2023-02-21 Na (Sodium) 163 mmol/L
        • 2023-02-20 Na (Sodium) 160 mmol/L
        • 2023-02-17 Na (Sodium) 141 mmol/L
        • 2023-02-13 Na (Sodium) 141 mmol/L
        • 2023-02-22 BUN 40 mg/dL
        • 2023-02-20 BUN 32 mg/dL
        • 2023-02-17 BUN 31 mg/dL
        • 2023-02-13 BUN 45 mg/dL
      • U/O
        • 2023-02-20 U/O 2807+loss
        • 2023-02-21 U/O 1560
      • Impression
        • hypernatremia, suspected osmotic diuresis
      • Suggestion
        • estimated free water deficit: 8.5L
        • correct hypernatremia with adequate free water (in diet and IVF), since pleural effusion and pitting edema were noted
        • monitor sodium level closely, sodium level decrease should not exceed 8mmol/L/d
        • record I/O
  • 2023-02-20 Infectious Disease
    • Q
      • For antibiotic evaluation
      • The 63-year-old man had past history with MDS with RAEB s/p vidasa. This time, he was visited ER due to dyspnea and progressed since 2023/02/02, the chest film manifasted bilateral ground glass opacity with severe pneumonia patch noted. Abomen CT showed left renal cyst and pleural effusion with pericardial. He was admited due to bilateral lung pneumonia with respiratory failure s/p intubation and COVID-19 infection.
      • The lab showed leucopenia, pancytopenia due to MDS, Lenograstim and Tapimycin, Mycamine for blood culture: Candida, sputum culture: PDR-K. oxytoca, so we need your help for antibiotic evaluation, thanks a lot!!
    • A
      • keep present antibiotic Rx, and adjust to culture data later
      • monitor CRR
  • 2023-02-08 Gastroenterology
    • Q
      • After admission, he received ventilator support, empiric antibiotics with Tapimycin and Cravit was prescribed for pneumonia treatment, Decan 6 mg IVD QD (2/2-2/10) and DC Remdisivir due to liver failure. LPRBC and LRP were tranfused for anemia and pancytopenia. We need your expert to evaluate his condition and give us advise with hepatitis. Thank a lot
    • A
      • B (-) C (-)
      • Impression
        • Abnormal liver function test, resolving, r/p sepsis related, r/o shock liver (The liver function test was abnormal but it is improving. This could be related to the recent sepsis the patient had and we need to rule out shock liver.)
      • Plan:
        • Arrange abdominal sonography when transfer to a general ward after isolation
        • Check Anti HAV IgM
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Silymarin 1#~2# TID (The National Health Insurance will reimburse when the levels of GOT and GPT are greater than or equal to twice the normal values.)

[chemotherapy]

  • 2022-05-10 - Vidaza (azacitidine) 230mg SC
  • 2022-01-17 - Vidaza (azacitidine) 260mg SC
  • 2022-01-10 - Vidaza (azacitidine) 260mg SC
  • 2021-12-13 - Vidaza (azacitidine) 260mg SC
  • 2021-12-06 - Vidaza (azacitidine) 260mg SC
  • 2021-11-15 - Vidaza (azacitidine) 260mg SC
  • 2021-11-08 - Vidaza (azacitidine) 260mg SC

[assessment]

  • The patient’s renal function has declined, as evidenced by a decrease in creatinine clearance based on Cockcroft-Gault formula to 33mL/min as of 2023-03-06.

    • 2023-03-06 Creatinine 2.37 mg/dL
    • 2023-03-03 Creatinine 1.79 mg/dL
    • 2023-02-27 Creatinine 1.54 mg/dL
    • 2023-03-06 eGFR 29.54
    • 2023-03-03 eGFR 40.84
    • 2023-02-27 eGFR 48.58
  • In patients with a CrCl between 25 and 50 mL/min, a recommended dose of 1g Q12H for meropenem is advised, compared to the intended dose of 1g Q8H.

  • By the way, there is no dosage adjustment necessary for any degree of kidney dysfunction for micafungin use. And there are no dosage adjustments for nystatin provided in the manufacturer’s labeling for patients with kidney Impairment.

700701354

230306

{Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.}

[lab data]

  • HBsAg 2022-06-04 Reactive, Value 4.62 S/CO
  • Anti-HCV 2022-06-04 Nonreactive, Value 0.10 S/CO
  • Anti-HBc 2022-06-04 Reactive, Value 7.96 S/CO
  • Anti-HBc IgM 2022-06-04 Nonreactive, Value 0.12 S/CO

[exam findings]

  • 2023-02-22 CT - chest
    • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA for esophageal cancer follow-up
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/11/07
      • Lungs: basal segmental consolidation and volume loss of LLL. long subpleural lines at RLL, may be fibrosis.
        • extensive ground-glass opacity at RML and centrilobular nodular opacities at RUL.
      • Mediastinum and hila: s/p left main bronchial stenting.
        • asymmetric wall thickness with luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 2022/08/08. enlarged subcarinal LNs in visceral space, in progression
        • filling defects in pulmonary arteries (distal main, intrapulmonary lobar and segmental/subsegmentsl branches)
      • Heart: normal in size of cardiac chambers.
      • Pleura: small Lt-sided effusion.
        • opacification of veins in the chest wall and mediastinum
      • Visible abdominal contents:
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node.
      • Visualized bones: unremarkable.
    • Impression:
      • proression of esophageal cancer with regional LN metastasus and newly developed pulmonary embolism and LLL consolidation/volume and pleural effusion as compared with CT on 2022/11/07
  • 2023-02-21 ECG
    • Sinus tachycardia
    • Incomplete right bundle branch block
    • Septal infarct, age undetermined
    • Inferior injury pattern
    • ACUTE MI / STEMI
  • 2023-02-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 25) / 93 = 73.12%
      • M-mode (Teichholz) = 73
    • Normal LV filling pressure; possibly impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis; mildly dilated aortic root.
    • Sinus tachycardia.
  • 2023-02-19, -02-02 ECG
    • Sinus tachycardia
  • 2023-01-26 Laryngoscopy
    • Findings
      • left nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, small airway
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2023-01-20 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Left hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2023-01-09 Esophagogastroduodenoscopy, EGD; Endoscopic Retrograde CholangioPancreatography, ERCP
    • Findings
      • Supraglottic swelling and posterior hypopharynx ulcer was noted.
      • A stricuture was noted at posterior hypopharynx. The regular EGD scope could not be inserted into esophageal inlet.
      • Using guidewire(Jagwire Revolution 0.025in x450cm) and balloon dilatation with CRE ballooin (15-18 mm, 3 ATM) was performed under fluroscopy.
      • After dilatation, the regular EGD scope still could not be inserted pass through the stricture due to the angulation at the stricture site.
    • Diagnosis
      • Hypopharyngeal stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Repeat CRE balloon dilatation
  • 2023-01-08 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear fibrosis or discoid atelectasis in LLL of the lung?
  • 2022-12-30 CXR
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-12-27 Laryngoscopy
    • Findings
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, no gross tumor found at hypopharynx, yellowish sputum accumulation at bi hypopharynx, patent airway but small
    • Conclusion
      • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
      • supraglottic swelling
  • 2022-12-19 SONO - abdomen
    • probable liver parenchymal disease
    • pancreas obscured
    • spleen not seen: obscured?
  • 2022-12-19 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, s/p endoscopic balloon dilatation
    • Suggestion
      • Suboptimal effect of the balloon dilatation was noted in this procedure.
      • Repeat dilatation is indicated.
  • 2022-12-13 Patho - stomach biopsy
    • Stomach, mid-body, PW, biopsy — inflammatory polyp. No H.pylori present
  • 2022-12-12 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal inlet stricture, suspected cancer stenosis s/p CRE balloon dilatation
      • C/W esophageal cancer, 20cm to 35cm below incisor
      • Gastric polyp, mid-body, PW, s/p biopsy, suspected adenoma
      • Superficial gastritis & hiatus hernia
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • Arrange CRE balloon dilatation again and placement of esophageal stent on 20221219.
  • 2022-12-06 CT - brain
    • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
  • 2022-12-05 Esophagography
    • Esophagography revealed obstruction of cervical esophagus with chocking.
  • 2022-12-01 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
  • 2022-11-29 Laryngoscopy
    • hypopharyngeal cancer s/p CCRT, no evidence of local tumor recurrence via scope exam
  • 2022-11-16, -11-04, -10-19, -09-30 CXR
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-11-07 CT - chest
    • residual subsegmental atelectasis at basal segments of LLL.
    • suspect progression of esophageal tumor as compared with CT on 20220808.
  • 2022-11-02 SONO - neck (lymph node)
    • Findings
      • Multiple LNs in left middle and left lower neck, with size up to 0.4cm in length at left.
      • No abnormal fluid collection.
    • Imp
      • Multiple small left neck LNs.
  • 2022-10-24 MRI - larynx
    • Remarkly regressed right hypopharyngeal tumor.
    • Multiple abnormal enlarged lymph nodes in left low neck and supraclavicular fossa were noted, suggest check sonography.
    • Severe artifacts at left upper face,neck and oral cavity was noted, this can mask details.
    • Highly suspected regrowth of upper thoracic esophageal tumor/CA, was noted.
  • 2022-09-22 Laryngoscopy
    • Findings:
      • right nasal cavity and left middle meatus clear, smooth nasopharynx, epiglottis and bi arytenoid mild edema, mucus coating on supraglottis and bi hypopharynx, no gross tumor found at hypopharynx
    • Conclusion:
      • hypopharyngeal cancer s/p CCRT, no evidence of tumor recurrence
  • 2022-09-07, -09-02 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-09-05 ECG
    • Sinus tachycardia
    • Rightward axis
    • Borderline ECG
  • 2022-08-25 Laryngoscopy, Stroboscopy
    • hypopharyngeal cancer s/p CCRT
  • 2022-08-08 CT - chest
    • Findings
      • Lungs: residual atelectasis at basal segments of LLL. normal appearance of LUL and Rt lung.
      • Mediastinum and hila: s/p left main bronchial stenting. decrease wall thickness and luminal dilatation of lower third esophagus compared with CT on 20220604. small LNs in visceral space.
      • Pleura: trace Lt-sided effusion or thickening or nodule.
    • Impression:
      • Regression of lower third esophageal tumor as compared with CT on 20220604. LLL basal segmental atelectasis.
  • 2022-08-02, -07-04 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
  • 2022-07-07 Abdomen - standing (diaphargm)
    • Left hemi-diaphragm elevation is noted, which may be due to left lower lung volume decrease .
  • 2022-06-23 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
    • post Lt main bronchial stent placement, with expansion of atelectatic left lung
  • 2022-06-15 CXR
    • Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-13 CXR
    • regression Lt pleural effusion and consolidation and volume loss over Lt lower lobe
  • 2022-06-08 CXR
    • Atherosclerotic change of aortic arch
    • Lung volume decrease of left lower lung is suspected.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
  • 2022-06-08 Bronchoscopy
    • Nasal mucosal lesion, favor mucocele
    • Orolaryngeal wall tumor invasion
    • Endobronchial tumors invasion of whole left main bronchus, combined with severely external compression with LM near-total obstruction.
  • 2022-06-06 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (30 - 4) / 30 = 86.67%
    • Normal LV systolic function with normal wall motion.
    • Normal LV diastolic function.
    • Normal RV systolic function.
    • Aortic valve calcificaiton with no AS and AR; mild MR; trivial TR.
    • LV chamber obliteration and flat IVC, consider hypovolemia.
  • 2022-06-04 CT - CTA, chest
    • CTA of chest revealed:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL.
      • S/P jejunostomy.
      • Hyperplasia of left adrenal gland.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Wall thickening of subcarinal esophagus. Left pleural effusion. Partial consolidation at left lung. A patchy density at RLL. No evidence of pulmonary embolism.
  • 2022-05-26 Electrocardiogram, EKG
    • Incomplete right bundle branch block
  • 2022-05-25 Nasopharyngoscopy
    • Scope: smooth NPx, oropharynx
    • post. pharyngeal wall ulcerative lesion s/p biopsy, wound healed
    • saliva and mucus pooling, aspiration+
  • 2022-05-05 Patho - larynx biopsy
    • Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma.
    • IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
    • Specimen submitted in formalin consists of 2 piece(s) of tan, irregular tissue measuring 0.2 x 0.2 x 0.1 cm.
  • 2022-05-02 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement
      • Gastric polyp, body, PW, s/p biopsy
      • Reflux esophagitis, LA grade A
      • Hiatal hernia
      • Superficial gastritis, body
    • Suggestion
      • suggest consult ENT for biopsy of hypopharynx lesion
      • Pursue pathology report
  • 2022-05-02 Nasopharyngoscopy
    • smooth nasopharynx and oropharynx;
    • small whitish lesion over left pyriform sinus;
    • bulging over right pyriform sinus;
    • posterior hypopharyngeal wall ulcerative lesion;
    • fair vocal cord movement.
  • 2022-04-29 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the lower C-spine, some T- and L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
    • Some faint hot spots in the skull and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-04-28 MRI - brain
    • No evidence of brain metastasis.
    • Mild general brain atrophy.
  • 2022-04-28 Abdominal Ultrasonography
    • Diagnosis
      • Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma
      • Suspected calcified spot, left kidney
    • Suggestion
      • Please correlate with other image study for liver lesion
  • 2022-04-19 Whole body PET scan
    • Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered.
    • Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
  • 2022-04-13 Patho - esophageal biopsy
    • Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
    • The specimen submitted consists of multiple small pieces of gray-tan soft tissue, labeled esophagus, 25 to 28 cm, measuring up to 0.2 x 0.1 x 0.1 cm. All for section and labeled S2020-05275 FS.
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and subtle stromal invasion. Keratin formation is evident.
  • 2022-04-09 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Soft tissue mass at middle to lower third esophagus up to 7.5cm in length is found. Esophageal cancer is considered. In comparison with CT dated on 2021-08-27, the lesion progressed.
        • Small lymph nodes are found at AP window and paratracheal region.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • Suggest clinical correlation
    • Imp:
      • Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression.
      • Mediastinal lymphadenopathy
  • 2021-08-30 Patho - esophageal biopsy
    • Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia)
    • The sections show high-grade (severe) dysplasia, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, cellular atypia and atypical mitotic figures. Changes extend to upper-third of the epithelium. Suggest closely follow up.
  • 2021-08-27 CT - lung/mediastinum/pleura
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Calcified coronary arteries is found.
        • The lung fields are clear.
        • Patent airway is found.
        • No evidence of bilateral pleural effusion.
        • There is no evidence of esophageal wall thickening.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Imp: no evidence of esophageal wall thickening in the study.
  • 2020-12-29 Patho - esophageal biopsy
    • Esophagus, middle, biopsy — high-grade dysplasia
    • Microscopically, it shows high-grade dysplasia with aacanthosis and dysplastic change of the epithelial cells.
  • 2020-12-29 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade AEsophageal lesion, middle esophagus s/p biopsy (B)
    • Superficial gastritis, antrum
    • Gastric polyp, GC of body s/p biopsy (A)
  • 2019-11-13 CT - mediastinum
    • Comparison: prior CT dated on 2017/11/27
      • Chest
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of visible thoracic aorta, central pulmonary arteries, and cardiac chmabers.
        • No pleural effusion or nodule.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • A tiny subupleural nodule at LUL. normal appearance of the LLL and Rt lung.
        • Unremarkable of the chest wall.
      • Visible abdomen
        • Unremarkable of the liver, spleen, pancreas, both kidneys, GB, and adrenal glands.
        • No enlarged LN.
        • No ascites in the abdominal cavity.
      • Visible bones
        • Mild marginal spurs of multiple vertebral bodies.
    • Impression:
      • esophageal cancer,T2N2M0, s/p compeleted CCRT with no obvious recurrent tumor or luminal narrowing based on this CT study.
  • 2018-07-03 Bone densitometry - hip
    • Hip BMD performed by DXA revealed:
      • Hip, BMD is 0.660 gms/cm2, about 1.5 SD below the peak bone mass (78%) and 0.6 SD below the mean of age-matched people (89%).
    • IMP: osteopenia
  • 2017-11-27 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hilars.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric juncntion.
        • Two tiny subupleural nodule at LUL srs5 img10
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys, GB, and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • No ascites in the abdominal cavity.
    • Impression:
      • esophageal cancer, T2N2M0, s/p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.
  • 2017-03-06 CT - lung/pleura, chest and upper abdomen
    • Findings
      • Chest:
        • No enlarged LNs in the mediastinum, supraclavicular fossa, and hila.
        • Normal appearance of aorta, pulmonary arteries, and cardiac chmabers.
        • No pleural effusion.
        • There is no soft tissue mass or enhanced wall thickening along the course of the esophagus and esopho-gastric jucntion.
        • Two tiny subupleural nodule at LUL
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
        • The GB is well distended without soft tissue lesion
        • Suggest clinical correlation
    • Impression:
      • esophageal cancer, T2N2M0, s∕p compeleted CCRT without obvious recurrent tumor or luminal narrowing based on CT study.

[consultation]

  • 2023-02-21 Cardiology
    • Q
      • This 61-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up.
      • Chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was started on 2022/12/21. C2D1 for Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09. C2D15 chemotherapy with Docetaxel + Leucovorin + Fluorouracil + Cisplatin was on 2023/01/09.
      • This time, he suffered from intermittent and progressive chest tightness and chest pain for 2 day. He denied fever, chills, abdominal pain, or dysuria. He visited our ER for management. During ER, vital sign showed BP:114/69, PR:122, BT:36.7 degree Celsius, RR:20. Lab data showed negative cardiac enzyme abnomality, but CRP was elevated. CXR showed focal increased density in the right lower lung field. Under the impression of pneumonia, he was admitted for further management.
      • He complatins chest pain, chest tightness, short of breathing, 12 lead EKG: II, III, aVF ST elevate, follow-up right side 12 lead EKG showed acut MI/ STEMI, so we need your help, thanks a lot!!
    • A
      • The patient was examined and hx was reviewed.
      • O
        • nsp chest tightness and chest pain;
          • aggravated productive cough with wheezing+ in recent days;
        • CxR: elevated L’t diaphragm, suspected LLL consolidation;
        • 2D echo showed preserved LV systolic function; no evidence of segmental asynergy.
      • Imp
        • Sinus tachcyardia, possibly due to underlying infection (possibly L’t pneumonia); no evidence of STEMI now.
      • Suggestion
        • Treat L’t pneumonia and bronchospasm firstly.
        • Check thyroid function for tachycardia survey.
  • 2023-01-09 Gastroenterology
    • Q
      • For esophagus balloon dilation
      • This 60-year-year-old male has the medical history of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He was found esphagus relapse and suspicious hypopharyngeal involvement by PES was done on 2022/04/13 and nasopharyngoscopy 2022/05/02.
      • He received 6 courses CCRT with PF from 2022/06/02 ~11/04. Radiotherapy from 2022/05/30~7/27.
      • This time, he was admitted for exam and chemotherapy on 2023/01/08.
      • He under went CRE balloon dilatation again on 2022/12/19 which showed esophageal inlet stricture.
      • Thus we need your expertise for his balloon dilatation at this admission. Thanks a lot!
    • A
      • 60M, A case of 1) Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence. 2) Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0. 3) Squamous cell carcinoma of the middle third esophagus. We are consulted for CRE balloon dilatation.
      • S+O:
        • conscious status: clear
        • HEENT: dysphagia, including drinking water
        • chest: smooth breath sound
        • abdomen: soft and flat
        • Lab
          • WBC: 4700
          • Hb: 11
          • Plt: 208
          • AST/ALT: 30/26
          • INR: 1
          • PT: 10.3
        • EGD(2022/12/19):
          • Esophageal inlet stricture, s/p endoscopic balloon dilatation
      • A:
        • Esophageal squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Esophageal inlet stricture
        • quamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0.
      • P:
        • We will arrange EGD for endoscopic balloon dilatation evaluation.
  • 2022-12-13 Thoracic Surgery
    • Q
      • He underwent jejunostomy surgery on 2022/05/06 by doctor Hsieh. The patient complaint about redness around Jejunostomy with leakage recently. We need your help for further evaluation. Thank you very much.
    • A
      • Dear Dr. Wan, I will visit the patient and educate about wound care. Thanks for your consultation!!
  • 2022-12-02 Gastroenterology
    • Q
      • The patient was unable to swallow even water. We need your help for further evalution of esophageal stent. Thank you very much.
    • A
      • Image
        • 2022/11/07 - asymmetric wall thickness and luminal dilatation of upper to middle third thoracic esophagus, seem in progression as compared with CT on 8/8. small LNs in visceral space
      • Impression
        • Dysphagia, suspicious obstruction of recurrent esophageal cancer
      • Suggestion
        • Please arrange Esophagography first to evalute the level of esophagus obstruction, then contact us for further management about esophageal stent placement
        • We would arrange EGD for tthis patient.
  • 2022-11-07 Rehabilitation
    • A
      • Assessment
        • Squamous cell carcinoma of upper to middle esophagus, cT3N3M0 stage IVA
        • Squamous cell carcinoma of the hypopharynx, p16 (+), stage cT2N2bM0
        • Carrier of viral hepatitis B
        • constipation
        • Dysphagia due to esophageal tumor progression
      • Plan
        • The patient is not suitable for swallowing training
        • Food and water cannot pass down the esophagus, they will go back retrogradely and cause aspiration or choking
  • 2022-07-08 Dental Clinic
    • Q
      • For dental evaluation and management
      • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy. He was extracting the teeth (14, 27, 28, 38, 45), and he received CCRT with PF. The family request consult dentistry for dental evaluation and management. Thanks a lot.
    • A
      • #11-#13 The dental bridge is loose, it is recommended to use interdental brushes to maintain oral hygiene.
      • A diagnostic certificate issued by an oral and maxillofacial surgery department is required.
    • 2022-06-09 Infectious Disease
      • A
        • Assessment
          • Consultation for Mepem antibiotic
          • 60-year-old esophageal cancer male patient has received recent chemotherapy
          • High fever yesterday afternoon despite Cravit use for left lung pneumonia.
          • Aspiration pneumonia is the first impression.
          • Sputum culture normal flora only.
          • Cravit is replaced by Mepem yesterday evening.
        • Suggestion:
          1. Continue Mepem for one week first.
          1. Check blood culture report, repeat sputum culture.
    • 2022-06-08 Family Medicine
      • Q
        • The patient and family request to combine hospice care (NHI card annoted DNR), so we need your help, thanks a lot!!
      • A
        • 60 y/o gentleman advanced esophageal cancer. admitted for CCRT
        • Our share care would follow up.
    • 2022-05-26 Thoracic Surgery
      • Q
        • This 60 y/o man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up.
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA status post jejunostomy and port-A catheter implantation on 2022-05-06.
        • The patient’s jejunostomy was done under your servise on 2022-05-06. This time, he was admitted due to acute epiglottitis. After admission, antibiotic with Cravit was given. The patient suffered from cold sweating and palpitation while G-tube feeding, and some yellowish discharge from jejunostomy for 4-5 days. NPO was told since last night. We request your consultation for further evaluation.
      • A
        • I have visited the patient and educated about care of jejunostomy. Thanks for your consultation!!!
    • 2022-05-10 Oral and Maxillofacial Surgery
      • Q
        • This is a 60-year-old man with past history of esophageal cancer (SCC, T2N2M0) lower third post CCRT in 2013 and HBV carrier without follow up. This time he has suffered from progressive dysphagia and weight loss of 8 kg in 1 month. In hematology OPD, chest CT was arranged and showed suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression and mediastinal lymphadenopathy.
        • Upper GI panendoscpope showed one lumen-obstructive tumor was noted from 25 to 30 cm and biopsy was done. Pathology revealed moderately differentiated squamous cell carcinoma. He was referred to our CS OPD. PET scan revealed a glucose hypermetabolic lesion involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis.Endoscopic biopsy proved Esophageal squamous cell carcinoma at middle/lower third esophagus. However, his EUS showed Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement.
        • We consult ENT Dr. Lan for hypopharynx lesion, nasopharngoscopy biopsy show squamous cell carcinoma.
        • After admission, we arranged WBBS, brain MRI, abd. sono, EUS and bronchoscope, for cancer work-up. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. We kept nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently. We also consulted ONCO and for further manegement.
        • Impression: upper to middle esophagus squamous cell carcinoma,cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma.
        • We need to consult you for for pre-RT dental evaluation and management.
      • A
        • This is a 60-year-old man suffered from upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. We were consulted for Pre-radiotherapy dental evaulation
        • O:
          • Hopeless teeth of tooth 14, 27, 28, 38, 45
          • Poor oral hygiene with full mouth gingivitis.
        • P:
          • Explain the finding to patient and his son.
          • Please prescribed Cefa 1g IV Q8H for prophhylaxis.
          • We were arranged further extraction for him .
          • OPD follow up.
    • 2022-05-09 Radiation Oncology
      • The patient’s history was reviewed and patient was examined.
      • S:
        • For radiotherapy due to recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • PI: The patient was a case of low third esophageal cancer (SCC, cT2N2M0) s/p CCRT in 2013 and HBV carrier without follow up. He suffered from progressive dysphagia since 2021 with body weight loss of 8 kg in 1 month. After a series of work-up, the impression was upper to middle esophageal squamous cell carcinoma, cT3N3M0 stage IVA and hypopharynx squamous cell carcinoma. On 2022-05-06, he underwent feeding jejunostomy + port-A insertion. Nutrition supplement with jejunostomy feeding since 2022-05-07 and increased calories gently.
        • Family history: (father: esophageal cancer).
        • Cancer site specific factors: Alcohol (quit); Smoking (quit); Betel nut (quit).
        • Personal Hx: DM(-); HTN(-); HBV(+)
      • O:
        • ECOG: 1
        • PE: neck and bil SCF: neg.
        • Pathology (2013-02-01; S2013-01656): Esophagus, esophagocardiac junction to 32 cm below incisor, biopsy — squamous cell carcinoma.
        • Esophagography (2013-02-22): lower esophageal cancer.
        • CXR (2013-02-18): neg.
        • Chest CT (2013-02-08): Soft tissue mass at lower third esophagus near EG junction up to 5*3.55cm with central necrotic part is found. There is no evidence of mediastinal LAP, however, some lymph nodes (3-4) around EG junction is noted. Esophageal cancer at lower third esophagus. T2N2M0 in the study. Stage IIIa.
        • PET scan (2013-02-20): Glucose hypermetabolism lesion in the esophagus, L/3, probably primary esophagus malignancy; hypermetabolism lesion in the right subcarinal region of mediastinum, probably reactive node or malignancy with lymph nodes metastasis. Staging: TxNxM0.
        • RT (2013-3-11 ~ 2013-4-15): 4500cGy/25fractions of the low third esophageal tumor to peripheral lymphatic area.
        • CT scan of mediastinum (2013-07): resolution of intraluminal mass in lower third of esophagus; post treatment change involving M/3 esophagus?
        • Pathology (S2021-11415, 2021-08-31): Esophagus, middle, 25 to 30 cm, biopsy — High-grade dysplasia (severe dysplasia).
        • CT scan of lung (2022-04-09): Suspected recurrent/residual esophageal cancer at middle/lower third esophagus with progression. Mediastinal lymphadenopathy.
        • UGI pandendoscopy (2022-04-13): One lumen-obstructin tumor was noted from 25 to 30 cm, s/p biopsy*8 (A). Lugol solution was applied. Area of sliver color sign was noted at 23-25cm. Biopsy was done. (A). One depressed lesion with loss of vasculature was noted at hypopharynx. Diagnosis: Esophageal cancer, s/p biopsy (A) + (B). Hypopharynx lesion, suspected metastatic lesion
        • Pathology (S2022-06234, 2022-04-14): Esophagus, 25 to 28 cm, biopsy — Squamous cell carcinoma, moderately differentiated
        • PET (2022-04-19): 1. Glucose hypermetabolism involving the middle portion of the esophagus and an adjacent lymph node, compatible with recurrent/residual esophageal malignancy with an adjacent lymph node metastasis. 2. Mild glucose hypermetabolism in some right neck level II lymph nodes, a left submandibular lymph node, a left supraclavicular lymph node and a right paratracheal lymph node. The nature is to be determined (inflammatory process? metastases of low FDG uptake?). 3. Glucose hypermetabolism involving the posterior pharyngeal wall of the hypopharynx. Hypopharyngeal malignancy should be considered. 4. Glucose hypermetabolism in a left neck level II lymph node and a left neck level IV lymph node. Metastatic lymph nodes may show this picture.
        • CXR (2022-04-27): a focal Rt-sided convexity of the azygoesophageal recess interface, raise suspicious of esophageal tumor. Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch. Clean lung fields based on plain image. Normal shape and size of heart. Marginal spurs of multiple vertebral bodies of T-L spine due to spondylosis. Normal appearance of both hila
        • MRI of brain (2022-04-28): No evidence of brain metastasis. Mild general brain atrophy.
        • Abd sono (2022-04-28): Hepatic lesion, S3, 1.22cm, suspected falciform ligament or hemangioma. Suspected calcified spot, left kidney.
        • Bone scan (2022-04-29): no evidence of bone metastasis.
        • Miniprobe EUS for UGI (2022-05-02): 1. Esophageal cancer, upper to middle esophagus, EUS estimated stage: at least T3NxMx with suspicious hypopharyngeal involvement. 2. Gastric polyp, body, PW, s/p biopsy. 3. Reflux esophagitis, LA grade A. 4. Hiatal hernia. 5. Superficial gastritis, body.
        • Operation (2022-5-6): Feeding jejunostomy + port A
        • Pathology (S2022-07892, 2022-5-9): Labeled as “Hypopharyngeal lesion”, punch biopsy — squamous cell carcinoma. IHC stains: CK5/6 (+), p40 (+), p16 (+, >70%).
      • A:
        • Squamous cell carcinoma of the L/3 esophagus, stage cT2N2M0 (stage IIIA), s/p CCRT, and s/p adjuvant chemotherapy, with local regional recurrence.
        • Squamous cell carcinoma of the hypopharynx, p16 (+).
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: recurrent esophageal carcinoma and hypopharyngeal carcinoma.
        • Goal: curative (if double primary), or palliation (if metastatic chypopharyngeal carcinoma).
        • Treatment target and volume: hypopharyngeal tumor, bilateral neck, to recurrent esopharyngeal tumor area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: probably 5000cGy/25 fractions of the esophageal tumor, bilateral neck, and 7000cGy/35 fractions of the hypopharyngeal tumor to involved neck nodal lesions (if hypopharyngeal carcinoma is 2nd primary).
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 10:30, 2022-05-11.
        • Please consult Dental department for pre-RT dental evaluation and management.
    • 2022-05-05 Hemato-Oncology
      • Impression:
        • Recurrent upper to middle esophagus squamous cell carcinoma, cT3N3M0 stage IVA
        • Hypopharynx tumor suspect SCC s/p biopsy, pending pathology
      • Suggestion
        • For recurrent esophagus cancer, SCC, systemic therapy is indicated (such as 5-FU/capecitabine + oxaliplatin[self-paid]/cisplatin) or clinical trial if available
        • Schedueled feeding jejunostomy + port-A had arranged
      • Thanks for your consultation. We will discuss with patient. If there is any problem, please feel free to let us known
    • 2022-05-02 ENT
      • A
        • Local finding: fair oral cavity and oropharynx
        • Scope: smooth nasopharynx and oropharynx; small whitish lesion over left pyriform sinus; bulging over right pyriform sinus; posterior hypopharyngeal wall ulcerative lesion; fair vocal cord movement.
        • Impression: hypopharyngeal malignancy cannot be ruled out
        • Plan: Biopsy for tissue proof may be required.

[surgical operation]

  • 2022-10-26 Removed port-A and insert new one. Revision of jejunostomy.
  • 2022-06-13 Tracheal stent inseriton.
  • 2022-05-06 Feeding jejunostomy

[radiotherapy]

  • 2022-05-30 ~ 2022-07-27 - 5000cGy/25 fractions (15MV and 6MV photon) of the hypopharyngeal tumor to bilateral neck, and 7000cGy/35 fractions of the reduced hypopharyngeal tumor to bilateral involved neck nodal area.

[chemoimmunotherapy]

  • 2023-02-02 - docetaxel 40mg/m2 65mg NS 200mL 1hr + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 400mg/m2 690mg NS 250mL 2hr + fluorouracil 1000mg/m2 1735mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 65mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2023-01-09 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-20 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-12-01 - docetaxel 40mg/m2 70mg NS 200mL 1hr + leucovorin 400mg/m2 700mg NS 250mL 2hr + fluorouracil 400mg/m2 700mg NS 250mL 2hr + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-D2 + cisplatin 40mg/m2 70mg NS 500mL 4hr D3
    • [dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg + NS 250mL] D1 + NS 500mL 2hr (after cisplatin) D3
  • 2022-11-04 - cisplatin 75mg/m2 130mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-30 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-09-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-08-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-07-04 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)
  • 2022-06-02 - cisplatin 75mg/m2 120mg NS 500mL 4hr D1 + fluorouracil 1000mg/m2 1700mg NS 500mL 24hr D1-4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + NS 500mL 2hr (before cisplatin) + NS 500mL 2hr (after cisplatin)

[note]

  • Esophageal and Esophagogastric Junction Cancers NCCN guidelines version 4.2022, 20220907
    • DEFINITIVE CHEMORADIATION (NON-SURGICAL) p51
      • Fluorouracil and cisplatin
        • Cisplatin 75-100 mg/m2 IV on Day 1
        • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4
        • Cycled every 28 days for 2 cycles with radiation followed by 2 cycles without radiation
      • ref: Minsky BD, Pajak TF, Ginsberg RJ, et al. INT 0123 (Radiation Therapy Oncology Group 94-05) phase III trial of combinedmodality therapy for esophageal cancer: high-dose versus standard-dose radiation therapy. J Clin Oncol 2002;20:1167
    • PERIOPERATIVE CHEMOTHERAPY (Only for adenocarcinoma of the thoracic esophagus or EGJ) p50
      • Fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) - (4 cycles preoperative and 4 cycles postoperative)
        • Fluorouracil 2600 mg/m2 IV continuous infusion over 24 hours on Day 1
        • Leucovorin 200 mg/m2 IV on Day 1
        • Oxaliplatin 85 mg/m2 IV on Day 1
        • Docetaxel 50 mg/m2 IV on Day 1
        • Cycled every 14 days
      • ref: Al-Batran S-E, Homann N, Pauligk C, et al. Perioperative chemotherapy with fluorouracil plus leucovorin, oxaliplatin, and docetaxel versus fluorouracil or capecitabine plus cisplatin and epirubicin for locally advanced, resectable gastric or gastrooesophageal junction adenocarcinoma (FLOG4): a randomised, phase 2/3 trial. Lancet 2019;393:1948-1957.
  • Concurrent Chemoradiotherapy with Docetaxel, Cisplatin, and 5-fluorouracil Improves Survival of Patients with Advanced Esophageal Cancer Compared with Conventional Concurrent Chemoradiotherapy with Cisplatin and 5-fluorouracil. J Cancer. 2018;9(16):2765-2772. Published 2018 Jul 16. doi:10.7150/jca.23456
    • All patients underwent chemotherapy and radiotherapy concurrently.
    • In the CF-RT group, cisplatin (70 mg/m2) was administered via intravenous drip infusion on day 1, and 5-FU (700 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • In the DCF-RT group, docetaxel and cisplatin (both 50 mg/m2) were administered via intravenous drip infusion on day 1, and 5-FU (500 mg/m2) via continuous intravenous drip infusion on days 1-5.
    • Patients underwent 2 cycles of chemotherapy during radiotherapy when no deterioration in overall health or occurrence of adverse events was verified.
    • Patients with severe neutropenia were immediately administered granulocyte-colony stimulating factor (G-CSF).

==========

2023-03-06

  • 2023-03-05 lab data CRP 5.25mg/dL.

  • 2023-03-05 sputum gram’s stain result showed:

    • G(+) Cocci 3+: There is a high amount of gram-positive cocci bacteria present in the sample being analyzed.
    • GNB 3+: There is a high amount of gram-negative bacilli bacteria present in the sample being analyzed.
    • Neutrophil/LPF <10 and/or Epithelial cell/LPF >25: This may indicate that the sample was not collected properly and that there is a risk of contamination.
  • As the staining results may suggest a possibility of contamination, it may be necessary to collect a new sample.

  • Moxifloxacin with an antibacterial spectrum encompassing both aerobic gram-negative and gram-positive strains, as well as anaerobic bacteria, can be used for pneumonia, community-acquired, outpatients with comorbidities and inpatients as an alternative agent. It is not recommended to be used in patients with risk factors for P. aeruginosa (ATS/IDSA [Metlay 2019]; File 2020). Based on the normal liver and kidney function lab results on 2023-03-05, the current dosage of 400 mg once daily is appropriate and does not require any adjustments.

2023-02-02

  • Lab data on 2023-02-01 were grossly normal. There is no problem with the active prescription, except for the anticipated less effective use of Boren-C by tube-feeding.

2023-01-09

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric-coated tablet designed to prevent the destruction of the bromelain enzyme by gastric juice.

  • Bromelain is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. ref: Mala T, Anal AK. Protection and Controlled Gastrointestinal Release of Bromelain by Encapsulating in Pectin-Resistant Starch Based Hydrogel Beads. Front Bioeng Biotechnol. 2021;9:757176. Published 2021 Oct 29. doi:10.3389/fbioe.2021.757176

  • There are no other drugs in the inventory that contain bromelain.

2022-12-19

  • It has been arranged on 20221219 for a CRE (controlled radial expansion) balloon dilatation and placement of an esophageal stent due to obstruction of cervical esophagus.
  • Medication is sometimes responsible for clogged feeding tubes. To prevent clogs and other related issues, there are general tips for giving medication through a feeding tube:
    • Administer each medication separately.
    • Stop the feeding and flush the tube with water before and after medication administration.
    • Crush only those medications which are immediate-release. Sustained-release and enteric-coated medications don’t dissolve well and may not absorb properly when crushed.
    • Use liquid medications when available.
    • Dilute liquid medications to prevent clogging and gastrointestinal upset, like diarrhea.

2022-12-12

[tube feeding]

  • Except for Broen-C, all oral medications in the active prescription can be administered by nasogastric tube.
  • In order to prevent the bromelain enzyme from being destroyed by gastric juice, Broen-C (bromelain + L-cysteine) is designed as an enteric-coated tablet.

2022-12-02

  • As a result of the CT result obtained on 2022-11-07, it appears that the esophageal tumor has progressed. It was then decided to change the regimen from [cisplatin + fluorouracil] to [docetaxel + leucovorin + fluorouracil + cisplatin], which was initiated during this hospitalization.
  • Neither a non-trivial adverse reaction nor an issue with the active prescription have been observed.

2022-12-01

[tube feeding]

  • With the exception of Boren-C, all other drugs in the active prescription can be administered via nasogastric tube.
  • As an enteric-coated tablet, Boren-C is designed to prevent gastric acids from destroying its key ingredient, bromelain enzyme.

2022-10-03

  • The underlying condition HBV is currently being managed with Vemlidy (tenovofir) without any problems.

2022-09-30

[tube feeding]

  • Broen-C (bromelain + L-cysteine) is an enteric coated tablet that should not be administered through a nasogastric tube. Right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

2022-09-05

[tube feeding]

  • As Harnalidge (tamsulosin 0.4mg PO QDAC) is not intended for use with nasogastric tubes, it is recommended to replace it with Urief (silodosin 8mg PO QD).
  • Broen-C (bromelain + L-cysteine) is formulated as an enteric coated tablet and is not intended for nasogastric tube feeding. Currently, there is no single ingredient bromelain item available in inventory, however, Actein (acetylcysteine 200mg/pk) is available and could partially serve as cysteine.

2022-06-06

  • Initially diagnosed in 2013, this patient now suffers from recurrent esophageal squamous cell carcinoma of cT3N3M0 stage IVA. He has begun receiving CCRT since late May 2022.
  • Additionally, the patient carries viral hepatitis B, which is treated with Vemlidy (tenofovir alafenamide) 25mg PO QDCC.

700081806

230303

[exam findings]

  • 2023-02-27 Patho - gingival/oral mucosa biopsy
    • Bone, chin, removal — Osteitis and osteonecrosis
  • 2022-09-20 MRI - nasopharynx
    • Indication: Recurrence SCC of mandibular gingiva
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
    • Pulse sequences:1. Precontrast: sagittal and axial, coronal T1WI, coronal T2WI images, axial T2WI 2. Post contrast: axial, coronal T1WI. Slice thickness: 3-5 mm
    • Comparison: 2022/05/13 MRI
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect at left mandible, bucco-gingival region.
      • No evident abnormal enlarged lymph node in the visible neck.
      • No obvious abnormal enhancement after contrast medium administration.
      • No obvious gingival nodule or mass was found, though early shallow lesion is hard to be defined on this study.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-15310
    • TC >= 1% and < 5%
    • Percentage of PD-L1 expressing tumor cells (%TC): 1%
  • 2022-09-12 Patho - soft tissue biopsy / simple excision (non lipoma)
    • Skin lesion, chin, frozen and excision — Squamous cell carcinoma, moderately differentiated
    • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated characterized by solid tumor nests show enlarged, pleomorphic nuclei infiltrate in the stroma with keratin formation.
  • 2022-09-09 CT - facial bone
    • Indication
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival (T1N0M0 stage I) s/p OP with tongue flap .
      • SCC of lower lower gingival (T4N0M0 stage IV) s/p OP with fibula flap reconstruction
      • During CCRT
      • The STSG wound of left fibula region was healing in progress .
      • Multiple ulceration of left floor of the mouth
      • A little swelling of chin region .
    • Protocol: 2.5mm slice thickness, axial scan and coronal/ sagittal reconstruction
    • Without contrast fical bone CT showed
      • The neck airway was unremarkable.
      • Suspicious a break at the metallic plate of the left posterior mandible.
      • Post-operation change at left buccal region, mandile and maxilla.
      • No neck LAP
    • IMp: suspicious a break at the metallic plate of the left posterior mandible.
  • 2022-07-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • Tissue blocks/unstained slides received labeled as: S2022-09325A1
    • Tumor cell (TC) staining assessment: TC < 1%
  • 2022-06-09 Patho - oral cancer (wide excision without lymph node)
    • PATHOLOGIC DIAGNOSIS
      • Mandibular gingiva, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, llevel 3, right, LN dissection — Negative for malignancy (0/1)
      • Bone, mandible, segmental mandibulectomy — Involved by carcinoma and free margin
      • Pathology stage: rpT4aN0(cM0); Stage IVA
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + segmental mandibulectomy + LN dissection
      • Specimen Type:
        • Main location: Left mandibular gingiva
        • Lymph node dissection: Yes, right level III
      • Specimen Integrity: intact
      • Specimen Size: 7.2 x 4.2 x 3.5 cm with skin 3.9 x 3.2 cm, mandible bone, 7.2 cm in length, and three teeth
      • Tumor Site: Mandibular gingiva; Laterality: Left
      • Tumor Focality: Single focus
      • Tumor Size: 2.0 x 1.0 x 0.8 cm
        • Depth of Invasion: 8 mm
      • Mucosal Surface : Ulcerated
      • Gross Tumor Extension: Tumor invades bone
      • Representative parts are taken for section and labeled: A1= tumor + anterior margin of mouth floor, A2= tumor + upper lip, A3= tumor + mouth floor, A4= tumor + buccal mucosa, A5= tumor + skin, A6= lower lip, A7= posterior area of molar, A8= mandible bone. B= level 3 lymph node. F2022-00263 FSA= mouth floor, left, FSB= mouth floor, right
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (moderate differentiated)
      • Microscopic Tumor Extension: To mandible bone
      • Margins: Margins free, Distance from closest margin: 0.5 cm (anterior margin of mouth floor)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes: Negative (0/1)
        • Number of LN examined: 1 (right level 3)
        • Number of LN metastasis: 0
      • Mandibule bone margin: Free of tumor
      • Surgical margins received for frozen section, including mouth floor, right and mouth floor left: Free of tumor
  • 2022-05-13 MRI - nasopharynx
    • Indication:
      • SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
      • SCC of left lower gingival s/p OP with tongue flap .
      • A ganuloma like mass was noted of left commisure region with bleeding tendancy s/p CO2 laser surgery on 2022/04/25. Pathology report: SCC
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • ill-defined enhancing mass lesion (largest diameter about 3.3cm) at left lower gingiva and oral commisure, with invasion to mandibular bone causing cortex destruction and bone marrow signal change, and probably also invasion to left inferior alvealar nerve. T4a disease is compatible.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Recurrent left lower gingival cancer, image staging favor T4aN0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T4a(T_value) N:0(N_value) M:____(M_value) STAGE:IVA(Stage_value)
  • 2022-05-10 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a faint hot spot in the midline lower frontal area of the skull and increased activity in the mandible, sacrum, bilateral shoulders and right sternoclavicular junction in whole body survey.
    • IMPRESSION:
      • Increased activity in the mandible. The nature is to be determined (dental problem? malignancy with local bone invasion?). Please correlate with other clinical findings for further evaluation.
      • Mildly increased activity in the sacrum. Degenerative change may show this picture.
      • A faint hot spot in the midline lower frontal area of the skull. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and right sternoclavicular junction, compatible with benign joint lesions.
  • 2022-04-25 Patho - gingival / oral mucosa biopsy
    • Oral cavity, left lower gingival, incisional biopsy — moderately differentiated squamous cell carcinoma
    • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests and sheets of non-keratinizing tumor cells in infiltrative growth pattern with squamous differentiation and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • Immunohistochemical stain reveals p16(-).
  • 2021-11-15 Patho - gingival/oral mucosa biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, left lower gingiva, wide excision — Squamous cell carcinoma
      • Resection margins, ditto — Tumor present at one of peripheral margins
      • Lymph node — N/A
      • AJCC Pathologic staging — pT1, if cN0 and cM0, stage I
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): wide excision
      • Specimen Type:
        • Main location: left lower gingiva
        • Other part(s) included: N/A
        • Lymph node dissection: NO
      • Specimen Integrity: Intact
      • Specimen Size: 1.0 x 0.7 x 0.4 cm
      • Tumor Site: left gingiva
      • Tumor Focality : solitary
      • Tumor Size: 0.4 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 0.1 cm
      • Mucosal Surface: ulcerative tumor
      • Gross Tumor Extension (specify) : can not be assessed
    • MICROSCOPIC EXAMINATION
      • Histologic Type: squamous cell carcinoma
      • Histologic Grade: G2, moderately differentiated
      • Microscopic Tumor Extension: 0.1 cm
      • Margins: tumor present at one of peripheral margins , < 0.1 cm from base
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: absent
      • Neck Lymph Nodes: N/A
      • Immunohistochemistry: CK5/6(+), P63(+), P53(+) and P16(-) for tumor
  • 2021-11-12 MRI - nasopharynx
    • History:
      • Squamous cell carcinoma of left buccal mucosa ,pT1N0M0 post of operation (2012)
      • Squamous cell carcinoma of left upper gingiva, pT1N0(cM0) post of operation (2017)
      • A verrucous like mass was noted of left lower gingival about 0.5 cm in diameter. Pathological report: Squamous cell carcinoma in situ at least.
    • Imaging protocol: 3-5mm slice thickness; coronal T1 & T2, sagittal T1, axial T1 & T2FS & DWI/ADC, axial and coronal T1FS+C images
    • Neck MRI without/with Gadolinium-based contrast enhancement shows:
      • magnetic suceptibility artifacts from dental prosthesis obscure the image details in oral cavity.
      • postoperative change at left buccal region, left neck, and left submandibular space.
      • the primary lesion at left lower gingiva is not obviously seen in this image study. No mandibular bone invasion is noted.
      • no enlarged cervical lymphadenopathy.
    • Impression:
      • Left lower gingival cancer, image staging favor T1N0.
      • Postoperative change at left buccal region and left neck.
    • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage) : T:T1(T_value) N:0(N_value) M:M0(M_value) STAGE:I(Stage_value)
  • 2021-11-04 Patho - gingival/oral mucosa biopsy
    • Gingiva, left lower, incisional biopsy — Squamous cell carcinoma in situ at least
    • The sections show squamous cell carcinoma in situ at least, composed of squamous epithelium with hyperkeratosis, parakeratosis, acanthosis, keratin pearls, marked cellular atypia and atypical mitotic figures. Changes involving the whole thickness of the epithelium. No stromal component can be found, and squamous cell carcinoma can not be excluded. Suggest excision.
  • 2021-04-24 MRI - nasopharynx
    • Indication: SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I). follow up.
    • IMP: C/W left buccal cancer s/p operation without recurrence. Stationary as compared with MRI on 20190907.
  • 2021-04-06 Patho - fissure/fistula
    • Anus, fistulotomy and hemorrhoidectomy — hemorrhoid and consistent with anal fistula
  • 2020-04-07 Whole body PET scan
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2019-09-07 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20190126.
  • 2019-01-26 MRI - nasopharynx
    • For oral cancer follow up. SCC of left buccal mucosa (T1N0M0 stage I) s/p OP ; SCC of left upper jaw (T1N0M0 stage I)
    • IMP: C/W left buccal cancer s/p operation, without recurrence. Stationary as compared with MRI on 20180629.
  • 2018-06-29 MRI - nasopharynx
    • bilateral neck LNs, stationary.
  • 2017-12-20 MRI - nasopharynx
    • prominent buccal mucosa in the right inferior buccal region. Nature? bilateral neck LNs, stationary.
  • 2017-08-09 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-05-04 Surgical pathology Level VI
    • PATHOLOGIC DIAGNOSIS
      • Gingiva, upper, left, wide excision — Squamous cell carcinoma
      • Lymph nodes, level V, left neck, dissection — No metastatic carcinoma (0/3)
      • Pathology stage: pT1N0(cMx)
    • MACROSCOPIC EXAMINATION
      • Surgical Procedure(s): Wide excision + neck dissection
      • Specimen Type:
        • Main location: Left upper gingiva
        • Other part(s) included: Bone of left maxilla
        • Lymph node dissection: Yes (specify): Left neck level V
      • Specimen Integrity: Intact
      • Specimen Size: 3.5 x 2.4 x 2.0 cm
        • Additional dimensions (maxilla bone): 3.0 x 1.5 x 1.0 cm
      • Tumor Site: Left upper gingiva
      • Tumor Focality: Single focus
      • Tumor Size: Greatest dimension: 0.5 cm
        • Additional dimensions (if available): 0.5 x 0.3 cm
        • Tumor thickness (for pT1 and pT2 tumors only): 3 mm
      • Mucosal Surface: Intact
      • Gross Tumor Extension: To subepithelial connective tissue
      • Representative parts are taken for section and labeled as: A1= anterior palatal, A2= palatal gingiva, A3= posterior buccal, A4= superior buccal, A5= anterior buccal, A6= bone, B= level V LN, C= left maxilla bone.
      • The specimen received for frozen section consists of four pieces of gray red soft tissue, labeled cheek mucosa, maxillary site, anterior margin, posterior margin; measuring 0.6 x 0.4 x 0.3 cm, 0.7 x 0.5 x 0.4 cm, 0.4 x 0.3 x 0.2 cm, 0.5 x 0.3 x 0.2 cm; respectively. All for paraffin section and labeled as: S2017-06679FS.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G2 (Moderately differentiated)
      • Microscopic Tumor Extension: To subepithelial connective tissue
      • Margins: Free, Distance from closest margin: 3 mm (superior buccal margin)
      • Lymph-Vascular Invasion: Not identified
      • Perineural Invasion: Not identified
      • Neck Lymph Nodes:
        • Ipsilatera (specify)l: level V
        • Number examined: 3
        • Number involved: 0
      • Left maxilla bone: Free of tumor
      • Margins for frozen section, including cheek mucosa, maxillary site, anterior margin, posterior margin: Free of tumor
  • 2017-04-29 MRI - nasopharynx
    • Left buccal CA, post OP with neck LNs dissection. No tumor recurrence. Small bilateral neck LNs, stationary.
  • 2017-04-26 Whole body bone scan
    • No evidence of bone metastasis.
    • Suspected benign lesions in the lower frontal area of the skull, maxilla, mandible, sacrum, bil. shoulders, elbows, and knees.
  • 2017-04-19 Surgical pathology Level IV
    • Left maxilla, biopsy — Squamous cell carcinoma IHC stain p16 (-)

[consultation]

  • 2022-06-24 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the left mandibular gingiva, stage rpT4aN0(cM0), Stage IVA; s/p operation (Wide excision of the malignant tumor of left mandibular gingiva plus segmental mandibulectomy. Intermaxillary fixation. Complicated extraction of tooth 31, 41, 42. Left fibula osseocutaneous free flap reconstruction. STSG (16*5cm) from the left thigh for wound closure of the left calf).
      • P: Radiotherapy is indicated for this patient with the following indicators: stage rpT4aN0(cM0)
        • Goal: curative
        • Treatment target and volume: left mandibular gingiva tumor bed, peripheral, to bilateral neck
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left mandibular gingiva tumor bed, peripheral, to bilateral neck, and 6000cGy/30 fractions of the left mandibular gingiva tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his family. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-06-30.

[radiotherapy]

[chemoimmunotherapy]

  • 2023-03-03 - cetuximab 250mg/m2 400mg 2hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-16 - cetuximab 250mg/m2 400mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-01-16 - cetuximab 400mg/m2 700mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 200mL 3hr
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-12-26 - docetaxel 40mg/m2 70mg NS 150mL + cisplatin 32mg/m2 60mg NS 150mL 3hr + leucovorin 80mg/m2 150mg & fluorouracil 800mg/2 1500mg NS 1000mL 22hr
    • dexamethasone 4mg + diphenhydramine 30mg
  • 2022-12-12
  • 2022-11-21
  • 2022-11-11
  • 2022-10-18
  • 2022-10-11
  • 2022-09-27
  • 2022-09-19
  • 2022-08-16
  • 2022-08-09
  • 2022-07-26
  • 2022-07-19

[assessment]

  • Lab data

    • 2023-03-03 CRP 3.90 mg/dL
    • 2023-02-27 CRP 0.34 mg/dL
    • 2023-02-23 CRP 0.68 mg/dL
    • 2023-02-16 CRP 0.57 mg/dL
    • 2023-03-03 WBC 20.65 x10^3/uL
    • 2023-02-27 WBC 1.34 x10^3/uL
    • 2023-02-23 WBC 1.67 x10^3/uL
    • 2023-02-16 WBC 5.48 x10^3/uL
    • 2023-03-03 HGB 10.4 g/dL
    • 2023-02-27 HGB 7.3 g/dL
    • 2023-02-23 HGB 8.2 g/dL
    • 2023-02-16 HGB 8.8 g/dL
    • 2023-03-03 PLT 198 x10^3/uL
    • 2023-02-27 PLT 210 x10^3/uL
    • 2023-02-23 PLT 230 x10^3/uL
    • 2023-02-16 PLT 249 x10^3/uL
  • According to recent lab results, there is no longer leukopenia observed, but instead an overboosted WBC count accompanied by an elevated CRP reading (G-CSF administered on 2023-02-27). Please be aware of any signs of infection or inflammation. Anemia has gradually improved, and there is no observed thrombocytopenia.

  • The patient received injectable Amsulber (ampicillin + sulbactam) from 2023-02-23 to 2023-03-02 and has been taking oral Soonmelt (amoxicillin + clavulanic acid) since 2023-03-03. However, there has been no recent culture result available for the patient.

  • The laboratory results from 2023-02-28 also showed 4+ stool occult blood, which could be a possible cause of the anemia. It would be beneficial to rule out gastrointestinal bleeding before discharging the patient.

700052706

230302

[exam findings]

  • 2023-02-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spines, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2022/08/18, the lesions in the middle T-spines are slightly more evident. Degenerative change in slightly more severe status is more likely. Please correlate with other imaging modalities for further evaluation.
      • No prominent change is noted in other bone lesions.
  • 2023-02-13 SONO - abdomen
    • mild fatty liver (incomplete exam of liver)
    • fatty infiltration of pancreas
  • 2023-02-01 Patho - gingival/oral mucosa biopsy
    • Labeled as “right mandibular gingiva near tooth of #43”, incisional biopsy — squamous cell carcinoma.
    • IHC stain: p16 (-).
  • 2023-01-20 MRI - nasopharynx
    • History: previous MRI showed an enlarged lymph node (14 mm) at right surpaclavicular fossa. He had received a series of operations on 2022-09-09 at the right buccal mucosa, retromolar trigone area and soft palate.
    • Without- and with-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), and axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm) and axial T1WI with FS (thickness=5 mm, gap=1mm) show:
      • Post-operation change at bilateral buccal regions, with flap reconstruction at left part of palate and buccal region.
      • S/P lymph node dissection on both sides of the neck.
      • No abnormality at nasopharynx, oropharynx, hypopharynx and larynx.
      • A 14-mm lymph node at right supraclavicular fossa, and a 7.5-mm one at left supraclavicular fossa. Stationary as compared with MRI on 20220817.
      • Atrophy with fatty degeneration of left parotid gland.
      • New lesions with diffuse heterogeneous enhancement along right pterygopalatine fossa and pterygoid muscles and temporalis mcsules near right pterygoid plate. Abnormal enhancement also noted along post-operated right posterior buccal region. D/D: recurrence or inflammatory process.
    • IMP:
      • C/W oral cancer s/p treatment, with highly suspicious recurrence along right pterygopalatine fossa and pterygoid plate.
      • Bilateral supraclavicular lymph nodes, stationary as compared with MRI on 20220817.
  • 2022-09-19 PD-L1 IHC (28-8 pharmDx Assay, Agilent/Dako)
    • PD-L1 Immunostaining Result, S2022-15256A1
      • Tumor cell (TC) staining assessment: TC >= 1% and < 5%
      • Percent of PD-L1 expression in tumor cells (TC): 1%
  • 2022-09-12 Patho - oral cancer (wide excision without lymph node)
    • Diagnosis
      • Buccal mucosa, right, wide excision —- Squamous cell carcinoma, moderately differentiated, AJCC 8th edition: pStage I, pT1Nx(if cM0)
      • Buccal mucosa, right, posterior tumor margin, re-excision —- Mild dysplasia
      • F2022-00419
        • FsA: Palatoglossal fold, resection margin, biopsy — Negative for malignancy
        • FsB: Oropharynx, resection margin, biopsy — Negative for malignancy
        • FsC: Posterior margin, resection margin, biopsy — Severe dysplasia, at least
        • FsD: Upper posterior margin, resection margin, biopsy — Negative for malignancy
        • FsE: Inferior posterior margin, resection margin, biopsy — Negative for malignancy
        • FsF: Middle inferior margin, resection margin, biopsy — Negative for malignancy
        • FsG: Anterior margin, resection margin, biopsy — Negative for malignancy
        • FsH: Inferior tumor margin, resection margin, biopsy — Negative for malignancy
    • Microscopic examination
      • Histologic Type: Squamous cell carcinoma,
      • Histologic Grade: G2: Moderately differentiated,
      • Microscopic Tumor Extension: (specify) submucosa
      • Margins (obtained from the main resection specimen): …
      • Lymph-Vascular Invasion: not identified
      • Perineural Invasion: not identified
      • Neck Lymph Nodes: not received
      • Extranodal extension: not received
      • Additional Pathologic Findings: The posterior tumor margin reveals focal residual squamous epithelium with mild dysplasia.
      • F2022-00419 Sections of the 8 specimens show squamous mucosa and salivary glands without malignancy. Severe dysplasia is seen in posterior margin specimen.
  • 2022-08-18 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the maxilla, mandible, middle T-spine, some L-spines, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2017/11/14, the lesions in some L-spines are slightly more evident. Degenerative change in slightly more severe status may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Other bone lesions are either stationary or a little less evident, possibly more benign in nature.
  • 2022-08-17 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. Stationary as compared with MRI on 20220304.
  • 2022-08-17 SONO - abdomen
    • renal cyst, bilateral
    • most pancreas masked by gas
  • 2022-08-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, incisional biopsy — verrucous carcinoma with high grade dysplasia.
    • IHC stain: p16 (-).
  • 2022-03-04 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20210715.
  • 2021-07-15 MRI - nasopharynx
    • C/W oral cancer s/p treatment without evidence of recurrence. An enlarged lymph node (14 mm) at right surpaclavicular fossa. Stationary as compared with MRI on 20200916.
  • 2020-09-16 MRI - nasopharynx
    • post-OP change in left maxilla floor, hard palate, upper bucco-gingival regions.
    • No local tumor recurrence.
    • No neck LAP.
  • 2020-08-30 CT - abdomen
    • dilated small bowels. suspected small bowel ileus
  • 2020-03-09 MRI - nasopharynx
    • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows: (comparison: 2019/10/18 MRI)
      • Post fat-containing flap reconstruction surgery with clips/sutures retention and/or bony defect of left maxilla floor, hard palate, upper bucco-gingival region. No obvious focal mass or nodule, stationary.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
      • Post resection of left submandibular gland.
      • No evident abnormal enlarged lymph node in the visible neck.
      • Presence of thick fluid accumulation and thickened mucoperiosteum in the bilateral paranasal sinuses.
      • No obvious abnormal enhancement after contrast medium administration.
    • Impression:
      • Stationary post OP change in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2019-10-22 Surgical pathology level VI
    • Pathologic Diagnosis
      • Buccal mucosa, right, wide excision — Squamous cell carcinoma
      • Resection margins, the same as above and frozen section — Free of tumor invasion
      • Lymph node, submandibular and submental gland, dissection — Free of tumor metastasis (0/5)
      • Lymph node, superficial Level II, the same as above — Free of tumor metastasis (0/2)
      • Lymph node, parotid area, dissection — Free of tumor metastasis (0/1)
      • Lymph node, Level III, dissection — Free of tumor metastasis (fat only)
      • AJCC Pathologic staging — pT1N0Mx, at least stage I.
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma
      • Histologic Grade: G1: Well differentiated
      • Microscopic Tumor Extension: 0.35 cm in thickness
      • Margins: Free, less than 0.1 cm from base, 0.1 cm from posterior margin, 0.6 cm from anterior margin, 0.5 cm from superior margin and 0.5 cm away from inferior margin
      • Lymph-Vascular Space Invasion: absent
      • Perineural Invasion: Present
      • Neck Lymph Nodes: free from tumor metastasis (0/8)
      • Salivary gland, submandibular and submental gland LN: chronic sialoadenitis
  • 2019-10-18 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. No evidence of right lower buccogingival lesion based on this study.
  • 2019-10-02 Surgical pathology level IV
    • Right buccal mucosa, biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stain: p16 (-)
  • 2019-05-02 MRI - nasopharynx
    • CC: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01. He complains of dry mouth and pain at his left lower lip area occasionally. The patient became anxious and sought medical attention at both Shuang Ho Hospital and Far Eastern Memorial Hospital, where they received cryotherapy treatment (2018-11-01).
    • Cancer Site-Specific Factors
      • Betel nut chewing [present]: 20 nuts per day, for the past 20 years.
      • Smoking [present]: 20 cigarettes per day, for the past 20 years.
      • Alcohol consumption [none].
    • Indication:
      • S: He is an oral cancer patient and received 3 cycles of induction chemotherapy followed by cancer operations and CCRT. CCRT ended on 2018-02-01.
      • O: cheilis of both oral commissure combined with fungus infection are noted. leukoplakia of the right palatoglossal fold is still present after injection treatment. chronic abnormal erythymatous lesion on the inner surface of lower lip near left oral commissure are still noted.
      • A: SCC of left maxillary gingiva with bone invasion (cT4aN1M0 before) (2017/11/17 OP) (pT4aN0M0)
      • P:
        • check BUN and creatinine before MRI examination
        • arrange MRI with contrast to evaluate undermining tumor status
    • IMP
      • Post OP in left maxilla floor, hard palate, upper bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-11-01 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions. No local tumor recurrence. No neck LAP.
  • 2018-03-06 MRI - nasopharynx
    • Post flap reconstruction surgery in left maxilla floor, hard palate, bucco-gingival regions.
  • 2017-11-20 Surgical pathology level VI
    • Pathologic Diagnosis
      • Gum, left upper, wide excision — Squamous cell carcinoma, moderately differentiated, with invasion to maxillary sinus, s/p induction chemotherapy
    • Microscopic Examination
      • Histologic Type: Squamous cell carcinoma, s/p induction chemotherapy; The immunohistochemical stain of p16 is negative.
      • Histologic Grade: G2: Moderately differentiated
      • Microscopic Tumor Extension: (specify) maxillary sinus
  • 2017-11-14 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot spot in the inferolateral aspect of right orbital area of the skull, some faint hot spots in bilateral rib cages and increased activity in the left aspect of the maxilla, middle T-spine, bilateral shoulders, bilateral sternocalvicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the left aspect of the maxilla. Malignancy with local bone invasion should be watched out. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the middle T-spine. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A hot spot in the inferolateral aspect of right orbital area of the skull and some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternocalvicular junctions, hips and knees, compatible with benign joint lesion.
  • 2017-11-13 MRI - nasopharynx
    • Indication: SCC of left maxillary gingiva with bone invasion (cT4aN2bM0)
    • Impression:
      • Residual left maxillary gingiva tumor with bone involvement, in regression
      • compared with previous brain MRI study.
      • paranasal sinusitis.
      • no cervical enlarged LNs.
  • 2017-08-14 Nerve Conduction Velocity, NCV
    • The NCV study showed (1) Prolonged distal motor latency and slowing of sensory nerve conduction velocity in bilateral median nerves. (2) Slowing of motor nerve conduction velocity in left ulnar nerve across elbow. (3) Decreased CMAP amplitude and slowing of motor conduction velocity in left peroneal nerve. (4) Decreased SAP amplitude in left ulnar nerve.
    • The F wave study showed prolonged latency in all sampled nerve of lower limbs. The H reflex showed prolonged latency of left side. The above findings suggest bilateral lumbosacral polyradiculopathy and entrapment neuropathy of bilateral median nerves at the wrist and left ulnar nerve across elbow. Advise careful clinical correlation.
  • 2017-08-12 MRA - brain
    • Indication: SCC of left maxillary gingiva with bone invasion
    • Impression:
      • Essential normal brain MR study.
      • Left chronic paranasal sinusitis

[chemotherapy]

  • 2023-02-22 - cetuximab 250mg/m2 460mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 1000mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2023-02-15 - cetuximab 400mg/m2 740mg 2hr + docetaxel 40mg/m2 70mg NS 150mL 1hr + cisplatin 40mg/m2 70mg NS 500mL 2hr + [leucovorin 100mg/m2 180mg + fluorouracil 1000mg/m2 1800mg + NS 500mL] 22hr D2 (TPF Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • 2022-08-30 ~ 2023-02-09 - UFT (tegafur + uracil) KUFT01 2# BID
  • 2017-10-26 ~ 2017-11-16 - UFT 2# BID

[assessment]

  • Leukopenia was observed in the patient, with a count of 1.97 K/uL, on 2023-02-27. This occurred 5 days after the patient received the second cycle of chemoimmunotherapy (cetuximab + TPF).
  • This patient also took UFT from 2022-08-30 to 2023-02-09. As UFT has been discontinued for some time, it is less likely to be the cause of the recent leukopenia.
  • According to the National Health Insurance medication reimbursement regulations, patients with malignant diseases who have experienced leukopenia (less than 1000/uL) or neutropenia (ANC less than 500/uL) after receiving chemotherapy are eligible to use short-acting granulocyte colony-stimulating factor (G-CSF) injections, such as filgrastim or lenograstim.
  • Self-paid G-CSF may be considered by the patient as an option to rapidly increase his white blood cell count.

700280118

230302

[exam findings]

  • 2023-02-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (132 - 56) / 132 = 57.58%
      • M-mode (Teichholz) = 58
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • Thick LVPW, Impaired LV relaxation
  • 2023-01-13 SONO - right knee
    • Right knee joint fluid. The differential diagnosis includes, but is not limited to hemarthrosis, gouty arthropathy.
  • 2023-01-03 Patho - bone marrow biopsy
    • PATHOLOGIC DIAGNOSIS
      • Bone marrow, biopsy — Myelodysplastic syndrome with excess blasts (RAEB-1)
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD71: positive for erythroid series
        • CD61: positive for megakaryocytes
        • CD117: positive for blast
        • CD34: positive for blast
        • CD138: positive for plasma cell
      • Histochemical stain:
        • Reticulin: increased reticulin fibers
    • Microscopically, the sections show pictures as follows:
      • Hypercellularity for his age >90%
      • M/E ratio about 2-3/1, proliferation with left shift maturation of myeloid and erythroid series
      • Proliferative megakaryocytes with nuclear dysplasia and clustering, accompanied by grade 2 (MF-2) reticulin/collagen fibrosis
      • Increased blast (5-9%)
      • Scater distribution of plasma cells
      • Myelofibrosis and osteosclerosis
      • According to all above histopathologic findings, it is suggestive of myelodysplastic syndrome with excess blasts, compatible with RAEB-1 and myelofibrosis. Please correlate with clinical and bone marrow smear findings for conclusive diagnosis.
  • 2022-12-28 SONO - abdomen
    • Splenoemgaly
  • 2022-07-25 Patho - stomach biopsy
    • Stomach, lower body, biopsy — Chronic erosive gastritis, Helicobacter Pylori: NOT present
  • 2022-07-25 SONO - abdomen
    • splenomegaly, mild to moderate
    • pancreas almost not shown
  • 2022-07-25 Esophagogastroduodenoscopy, EGD
    • Reflux esophagitis LA Classification grade A
    • Gastric ulcer, multiple, shallow, lower body, s/p biopsy
    • Hiatal hernia
  • 2022-06-17 Patho - gingival/oral mucosa biopsy
    • Labeled as “right buccal mucosa”, excisional biopsy — verrucous hyperplasia, involving un-oriented and unspecified excisional side margin.
  • 2021-11-01 MRI - nasopharynx
    • History: a tongue cancer at the right side was noted and he had received cancer surgeries on 2021-07-07. suspected SCC of right floor of mouth (cT2N2bM0)
    • Indication:
      • S: He is cheek cancer (2016-09) and tongue cancer (2017-03). He finished 3 cycle of induction chemothrapy followed by surgery to remove oral cancer (2016-06).
      • O: Toothace due to gingivitis of residual teeth and residual roots of #22 is noted. red color change on the left palatlglossal fold is noted.
      • A:
        • Verrucous carcinoma of right tongue border (2017-03-15)
        • SCC of left buccal mucosa, lower gingiva and retromolar area, size about 5 cm with suspicous lymph node involment and skin invasion near oral commissure (cT3N1M0 preChemo) (2016-06) (pT2N0M0 postChemo)
      • P:
        • BUN and creatinine before the MRI examination
        • arrange MRI examination to evaluate the underming tumor status
    • Impression:
      • Post OP at right tongue and mouth floor, no obvious focal residual mass
      • Post OP at left bucco-gingival region with neck LNs dissection.
      • No local tumor recurence.
      • No neck LAP.
  • 2021-07-08 Patho - oral cancer (wide excision + lymph node)
    • Oral cavity, right mouth floor, wide excision — Well differentiated squamous cell carcinoma
  • 2021-06-03 Patho - gingival/oral mucosa biopsy
    • Labeled as “right floor of mouth and tongue”, incisional biopsy — Squamous cell carcinoma, well differentiated.
    • IHC stains: CK5/6 (+), p40 (+), p16 (-).
  • 2021-05-19 Tc-99m MDP bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, S-I joints, hips, right knee, and left ankle.
  • 2021-05-18 MRI - nasopharynx
    • Post OP at left bucco-gingival region with neck LNs dissection. No local tumor recurence. No neck LAP.
    • No obvious discernible right mouth floor lesion. Stationary and hard to define right tongue or mouth floor tumor? after comparing with 2020/02/11 MRI, need clinical correlation. (revised on 2021/06/10)
  • 2021-02-11 MRI - nasopharynx
    • Post-operation change without evidence of recurrence. Stationary as compared with MRI on 20190402.
  • 2020-02-05 Patho - gingival/oral mucosa biopsy
    • Right floor of mouth? biopsy — Verrucous hyperplasia. Please excise entire lesion for further patholoigcal evaluation.
  • 2019-04-02 MRI - nasopharynx
    • Post-operation change without recurrence. Stationary as compared with MRI on 20180828.
  • 2018-10-02 Surgical pathology level IV
    • Oral cavity, right, buccal mucosa, laser remove — Verrucous carcinoma — margin free
  • 2018-08-28 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2018-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-06-22 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.
  • 2017-03-15 Surgical pathology level IV
    • Tongue, right border, wide excision —- Verrucous carcinoma
    • Pathology stage: pStage I, pT1 Nx (cMx)
  • 2017-01-03 MRI - nasopharynx
    • Post flap reconstruction surgery at left bucco-gingival region with neck LNs dissection. No tumor recurence.

[consultation]

  • 2021-06-23 Hemato-Oncology
    • Q
      • This is a 51-year-old male who had medical history of squamous cell carcinoma of left bucco-gingival region with retromolar extension and possible anterior skin invasion, cT4aN1M0 status post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa thereafter. He didn’t return to OPD follow-up until this time with a painless malignant tumor with firm texture on the right floor of mouth and ventral tongue. After thorough tumor work-up, he was diagnosed with squamous cell carcinoma of right floor of mouth, cT2N2bM0. This time, he was admitted for surgical intervention. However, his platelet count was lower than average (50x10^3/uL) without any underlying known cause and coagulation defiency. Therefore, we need your expertise for further survey of idiopathic thrombocytopenia.
    • A
      • The 51 y/o male, a pt of L bucco-gingival SCC wt retromolar extension and possible anterior skin invasion, cT4aN1M0 s/p post induction chemotherapy and surgery, ypT2N0M0 in 2016 and several cancer surgeries for verrucous carcinoma of tongue and right buccal mucosa, was noted to have thrombocytopenia just before Op in June 2021.
      • The definite diagnosis of thrombocytopenia is to be under further investigation.
      • Image
        • Abd sono (20210520): splenomegaly.
      • Lab data
        • Hb (20210622):15.6, MCV:95.0, MCHCL34.5, plt:50K, WBC:3600
        • Hb (20210517):15.9, MCV:96.0, MCHC:34.6, plt:51K, WBC:4270
        • LFT & RFT (20210622): normal
        • HBsAg & antti-HCV (20210519): negative.
      • Dx: Thrombocytopenia, cause ? R/I splenomegaly related R/I idiopathic thromcytopenic purpura (ITP) R/I autoimmune related
      • Medical advice:
        • By Tracing his medical history, thrombocytopenia has been noted recently in May & June 2021.
          • Abd CT (20210520) showed splenomeagly. Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia.
        • May check Rheumatoid factor & ANA to exclude possible autoimmune dz. But autoimmune dz very rarely occurs in male pt. 
          • By clinical pictures, hematologic dz, TTP with toxic S/S, or DIC by infection were less likely to be the causes of thrombocytopenia of this pt. 
          • Splenomegaly related thrombocytopenia seems to be likely cause of thrombocytopenia if RF & ANA show negative.
        • If RF or ANA shows positive, may consult rheumatologist for further Tx. Tx of underlying autoimmune Dz may improve thrombocytopenia or may try prednisolone 1mg/kg/day for 2 weeks. If no response, splenectomy or IVIG or immunosuppressant (eg: Azathioprin, cyclophosphamide or Vincristine ) may be tried.
        • The current platelet count 50 K/uL is safe for this pt if no trauma happens. If platelet count requirement for Op is above 100K /uL, may consider platelet transfusion wt single donor ( pheresis ) platelet transfusion which is more effective to elevate platelet count & may less induce autoAb that will cause poor response to next platelet transfusion in the future.
          • But it is hard for pt wt splenomegaly related thrombocytopenia to elevate plt count by plt transfusion.

[chemotherapy]

  • 2023-03-01 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2023-02-02 - Vidaza (azacitidine) 75mg/m2 150mg SC D1-7

  • 2021-05-17 ~ 2021-07-05 UFT (tegafur + uracil) KUFT01

[assessment]

  • Lab data

    • WBC
      • 2023-03-01 WBC 21.51 x10^3/uL
      • 2023-02-27 WBC 3.45 x10^3/uL
    • HGB
      • 2023-03-01 HGB 7.4 g/dL
      • 2023-02-27 HGB 9.3 g/dL
    • PLT
      • 2023-03-01 PLT 16 x10^3/uL
      • 2023-02-27 PLT 3 x10^3/uL
      • 2023-02-26 PLT 7 x10^3/uL
      • 2023-02-24 PLT 17 x10^3/uL
      • 2023-02-22 PLT 12 x10^3/uL
      • 2023-02-19 PLT 6 x10^3/uL
      • 2023-02-17 PLT 4 x10^3/uL
      • 2023-02-15 PLT 1 x10^3/uL
      • 2023-02-14 PLT 2 x10^3/uL
      • 2023-02-13 PLT 1 x10^3/uL
      • 2023-02-12 PLT 1 x10^3/uL
      • 2023-02-11 PLT 1 x10^3/uL
      • 2023-02-10 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-09 PLT 1 x10^3/uL
      • 2023-02-08 PLT 7 x10^3/uL
      • 2023-02-08 PLT 3 x10^3/uL
      • 2023-02-07 PLT 2 x10^3/uL
      • 2023-02-06 PLT 1 x10^3/uL
      • 2023-02-04 PLT 3 x10^3/uL
      • 2023-02-03 PLT 1 x10^3/uL
      • 2023-02-02 PLT 2 x10^3/uL
      • 2023-02-01 PLT 3 x10^3/uL
      • 2023-01-30 PLT 5 x10^3/uL
      • 2023-01-18 PLT 6 x10^3/uL
      • 2023-01-16 PLT 7 x10^3/uL
      • 2023-01-13 PLT 10 x10^3/uL
      • 2023-01-11 PLT 9 x10^3/uL
      • 2023-01-10 PLT 6 x10^3/uL
      • 2023-01-08 PLT 5 x10^3/uL
      • 2023-01-06 PLT 3 x10^3/uL
      • 2023-01-05 PLT 5 x10^3/uL
      • 2023-01-03 PLT 15 x10^3/uL
      • 2023-01-02 PLT 7 x10^3/uL
      • 2022-12-31 PLT 7 x10^3/uL
      • 2022-12-27 PLT 9 x10^3/uL
      • 2022-12-27 PLT 7 x10^3/uL
      • 2022-07-13 PLT 15 x10^3/uL
      • 2022-03-29 PLT 24 x10^3/uL
      • 2021-07-12 PLT 44 x10^3/uL
      • 2021-07-09 PLT 74 x10^3/uL
      • 2021-07-07 PLT 125 x10^3/uL
      • 2021-07-06 PLT 153 x10^3/uL
      • 2021-07-05 PLT 77 x10^3/uL
      • 2021-06-22 PLT 50 x10^3/uL
      • 2021-05-17 PLT 51 x10^3/uL
  • According to the lab data on 2023-03-01, leukopenia has improved in the patient. However, anemia is still progressing, and blood transfusion might be necessary.

  • Erythropoiesis-stimulating agents (ESAs) have been recommended as an effective treatment option for lower-risk MDS, including biosimilar epoetin alfa. ref: Epoetin alfa for the treatment of myelodysplastic syndrome-related anemia: A review of clinical data, clinical guidelines, and treatment protocols. Leuk Res. 2019;81:35-42. doi:10.1016/j.leukres.2019.03.006

  • In addition to leukopenia and anemia, the patient has been experiencing thrombocytopenia for years with no substantial improvement. Therefore, increased risk of bleeding should be carefully monitored and managed.

  • Thrombocytopenia is a significant problem in myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Eltrombopag, a thrombopoietin receptor agonist, has shown potential clinical activity in MDS and AML clinical trials. Studies have shown that eltrombopag is well tolerated and clinically effective in both low-risk and higher-risk MDS and AML patients. ref: Eltrombopag reduces clinically relevant thrombocytopenic events in higher risk MDS and AML. Lancet Haematol. 2018;5(1):e6-e7. doi:10.1016/S2352-3026(17)30229-6

  • There was another study evaluated the safety and efficacy of Eltrombopag in low to intermediate risk myelodysplastic syndromes (MDS) patients. The primary efficacy endpoint was hematologic response at 16-20 weeks, and 44% of the patients responded. The safety profile was consistent with previous studies, and Eltrombopag was effective in restoring hematopoiesis in these patients. ref: Eltrombopag monotherapy can improve hematopoiesis in patients with low to intermediate risk-1 myelodysplastic syndrome. Haematologica. 2020;105(12):2785-2794. Published 2020 Dec 1. doi:10.3324/haematol.2020.249995

700207892

230301

[present illness] - 2023-02-27 admission note

  • The 44 year old woman has history of
    • Renal stone /p ESLW once and /p URS on 2018
    • Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV under Leukeran (chlorambucil) 2mg 1# qd treatment on 2021/05 ~ 2022.

[past history]

  • medication history:
    • small lymphocytic lymphoma/ chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV, ECOG:  1
  • operation history:
    • Renal stone s/p ESLW and URS
    • anal fissure and mixe dhemorhroids s/p operation
    • right thigh intramascular abscess s/p debridement                    

[allergy]

  • NKDA     

[family history]

  • no family history of DM, CAD, CVA and cancer

[exam findings]

  • 2022-10-13 Patho - abscess
    • Labeled as “right thigh soft tissue”, clinical history of chronic lymphocytic leukemia, debridement — chronic inflammation.
    • IHC stains: CD3 and CD20 show no predominant sub-population.
  • 2022-10-08 MRI - lower extremity
    • Indication: Small lymphocytic lymphoma / chronic lymphocytic leukemia with bone marrow involvement, Lugano stage IV
    • MRI of lower extremity without/with Gadolinium-based contrast enhancement shows:
      • swelling of right anterior thigh muscle (mainly rectus femoris) with a rim-enhancing intramuscular mass lesion (about 3.1x2.4x4.5cm) with central necrosis. Marked adjacent subcutaneous fat stranding and superficial fascial fluid collection is noted. An intramuscular abscess is first considered. Suggest follow up after treatment to exclude lymphoma involvement.
      • clustered enlarged inguinal lymph nodes.
      • no abnormal bone marrow edema nor hyperemia.
    • Impression:
      • Favor an intramuscular abscess (about 3.1x2.4x4.5cm) at right anterior thigh. Suggest follow up after treatment to exclude lymphoma involvement.
  • 2022-08-23 Patho - fissure/fistula
    • Anus, PIS — Anal fissure
  • 2022-08-12 Abdomen - standing (diaphragm)
    • There is hepatosplenomegaly. please correlate with clinical condition
  • 2022-06-29 CT - abdomen
    • Indication: intermittent, whole abdominal dull pain for 3 days
    • IMP:
      • no evidence of free abdominal air.
      • a nodular lesion, about 14mm, in the spleen. Nature?
  • 2022-06-04 CT - brain
    • Clinical information: Cranial CT scans from the vertex to the mid-maxillary level were performed without i.v. contrast injection.
    • Impression:
      • The brain shows normal grey and white matter attenuation without evidence of focal lesion. There is no intracranial hemorrhage seen.
      • The size of the lateral and third ventricles appears normal.
      • The posterior structures including the brain stem, cerebellum and CP angles look normal.
  • 2021-05-27 Patho - bone marrow biopsy
    • Bone marrow, iliac, biopsy — Small lymphocytic lymphoma / chronic lymphocytic leukeima
    • The sections show hypercellular marrow (>90%) for her age with small lymphocytes proliferation. Immunohistochemistry of CD20(+), CD3(-), CD5(+), CD23(+), Bcl2(+), CD34(-), CD61 showed adequate megakaryocyte, CD71 showed mild decreas of erythroid series and MPO showed decreased myeloid series. Clinical correlation is advised.
  • 2021-05-25 CT - abdomen
    • Lymphoma in paraaortic, iliac and pelvic cavity, inguinal regions. Progression.
    • Splenomegaly with splenic nodule, progression, suspected lymphoma.
  • 2021-01-05 CT - abdomen
    • Splenomegaly.
    • Lymphadenopathy at paraaortic and mesenterric region. Stable.
  • 2020-09-25 CT - abdomen
    • Lymphoma S/P C/T show stable disease.
  • 2020-07-01 Whole body PET scan
    • Glucose hypermetabolism in bilateral cervical lymph nodes, bilateral axillary lymph nodes, pelvis, and bilateral inguinal lymph nodes, lymphoma should be the first considered.
    • Glucose hypermetabolism in bnilateral palatine tonsils, reactive change resulting from locoregional inflammation may show such a picture.
    • Lymphoma (if proved), stage III at least (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
  • 2020-06-12 Patho - lymphnode biopsy
    • Lymph node, right inguinal, excision —– Small lymphocytic lymphoma / chronic lymphocytic leukemia
    • Histology type: B-cell neoplasms: B-lymphoblastic lymphoma/leukemia
    • Immunohistochemical stain profiles: CD20(+), CD3(-), CD5(+), BCL2(+), CD23(+), CD43(+), SOX11(-), Cyclin D1(-), BCL6(-), CD10(-). The Ki-67 is about 15%.
  • 2020-06-12 CT - abdomen
    • Lymphoma is highly suspected.
    • The differential diagnosis include metastases.
  • 2020-06-10 Patho - bone marrow biopsy
    • clinical diagnosis: D72.829 Elevated white blood cell count, unspecified
    • Bone marrow, iliac, biopsy — B cell lymphoma.
    • IHC stains: CD34: 1%; MPO: approximaltely: 10%; LCA (+, 80-90%); CD20: a predominant monoclonal subpopuation. CD3: few.
    • Additional IHC stains: bcl-2 (diffuse +++), bcl-6 (-), CD23 (+++), cyclin-D1 (-).
    • The IHC pattern is that of a small lymphocytic lymphoma / chronic lymphocytic leukeima.
    • Section shows one piece of bone marrow with 60-70 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and a predominant subpopulation of small round blue cells. Megakaryocytes are adequate in number. B cell lymphoma.
  • 2020-06-09 CXR
    • A nodular opacity projecting in the left upper lung is suspected that may be left 1st rib cartilage calcification or true lesion? Follow up is indicated. Otherwise, Please correlate with CT.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.

[chemoimmunotherapy]

  • 2023-02-27 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1450mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-30 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2023-01-04 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-12-13 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2022-11-07 - rituximab 375mg/m2 700mg NS 500mL 8hr D1 + cyclophosphamide 750mg/m2 1350mg NS 250mL 30min D2 + vincristine 1.4mg/m2 2mg NS 50mL 10min D2 + prednisolone 60mg/m2 55mg BID D2-6 (R-COP, Q3W)
    • acetaminophen 500mg PO D1 + [dexamethasone 4mg + diphenhydramine 30mg + NS 250mL] D1-2 + palonosetron 250ug D2
  • 2021-05-26…2021-07-04 - Leukeran (chlorambucil 2mg/tab) KLEUK BID PO

[G-CSF]

  • Granocyte (lenograstim) CGRAN01
    • 2022-11-29 ~ 2022-11-30 250ug SC 2022-11-17 IPD
    • 2022-08-27 ~ 2022-08-26 250ug SC 2022-08-12 IPD
  • G-CSF (filgrastim) CGCSF01
    • 2023-02-27 150ug SC 2023-02-27 IPD self-paid
    • 2022-08-12 300ug SC 2022-08-12 IPD

[assessment]

  • It is recommended avoiding the administration of filgrastim from 24 hours before to 24 hours after the administration of cytotoxic chemotherapy, due to the potential sensitivity of rapidly dividing myeloid cells to the cytotoxic effects of chemotherapy.

  • Filgrastim was administered on 2023-02-27 and chemotherapy is scheduled to be administered on 2023-03-01, with one day in between. Our administration pattern for the patient helps to uphold this principle without an issue.

700853234

230301

[exam findings]

  • 2023-02-27 CXR
    • small Lt hemithorax, decreased pulmonary vascularity, and small hilum, due to fibrotic and bronchiectatic change
    • extensive mixed consolidation and hazy increased opacity over Rt lower lung zone
    • pathological compression fracture of multiple vertebral bodies
    • compression fracture of L2 vertebral body priop vertebroplasty
  • 2023-02-07 Tc-99m MDP whole body bone scan with SPECT
    • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the skull, multiple C-, T- and L-spines, bilateral multiple ribs and bilateral pelvic bones.
    • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
  • 2023-02-03 MRI - spine
    • Diffuse bony metastases involving C2-T12 vertebral bodies and bilateral ribs. LUL lesion, suspected metastases.
    • Diffuse bony metastases involving vertebral column (T10-S1) and iliac bones. Recent compression fratucre of L1 vertebral body, pathologic? S/P VP at L4 vertebral body.
  • 2023-02-03 ECG
    • Sinus tachycardia with Premature atrial complexes
  • 2023-02-01 T-spine AP + Lat
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Presence of thoracic-lumbar spinal kyphosis, mild.
  • 2023-02-01 KUB + L-spine Lat
    • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s).
    • Post percutaneous vertebroplasty of the visible lumbar or thoracic spine at L4.
  • 2022-09-21 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O A-colon cancer with obstruction. pathology: Signet-ring cell carcinoma
      • 20220504 CT:T4bN2aM0, cSTAGE:IIIC
      • 20220511 S/P right hemicolectomy:Advanced A-colon CA wt peritoneal seeding, pT4aN2bM1c , stage IVC
    • Indication: A-colon cancer S/P C/T for FU
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P right hemicolectomy
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • Prior CT identified two confluent cystic dilatation lesion in LUL and LLL of the lung are noted again, stationary.
        • Bronchiectasis are highy suspected.
      • Others
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P right hemicolectomy.
      • There is no evidence of tumor recurrence.
  • 2022-09-21 CXR
    • Fibrosis of left upper lung is noted. Please correlate with clinical history to rule out old inflammatory process.
    • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-05-12 Patho - colon segmental resection for tumor
    • PATHOLOGIC DIAGNOSIS
      • Ascending colon, right hemicolectomy — Signet-ring cell carcinoma
      • Resection margins, bilateral, ditto — Free of tumor
      • Lymph node, mesocolic, dissection — Tumor metastasis (14/18) with extracapsular extension (7/14)
      • Appendix, right hemicolectomy — Appendiceal wall invasion
      • Omentum tissue, ditto — Signet-ring cell carcinoma
      • AJCC pathologic stage — pT4aN2bM1c, stage IVC
    • MACROSCOPIC EXAMINATION
      • Operation procedure: right hemicolectomy
      • Specimen site: Ascending colon, terminal ileum and appendix
      • Specimen size: (a) A-colon: 22.5 cm in length, up to 5.2 cm in diameter with some omentum tissue, (b) Terminal ileum: 6.5 cm in length, 2.7 cm in diameter; (c) Appendix: 3.4 cm in length, 0.3 cm in diameter
      • Tumor size: 6.9 x 4.8 cm
      • Tumor location: 15 and 6.5 cm away from bilateral resection margins
      • Tumor appearance: protruding mass
      • Depth of invasion grossly: visceral peritoneum
      • Representative sections as A1: ileum + colonic margin, A2: appendix, A3: tumor + radial margin, A4-A6: tumor + serosal layer, A7-A8: tumor, A9-A12: lymph nodes, A13: omentum nodules
    • MICROSCOPIC EXAMINATION
      • Histology: signet-ring cell carcinoma with abundant mucin production
      • Histology Grade: G3, poorly differentiated
      • Depth of invasion: visceral peritoneum
      • Angiolymphatic invasion: present
      • Perineural invasion: present
      • Discontinuous extramural tumor extension: not identified.
      • Circumferential (radial) margin of rectosigmoid: involved
      • Lymph node metastasis, mesocolic: tumor metastasis (14/18)
      • Lymph node metastasis, IMA / SMA: N/A
      • Extranodal involvement: Present (7/14)
      • Pathological TNM Stage: pT4aN2bM1c
      • Type of polyp in which invasive carcinoma arose: N/A
      • Omentum tissue: tumor deposition
      • TNM descriptors: N/A
      • Tumor regression grading S/P CCRT: N/A
      • Appendix: appendiceal wall invasion
  • 2022-05-10 CT - chest
    • post infectios or inflammatory fibroticalcified change of lungs
    • with bronchiectasis/bronchiolitis and volume loss especially left lung.
  • 2022-05-10 Flow volume chart
    • mild restrictive impairment
  • 2022-05-09 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (74 - 15) / 74 = 79.73%
      • M-mode (Teichholz) = 79.5
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
    • Mild MR, TR and PR
  • 2022-05-04 CT - abdomen
    • History: abdominal pain and cramp for 1 m. poor appetite. diarrhea but small amount 3-4/day. blood stool (-).
      • 20220426 colonoscopy: R/O colon cancer with obstruction at hepatic flexture. pathology: Signet-ring cell carcinoma
    • Indication: colon cancer, hepatic flexure for staging
    • Findings:
      • There is asymmetrical wall thickening with whole layer involvement and irregular outer margin at the ascending colon, ileo-cecal valve and terminal ileum, measuring 7.5 cm in length. The adjacent omentum shows fatty stranding and suspicious soft tissue nodules.
        • Adenocarcinoma of the ascending colon with direct invasion the adjacent omentum (T4b) is highly suspected.
        • In addition, There is are four enlarged nodes in the adjacent mesocolon (N2a).
      • There is minimal ascites in the cul-de-sac.
      • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left lower pole.
      • There are two confluent cystic dilatation lesion in LUL and LLL of the lung that may be bronchiectasis? Please correlate with chest CT.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-04-26 Patho - colon biopsy
    • Colon, hepatic flexure, biopsy — Signet-ring cell carcinoma
    • Section shows pieces of colonic tissue with invasive signet-ring cells.
    • The immunohistochemical stains reveal CK7(-) and CK20(+), EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • Please correlate with the clinical presentation and image study to exclude other primary origin.
  • 2022-04-26 Colonoscopy
    • Suspected colon cancer, hepatic flexure, s/p biopsy
    • Suspected lumen stricture, hepatic flexure
    • Mixed hemorrhoid
  • 2018-02-12 MRI - L-spine
    • Recent compression fracture of L4 vertebral body
    • Mild central HIVD, L3-L4.
    • Disc bulge with fissure of posterior annulus, L4-L5
    • Disc bulge with tear fissure, L2-L3.

[surgical operation]

  • 2022-05-11
    • Surgery: Right hemicolectomy        
    • Finding: large A-colon cancer withmesentary LN enlargement R/O Omental carcinomatosis and tumor seeding on viceral peritoneum
  • 2018-02-13
    • Diagnosis: L4 compression fracture
    • PCS code: 64160B

[chemoimmunotherapy]

  • 2022-10-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 230mg D5W 250mL 90min + leucovorin 400mg/m2 500mg NS 250mL 2hr + fluorouracil 2400mg/m2 3170mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-09-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3220mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-22 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 535mg NS 250mL 2hr + fluorouracil 2400mg/m2 3235mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-08-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-07-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 240mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3240mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-27 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 220mg D5W 250mL 90min + leucovorin 400mg/m2 530mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL
  • 2022-06-09 - irinotecan 180mg/m2 200mg D5W 250mL 90min + leucovorin 400mg/m2 540mg NS 250mL 2hr + fluorouracil 2400mg/m2 3200mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + atropine 1mg + NS 250mL

[assessment]

  • A blood transfusion may be considered in light of the patient’s HGB level of 8.6 g/dL, PLT count of 31K/uL, and 4+ stool occult blood in 2023-02-28 lab results.

  • The sputum culture result 2023-02-28 revealed the presence of 1+ gram-positive cocci and 2+ gram-negative bacilli. Levofloxacin has been prescribed appropriately to target and treat these strains.

701462331

230301

[present illness]

  • The 72-year-old men has had history of
    • Hypertension for more than 5 years under regular medication treatment at CGMH
    • Coronary artery disaeae post stent for more than 10 years under regular medication treatment at CGMH
    • Gallbladder stone
    • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH
    • Right clavicle fracture s/p plating, union on 2003/10/27
    • Diagnosis lung cancer in ECKH (En Chu Kong Hospital) 2022/11/23, status post Tarceva (erlotinib) since 2022/11/25, change to Giotrif (afatinib) since 2022/12/08.

[past history] - 2023-02-25 admission note

  • Hypertension for more than 5 years under regular medication treatment at CGMH.
  • Coronary artery disaeae post stent for more than 10years under regular medication treatment at CGMH.
  • Gallbladder stone.
  • Hyperlipidemia for more than 5 years under regular medical treatment at CGMH.
  • Right clavicle fracture s/p plating, union on 2003/10/27.
  • COVID-19 infection on 2022/06     

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, mental diseases or asthma.
  • No members of the family with diabetes.   

[exam findings]

  • 2023-02-25 - CXR
    • Ground glass opacity in bilateral lower lungs.
  • 2023-02-01 CT - chest
    • Indication: Lung adenocarcinoma with lung to lung mets, cT4N3M1a, TTF-1 (+)
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.625 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT )other hospital) dated on 2022/11/16
      • Lungs: diffus reticular and small nodules opacities over both lungs, with subpleural ground glass opacity over Rt lower lobe.
      • Mediastinum and hila: extensive lymphadenopathy in the visceral space and left anterior prevascular space and both hila/ small calcifiecations are noted, may be sequela of previous TB infection
        • extensive coronary arterial calcification.
      • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: trace Rt-sided effusion.
      • Chest wall and visible lower neck: small LNs at Lt supraclavicular fossa.
      • Visible abdominal contents: gall bladder stone (20mm).
        • no focal lesion in visible portion of liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression: RLL cancer with lung to lung (hematogeneous, lyphaphatic routes) and mediastinal-hilar LNs metastases in regression compared with CT on 2022/11/16, and suspect RLL fibrosis extensive 3V-CAD
  • 2023-02-01, -01-19, -01-05, 2022-12-22, -12-01 CXR
    • There are multiple nodular opacities projecting at both lung that are c/w lung to lung metastases after correlate with CT.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-12-01 Patho - lung transbronchial biopsy
    • Lung, RB7a, TBLB — adenocarcinoma, moderately differentiated
    • Sections show acinar glandular cells infiltrating in a fibrotic stroma. The immunohistochemical stains reveal TTF-1(+) and Napsin A(+). The results are supportive for the diagnosis.
  • 2022-12-01 Cell Block
    • Indication: multiple metastatic lung nodules, ADC proved by CGMH, but origin unknown
    • Result: Malignancy
    • Smears and cell block show clusters of pleomorphic tumor cells. The immunohistochemical stains reveal CK(+), TTF-1(+), and Calretinin(-). The results are consistent with meatstatic adenocarcinoma from lung. Please correlate with the clinical presentation.
  • 2022-12-01 Bronchoscopy
    • Chronic rhinitis with post-nasal drip
    • Multiple mucosa anthrocosis change
    • No any visible endobronchial lesion
    • RB7 para- and peribronchial lesion, s/p TBLB.

[medication]

  • 2022-12-08 ~ undergoing - Giotrif (afatinib 30mg/tab) KGIOT03 QDAC
  • 2022-11-25 ~ 2022-12-?? - Tarceva (erlotinib)

[assessment]

  • Based on the patient’s medication history of erlotinib followed by afatinib, it can be inferred that the disease is likely positive for EGFR exon 19 deletion or L858R, S768I, L861Q, and/or G719X mutations.

  • The patient had Grade 1 diarrhea which responded well to Smecta treatment (bowel movement of 3 times each day on 2023-02-27 and 2023-02-28). Additionally, the patient also experienced Grade 2 dermatitis and onychomycosis, which are currently being treated externally with tetracycline. If severe or prolonged diarrhea is not responding to antidiarrheal agents, GILOTRIF should be withheld to prevent dehydration and renal failure. In addition, GILOTRIF should be discontinued for life-threatening cutaneous reactions. Severe bullous, blistering, and exfoliating lesions occurred in 0.2% of patients. Severe and prolonged cutaneous reactions also require withholding of GILOTRIF.

  • After ground glass opacity was detected in bilateral lower lungs on the chest X-ray 2023-02-25, and G(+) Cocci were identified from sputum culture 2023-02-26, the afatinib treatment was temporarily suspended until the lung symptoms were relieved.

  • The current prescription is without any issue.

700838300

230224

[diagnosis] - 2023-02-23 admission note

  • Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
  • Malignant neoplasm of unspecified site of right female breast
  • Mastodynia
  • Essential (primary) hypertension
  • Insomnia, unspecified
  • Constipation, unspecified

[past history] - 2022-12-08 admission note

  • The patient has history of hypertension under medication treatment.
  • history of operation: s/p bilateral mammoplasty.
  • G2P0SA2
  • Breast feeding (-)
  • menarche : 13y/o
  • menopause: y/o
  • Hormone therapy: (+) due to In Vitro Fertilization
  • Family history of breast cancar: NIL       

[lab data]

  • 2022-08-29 HBsAg Negative
  • 2022-08-29 HBsAg Value 0.524
  • 2022-08-29 Anti-HCV Negative
  • 2022-08-29 Anti-HCV Value 0.0352
  • 2022-08-29 Anti-HBc Nonreactive
  • 2022-08-29 Anti-HBc-Value 0.19 S/CO
  • 2022-06-29 Anti-ENA Scl-70 Ab <0.6 EliA U/ml
  • 2022-06-29 Anti Jo-1 antibody <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-A(Ro) <0.3 EliA U/ml
  • 2022-06-29 Anti-ENA SS-B(La) <0.3 EliA U/ml
  • 2022-06-29 ANA Negative

[exam findings]

  • 2022-12-19 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 22) / 89 = 75.28%
      • M-mode (Teichholz) = 76
    • Normal chambers sizes
    • Normal LV and RV systolic function.
    • Typical mitral valve prolapse ( anterior leaflet); mild PR.
    • poor apical echo window due to previous mammloplasty procedure.
  • 2022-12-10 CT - chest
    • Indication: Invasive carcinoma, no special type of right breast cT1bN0M0, stage IA, IHC stains: ER (+), PR(+), Her2/neu: (-).
    • Chest CT with and without IV contrast ehnancement shows:
      • S/p port-A placement with its tip at Superior vena cava.
      • s/p op. over right axillary region is found. Some fibrotic mass like lesion at op region. Regional lymph nodes are also found.
      • Calcified dot at uncinate process of the pancreas is found.
    • Imp:
      • Right axillary soft tissue mass with lymph nodes.
      • Calcified dot at uncinate proces of the pancreas.
  • 2022-10-05 Pap Smear Test (for cervical cancer screening)
    • Atypical squamous cells (ASC-US)
  • 2022-08-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (72.1 - 26.8) / 72.1 = 62.83%
      • M-mode (Teichholz) = 62.8
    • Normal AV with no AR
    • Normal MV with no MR
    • Normal LV chamber size and wall thickness
    • Preserved LV and RV systolic function
    • Mild PR, trivial TR, normal IVC size
  • 2022-08-11 Patho - breast biopsy
    • PATHOLOGIC DIAGNOSIS
      • Tumor, right breast, frozen+ partial mastectomy —- Invasive carcinoma of no special type
      • Resection margins, frozen section — Free, closest 0.2 cm at upper side of 1 o’clock margin
        • 12 o’clock margin, recut — Free of tumor invasion
      • Skin, ditto — Free of tumor invasion
      • Lymph node, R’t axillary SLN, frozen section — Tumor metastasis (2/4) without extracapsular extension (0/2)
        • Lymph node, R’t level I, dissection — Free of tumor metastasis (0/14)
        • Lymph node, R’t level II, dissection — Free of tumor metastasis (0/7)
      • Cyst, R’t chest wall, excision — Epidemal cyst
      • AJCC Pathologic Anatomic Stage — pT1cN1a, if cM0, stage IIA; Prognostic Stage — Stage IA
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type with focal ductal carcinoma in situ, low grade
      • Size of invasive carcinoma: 1.1 x 0.9 cm
      • Histologic grade (Nottingham histologic score): Grade I (score 5) including (A) Tubule formation: score 2; (B) Nuclear pleomorphism: score 2 and (C) Mitotic count: score 1]. Besides, focal ductal carcinoma in situ, low grade arranged in cribriform pattern is also noted
      • Margins: Free, closest 0.2 cm away from upper side of 1 o’clock, 2.6 cm from 12 o’clock, 1.1 cm from 3 o’clock, 2.6 cm from 9 o’clock, 2.4 cm from 6 o’clock and 0.5 cm from base
      • Nodal status:
        • R’t axillary SLNs: Tumor metastasis (2/4) without extracapsular extension (0/2)
        • R’t level I: Free of tumor metastasis (0/14)
        • R’t level II: Free of tumor metastasis (0/7)
      • Treatment Effect: N/A
      • Lymphovascular space invasion: present
      • Perienural invasion: Not identified
      • Immunohistochemistry: Please refer to S2022-11514
  • 2022-08-11 Frozen Section
    • Margins, right breast, frozen section — Free, closest margin 0.3 cm at 12 o’clock and 0.2 cm at upper side of 1 o’clock margin
    • Sentinel lymph nodes, right axilla, ditto — Tumor metastasis (2/4)
  • 2022-08-11 Lymphoscintigraphy
    • Finding
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the right breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the right axilla.
    • Impression
      • Probably a sentinel lymph node at the right axillary region.
  • 2022-07-28 Tc-99m MDP whole body bone scan with SPECT
    • Mildly increased activity in lower L-spines. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem may show this picture.
    • Some faint hot spots in the anterior aspect of bilateral rib cages and increased activity in the nasal bon. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral elbows, hips and knees, compatible with benign joint lesions.
  • 2022-07-25 SONO - abdomen
    • Calcified spots in the liver.
    • Liver cysts.
    • Gallbladder stone.
  • 2022-07-18 Patho - breast biopsy
    • Breast, right, 1/3 tumor, core biopsy — Invasive carcinoma, no special type, NST.
    • IHC stains: ER (+, 100%, strong intensity), PR(+, 100%, strong intensity), Her2/neu: negative(score=1+), Ki-67(<10 %), p53 (<10%).
  • 2022-06-28 SONO - breast
    • Diagnosis
      • Bil. fibroadenomas as described
      • Suspected right breast tumor (#2)
      • S/P bil. mammoplasty
    • Suggestion
      • tissue study
    • BI-RADS:
      • suspicious abnormality, biopsy should be considered
  • consultation
    • 2022-08-16 Dermatology
      • Q
        • For dermatitis
        • This 41 y/o female a case of right breast cancer. She underwent right partial mastectomy + ALND on 20220811. She has noted dermatitis at forehead, without itch. We need your expertise for dermatitis evaluation and treatment.
      • A
        • The patient had sufferred from facial and scalp erythematous papules
        • Under the impression of seborrheic dermatitis
        • The following sugeetion:
          • Topysm lotion 2 bot. topical bid use on the scalp lesions.
          • Rinderon-V cream 1 tube topical bid use on the facial and post-aucurial area.

[surgical operation]

  • 2022-08-11
    • Surgery
      • right partial mastectomy and ALND (axillary lymph node dissection)
      • tumor excision
    • Finding
      • right 1/3 tumor, about 1cm in diameter
      • SLNB (sentinel lymph node biopsy): positive of malignancy, 2/4
      • epidermoid cyst over right chest wall, LIQ, no infection

[chemoimmunotherapy]

  • 2023-02-23 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2023-01-31 - doxorubicin 60mg/m2 95mg NS 100mL 10min + cyclophosphamide 600mg/m2 950mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-28 - doxorubicin 60mg/m2 94mg NS 100mL 10min + cyclophosphamide 600mg/m2 940mg NS 500mL 1hr (AC, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-12-08 - docetaxel 75mg/m2 115mg NS 250mL 1hr + cyclophosphamide 600mg/m2 945mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-11-17 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-10-26 - docetaxel 75mg/m2 118mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant TC)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • 2022-09-23 - docetaxel 60mg/m2 90mg NS 250mL 1hr + cyclophosphamide 600mg/m2 900mg NS 500mL 1hr (post-Op adjuvant)
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL
  • G-CSF (granulocyte colony stimulating factor)
    • 2022-12-17, -18, -19 (20221217 OPD)
    • 2022-11-26, -27, -28 (20221126 OPD)
    • 2022-11-20, -21, -22 (20221117 IPD)
    • 2022-10-29, -30, -31 (20221026 IPD)
  • Low WBC data points
    • 2022-12-17 WBC 1.29 *10^3/uL
    • 2022-11-26 WBC 2.59 *10^3/uL
    • 2022-10-04 WBC 1.34 *10^3/uL

==========

2023-02-24

  • The most common sequelae, or aftereffects, of axillary lymph node dissection (ALND 2022-08-11) are arm lymphedema, numbness, and limited shoulder mobility.

  • For patients with lymphedema (ie, International Society of Lymphology - ISL stage I, II, III), there is a recommendation to measure blood pressure in the contralateral arm, particularly in any setting in which blood pressure is being closely repeatedly or continuously monitored.

  • The effectiveness of these treatments in patients with established breast cancer-associated lymphedema (BCAL) is summarized below.

    • For patients with mild lymphedema (ISL stage I), it is suggested physiotherapy in the form of manual lymphatic drainage and compression garments, rather than more intensive therapy. Manual lymphatic drainage (MLD) is a massage-like technique that is typically performed by specially trained physical therapists, but a self-help maneuver (simple lymphatic drainage) has also been used for mild cases. Light pressure is used to mobilize edema fluid from distal to proximal areas.
    • For patients with moderate-to-severe lymphedema (ISL stages II to III) and no contraindications, it is suggested intensive physiotherapy, usually in the form of complete decongestive therapy, rather than less intense therapy. Complete decongestive therapy (CDT) refers to a two-phase (treatment phase, maintenance phase) multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures.
    • Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC) in addition to CDT. IPC (also called sequential pneumatic compression) devices employ a plastic sleeve or stocking that is intermittently inflated over the affected limb. Most pneumatic compression pumps sequentially inflate a series of chambers in a distal-to-proximal direction.
  • This (2023-02-24) morning, there was a decrease in blood pressure by 10mmHg resulting in a reading of 96/57, which should be noted. If the blood pressure continues to decrease, the administration of Concor (bisoprolol 5mg) may be suspended.

  • No medication reconciliation issues were found during this hospital stay, and the recently prescribed drugs disclosed in the NHI PharmaCloud System have been accurately prescribed as self-carried items that cover the patient’s underlying conditions.

2022-12-09

  • 2D transthoracic echocardiography performed on 2022-12-19 and 2022-08-29 did not demonstrate deteriorations in heart function.

2022-11-18

  • Docetaxel has been associated with adverse dermatologic reactions: Alopecia (56% to 76%, can be permanent), dermatological reaction (20% to 48%; severe dermatological reaction: 5%), nail disease (11% to 41%). There have also been reports of adverse reactions associated with cyclophosphamide: Alopecia, changes in nails, dermatitis, erythema multiforme, erythema of skin, hyperhidrosis, palmar-plantar erythrodysesthesia, pruritus, skin abnormalities related to radiation recall, skin blister, skin rash, skin toxicity, Stevens-Johnson syndrome (Assier-Bonnet 1996), toxic epidermal necrolysis (Sasak 2016), urticaria (Thong 2002).
  • It is not recommended to immediately reduce the dose of chemotherapy once a mild adverse reaction has been observed in order to gain expected therapeutic effect. Skin symptoms are currently treated with drugs prescribed by dermatologists.
  • The underlying conditions of hypertension, constipation, mastodynia, and insomnia are all appropriately treated with appropriate medication without a problem.

2022-10-06

  • A rise in serum creatinine has been observed over the last three months, while the patient has been taking several NSAIDs, including Tonec (aceclofenac), Arcoxia (etoricoxib), and Volna-K (diclofenac). If NSAIDs are required for myositis and/or mastodynia, the renal function should be routinely monitored.
    • 2022-10-04 Creatinine 0.70 mg/dL
    • 2022-09-23 Creatinine 0.64 mg/dL
    • 2022-08-10 Creatinine 0.55 mg/dL
  • For this patient with ER(+), PR(+) and HER2(-) breast cancer, the current adjuvant chemotherapy might be followed by endocrine therapy (e.g., aromatase inhibitor or tamoxifen).

700851656

230224

[exam findings]

  • 2023-02-17 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2023-02-17 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH (left ventricular hypertrophy), may be normal variant
    • Borderline ECG
  • 2022-09-23 SONO - nephrology
    • chronic parenchymal renal disease
  • 2022-01-28 Merchant view (patella 45 0) Rt
    • No lateral subluxation or lateral tilting of the patella
    • Patellofemoral osteoarthritis
    • Sperner classification: 4
  • 2022-01-28 Knee Rt standing AP and Lat views
    • Severe osteoarthritis of right knee with valgus deformity
    • Ahlback calcification: grade 4
  • 2021-11-04 Patho - colorectal polyp
    • Mid transverse colon, polypectomy — Tubular adenoma, low grade
    • Proximal transverse colon, polypectomy — Tubular adenoma, low grade
  • 2021-07-02 SONO - nephrology
    • chronic parenchymal renal disease
    • distended urinary bladder
  • 2021-06-28 CT - abdomen
    • Bilateral kidney atrophy
    • Lumbar spondylosis
  • 2020-12-24 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Duodenal ulcer scars, bulb
      • Superficial gastritis, antrum, s/p CLO
      • Reflux esophagitis LA Classification grade A
    • Suggestion
      • PPI use
      • Pend for CLO
  • 2020-08-01 SONO - abdomen
    • Diagnosis
      • liver parenchyma disease
      • gallstones, GB wall thickening
      • suspect renal parenchyma disease
    • Suggestion
      • correlate with kidney echo
  • 2020-07-30 CXR
    • Increased bilateral lung markings.
    • Cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-07-29 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (104 - 45.4) / 104 = 56.35%
      • M-mode (Teichholz) = 56.3
    • Dilated LA
    • Adequate LV,RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR, AR, PR
    • Mild Pulmonary HTN
  • 2020-07-28 CXR
    • Mild increased infiltration in both lungs
    • No pleural lesion
    • Borderline enlarged cardiac sihoutte
  • 2020-05-08 SONO - nephrology
    • chronic parenchymal renal disease
  • 2020-04-30 CXR
    • Increased bilateral lung markings.
    • Borderline cardiomegaly.
    • Intimal calcification of thoracic aorta.
  • 2020-04-30 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Left ventricular hypertrophy
    • Nonspecific ST abnormality
    • Abnormal ECG

[assessment]

  • Based on the available lab data in HIS5, the patient’s HGB level has been consistently below the lower limit of normal since May 2020. The most recent HGB level recorded on 2023-02-23 was 7.4g/dL. It is recommended to closely monitor the patient’s ability to oxygenate.

  • For patients with chronic kidney disease-related anemia (2023-02-07 Ferritin 731.6ng/mL), the initiation of epoetin alfa or its biosimilars is generally recommended when Hb levels fall below 10 g/L, according to the Kidney Disease: Improving Global Outcomes (KDIGO) Anemia Work Group. Reference: KDIGO clinical practice guideline for anemia in chronic kidney disease, published in Kidney Int Suppl in 2012;2(suppl):279-335.

  • Please evaluate if the detected bacteriuria (2023-02-24 lab result) indicates an asymptomatic UTI or not. Asymptomatic bacteriuria is common, but most patients with asymptomatic bacteriuria have no adverse consequences and derive no benefit from antibiotic therapy. With few exceptions, nonpregnant patients should not be screened or treated for asymptomatic bacteriuria.

701296927

230224

{not completed}

[diagnosis]

  • K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.

[past history]

  • Denied history of Hypertension        

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer

[exam findings]

  • 2023-01-02, 2022-12-20, -12-15 Abdomen - Standing (Diaphragm)
    • Ascites is noted.
    • S/P clips projecting at RUQ and LMQ abdomen, and pelvis.
    • Spondylosis of the L-spine is noted.
    • 2023-01-02 Partial Small bowel obstruction with partial resolving is suspected. Follow up is indicated.
    • 2022-12-20 Partial Small bowel obstruction is suspected. Please correlate with CT.
    • 2022-12-15 Small bowel obstruction is suspected. Please correlate with CT.
  • 2022-12-14 CT - abdomen
    • CC: Abd fullness for 2+ weeks, poor appetite,
    • Past History: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, hemicolectomy at TSGH on 2021-05-13.
    • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is massive ascites and soft tissue lesions in the omentum and mesentery.
        • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • There is suggestive tumor seeding in splenic flexure colon, causing marked dilatation of the proximal colon and small intestine.
        • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • There are multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space that are c/w metastatic nodes.
      • There are two kissing poor enhancing lesions in S4/8 of the liver that are c/w liver metastases.
      • Abdominal aorta shows atherosclerosis, aneurysm 3.2 cm and mild intramural thrombus formation.
      • A calcification 7 mm in S4 liver is noted that is c/w old granuloma.
      • There are several renal stones on both kidney and the largest one measuring 0.6 cm in right middle pole.
        • There are several renal cysts on both kidney and the largest one measuring 1.1 cm in size at right upper-middle pole.
      • S/P LAR with autosuture retention over the sigmoid colon.
      • S/P cholecystectomy.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, and spleen.
        • The IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
    • Impression:
      • Carcinomatosis is highly suspected. Please correlate with ascites cytology.
      • Tumor seeding in the splenic flexure colon induce mechanical colonic obstruction is highly suspected. Please correlate with clinical condition and colonoscopy.
      • Multiple metastatic nodes in the celiac trunk, para-aortic space and para-cava space.
      • Two metastases in S4/8 of the liver.
  • 2022-12-14 KUB
    • Increased air in distended loops of small bowel over abdomen and pelvicr ,could be adhesive or mechanical ileus.
    • Abdominal ascites
    • Surgical clips over the abdomen
  • 2022-12-14 ECG
    • Sinus tachycardia
    • Possible Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-10-14 Anoscopy
    • Stool color: normal
    • Rectal mucosa: normal
    • Anal canal: abnormal
    • Impression: 2022-05-20 DRE/anoscopy: mixed morrhoids with perianal skin erosion(+)
  • 2022-10-01 CT - abdomen
    • Colon cancer s/p operation. Increased soft tissues at left abdominal cavity suspected tumor seeding.
    • A poor enhancing nodule (1.1cm) at pancreatic tail.
  • 2022-06-13 CT - abdomen
    • Very faint soft tissue nodule at left subphrenic region about 0.74cm in largest dimension.In comparison with CT dated on 2022-03-11, the lesions are stationary.
    • s/p cholecystectomy
    • s/p LAR.
  • 2022-03-21 Anoscopy
    • Hemorrhoid and anterior anal fissure
  • 2022-03-11 CT - abdomen
    • Two soft tissue nodules in LUQ omentum measuring 8 mm and 5 mm that may be post-operative change.
    • The differential diagnosis include tumor seeding but less likely.
  • 2022-02-21 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed faint hot spots in the left rib cage, and increased activity in the maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees, in whole body survey.
    • IMPRESSION:
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the left rib cage, maxilla, mandible, some T- and L-spine, bilateral sternoclavicular junctions, shoulders, and knees.
  • 2021-12-06 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
    • Wall edema of colon r/o colitis. Focal small bowel ileus.
  • 2021-08-26 CT - abdomen
    • Colon cancer s/p operation. No evidence of tumor recurrence.
  • 2021-06-10 Whole body PET scan
    • Glucose hypermetabolism in multiple abdominal bilateral paraaortic lymph nodes, compatible with metastatic lymph nodes.
    • Glucose hypermetabolism in some left supraclavicular lymph nodes. Metastatic lymph nodes should be watched out. Please correlate with other clinical findings for further evaluation.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar lymph nodes and in a small focal area in the upper lobe of right lung. The nature is to be determined (inflammatory process? other nature such as metastases?). Please follow up other imaging modalities for further evaluation.
    • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation is more likely.

[consultation]

  • 2022-12-21 Orthopedics
    • Q
      • The patient is an 63-year-old man with a history of K-ras wild type Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV, Hypertension.
      • He presented with left knee painful since yesterday, progression when movement. Suspect OA knee.
      • Follow-up knee bil. x-ray today. We need your further evaluation and management.
    • A
      • S: 63 male
      • Dx: Left knee OA, grade II
      • O
        • No open fracture
        • Intact N/V
      • Plan:
        • OPD f/u
        • Pain management with pain killers
        • RICE (Rest, Ice, Compression, and Elevation)
  • 2022-01-04 Infectious Disease
    • Q
      • The 61 y/o man has watery diarrhea per day for 2-3 weeks and went to PoJen General Hospital for colonscopy /p biopsy. Thus, he sent to TSGH for future management and D- and Sigmoid PD adenocarcinoma with invading to the visceral peritoneaum, pT4aN2b, stage IIIC at least, lymphovascular invasion (+), perineural invasion (+) (LN met 11/16 and 5/11) at least post hemicolectomy at TSGH by GS Chan DChung on May 13, 2021.
      • port-A insertion on 2021-06-09. PET was performed on 2021-06-11 which showed There was increased FDG uptake in some left supraclavicular lymph nodes (SUVmax early: 8.27, delay: 10.54), in a small focal area in the upper lobe of right lung (SUVmax early: 3.30, delay: 5.38), in bilateral pulmonary hilar lymph nodes (SUVmax early: 4.86, delay: 6.77) and in multiple abdominal bilateral paraaortic lymph nodes (SUVmax early: 7.50, delay: 13.69). Besides, there was increased FDG accumulation in both kidneys and bilateral ureters. Radiotherapy with 4500cGy/25 fractions were done. Under the diagnosis of Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon with LNs and right upper lung metastases, pT4aN2bM1, stage IV.
      • He received chemotherapy with
        • C1D1 FOLFIRI on 2021/06/11-13.
        • C1D15 Avastin plus FOLFIRI on 2021/06/25-27.
        • C2D1 Avastin plus FOLFIRI on 2021/07/12-14.
        • C2D15 Avastin plus FOLFIRI on 2021/07/27-29
        • C3D1 Avastin plus FOLFIRI on 2021/08/10-12
        • C3D15 Avastin plus FOLFIRI on 2021/08/23-25.
        • => Followed CT of abdomen on 2021/08/26 which revealed Colon cancer s/p operation. No evidence of tumor recurrence.
        • C4D1 Avastin plus FOLFIRI on 2021/09/06-09/08
        • C4D15 FOLFIRI on 2021/9/27-29.
        • C5D1 Avastin plus FOLFIRI on 2021/10/12-14.
        • C5D15 Avastin plus FOLFIRI on 2021/10/26-28.
        • C6D1 Avastin plus FOLFIRI on 2021/11/10-12.
        • C6D15 Avastin plus FOLFIRI on 2021/11/23-25
      • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
      • clostridium difficileGDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec,2021 although cultural results showed no infection signs.
      • He was admitted for scheduled chemotherapy this time, however still severe diarrhea and clostridium difficileGDH andToxin A/B, which still showed GDH and Toxin A/B all positive. we need your expertise for further management,thanks
    • A
      • The patient’s condition was as your description.
        • RT 4500cGy/25 fractions at primary tumor bed, peripheral, to regional lymphatic including pelvic area started from 2021/11/11.
        • clostridium difficile GDH as well as Toxin A/B, which showed GDH and Toxin A/B all positive on Dec, 2021.
      • Clostridium difficile associated diarrhea was impressed.
      • Suggestion:
        • Vancomycin 125 mg po qid is suggested for 10 days.
        • Please keep contact isolation
  • 2021-09-06 Radiation Oncology
    • A
      • A: Adenocarcinoma, poorly differentiated, invading to the visceral peritoneum, of the Descending to sigmoid colon, AJCC pathological staging pT4aN2b(cM0), stage IIIC at least, s/p operation.
      • P: Radiotherapy is indicated for this patient with the following indicators: D-S colon cancer, stage pT4aN2b(cM0), stage IIIC, wth visceral peritoneum invasion and tumor focal attach to the nearest circumferential margin.
        • Goal: curative
        • Treatment target and volume: primary tumor bed, peripheral, to regional lymphatic including pelvic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions.
        • The patient’s family is going to apply the details of medical records. I would like to view those including preoperative CT scan image to clarify the tumor location and then make a decision.
        • RTC: in one week

[radiotherapy]

[chemoimmunotherapy]

  • 2023-02-23 - ramucirumab 8mg/kg 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 140mg D5W 250mL 2hr + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4560mg NS 500mL 46hr (Cyramza + FOLFOX, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-02-03 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2023-01-15 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-30 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-16 - ramucirumab 8mg/kg 500mg NS 250mL 1hr + oxaliplatin 85mg/m2 145mg D5W 250mL 2hr + leucovorin 400mg/m2 684mg NS 250mL 2hr + fluorouracil 2800mg/m2 4800mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-06-13 - irinotecan 180mg/m2 290mg D5W 250mL 90min + leucovorin 400mg/m2 650mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2022-03-08 - bevacizumab 5mg/kg 300mg NS 100mL 90min + irinotecan 180mg/m2 300mg D5W 250mL 90min + leucovorin 400mg/m2 670mg NS 250mL 2hr + fluorouracil 2800mg/m2 4680mg NS 500mL 46hr (Avastin + FOLFIRI, Q2WK)

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg + NS 250mL
  • … … ..

  • 2021-06-11 - irinotecan 180mg/m2 310mg D5W 250mL 90min + leucovorin 400mg/m2 690mg NS 250mL 2hr + fluorouracil 2800mg/m2 4830mg NS 500mL 46hr

    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 1mg SC + NS 250mL

==========

2023-02-24

  • There is a possible trend towards leukopenia as the patient’s WBC count has gradually decreased over time.

    • 2023-02-23 WBC 3.44 x10^3/uL
    • 2023-02-10 WBC 2.83 *10^3/uL
    • 2023-02-03 WBC 3.09 *10^3/uL
    • 2023-01-27 WBC 4.43 *10^3/uL
    • 2023-01-15 WBC 4.05 *10^3/uL
    • 2023-01-12 WBC 5.79 *10^3/uL
    • 2022-12-29 WBC 5.29 *10^3/uL
    • 2022-12-26 WBC 7.99 *10^3/uL
  • The patient’s HbA1c levels have slowly increased and warrant attention.

    • 2023-02-20 HbA1c 6.1 %
    • 2022-12-06 HbA1c 5.8 %
    • 2022-09-05 HbA1c 5.7 %
  • Diarrhea seems to have improved as there was no bowel movement recorded on 2023-02-23.

  • The medications recently prescribed for the patient are in accordance with the records in the NHI PharmaCloud System, and have been correctly prescribed as self-carried items during this hospital stay to cover his underlying conditions. No issues related to medication reconciliation have been identified.

2023-01-16

  • Based on the records, bowel movements were 2, 2, 1 over the past three days. No further diarrhea has been observed; loperamide might not be continued. (The drug has not been refilled after the original prescribed expired.)
  • Blood sugar levels remain at 90 mg/dL, they are in good control.

700174936

230223

[past history]

  • Medical history:

    • Heart: hypertension and dyslipidemia for 10+ years under medical control
    • Other medical:
      • Insomnia, but does not use sleeping pills
      • Asymptomatic gallbladder stones
  • Surgical: operation for endometriosis x3, 10+ years ago (open abdominal x1 + hysteroscopic x2)

  • Menstrual history: G0P0, Last menstrual period:2022/8/2

    • Menarche at the age of 13 years old
    • Menstrual cycle:Duration/Interval:7-14days/28days
    • Amount: moderate —> changed to menstruation 1 time per year for the past 3 years
  • Has regular Pap smear examination (most recent 2022/08/03)

[allergy]

  • NKDA         

[family history]

  • Mother had hysterectomy, but the patient doesn’t know why
  • Mother has thalasemia anemia and hypertension

[exam findings]

  • 2022-12-30 - CT - abdomen
    • History: Left ovary cancer of clear cell carcinoma s/p Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy on 2022/09/22, pT1aN0; stage IA; FIGO stage IA
    • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • There is a soft tissue enhancing lesion in left adrenal gland, measuring 1.3 x 0.9 cm in size, that may be adenoma. please correlate with clinical condition.
      • Others
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
    • Impression:
      • S/P hysterectomy
      • Severe fatty liver, grade 5, is noted.
      • The gallbladder shows stones and mild wall thickening. please correlate with clinical condition.
      • Left adrenal adenoma is highly suspected. please correlate with clinical condition.
  • 2022-10-19 Gynecologic Ultrasonography
    • Suspected LT skin sub? cyst: 16mm x 11mm
    • ATH + BSO
  • 2022-09-23 Patho - uterus (with or without SO) neoplastic
    • PATHOLOGIC DIAGNOSIS
      • Ovary, left, BSO — Clear cell carcinoma
      • Lymph nodes, pelvic, bilateral, BPLND — Negative for malignancy (0/15)
      • AJCC 8 th edition, Pathology stage: pT1aN0; stage IA; FIGO stage IA
    • MACROSCOPIC EXAMINATION
      • Procedure: Laparoscopic hysterectomy + BSO + BPLND
      • Specimen Size:
        • Multiple pieces, up to 7.5 x 2.2 x 0.5 cm (Lt ovary, received for frozen section), multiple pieces up to 2.5 x 2.0 x 1.5 cm (Lt ovary), 5.5 x 1.2 x 0.7 cm (Lt tube), 4.5 x 3.2 x 2.5 cm (Rt ovary), 4.5 x 1.5 x 0.9 cm (Rt tube), 12.0 x 7.0 x 5.0 cm and 100 gm (uterus)
      • Specimen Integrity
        • Right ovary: Capsule intact
        • Left ovary: Fragmented
        • Right fallopian tube: Serosa intact
        • Left fallopian tube: Serosa intact
      • Tumor Site: Left ovary
      • Ovarian Surface Involvement: Absent
      • Fallopian tube Surface Involvement: Absent
      • Tumor Size: Cannot be assessed (about 5-6 cm in dimension)
      • Lymph Nodes: Four groups including left iliac, left obturator, right iliac, right obturator
      • Representative parts are taken for section and labeled as: F2022-00449FS and A1-A3, A4, A6 = left ovary, A5 = left tube. S2022-16185A = left iliac LNs, B = left obturator LNs, C = right iliac LNs, D = right obturator LNs, E1 = cervix, E2-E7 = uterine corpus, E8-E9 = endometrium, E10-E11 = right ovary, E12 = right fallopian tube, F1-F2 = left ovary.
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Clear cell carcinoma
      • Histologic grade: High-grade
      • Implants: Not identified
      • Other Tissue/Organ Involvement: Not identified
      • Peritoneal Fluid: Not submitted
      • Regional Lymph Nodes: All lymph nodes negative for tumor cells
        • number of lymph node examined: 2 (left iliac), 7 (left obturator), 1 (right iliac), 5 (right obturator)
        • number with metastases >10 mm: 0
        • number with metastases 10mm or less: 0
        • number with isolated tumor cells (<=0.2mm): 0
      • Pathologic Stage
        • Primary Tumor: pT1a (tumor limited to one ovary)
        • Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IA
      • Lymphovascular invasion: Absent
      • Perineural invasion: Absent
      • Additional Pathologic Findings:
        • Cervix: Chronic cervicitis with squamous metaplasia
        • Endometrium: Endometrial polyp with endometrial hyperplasia
        • Myometrium: Leiomyoma and adenomyosis
        • Ovary, right: Endometrosis
        • Fallopian tube, left: Unremarkable
        • Fallopian tube, right: Hydrosalpinx and hemosalpinx
  • 2022-09-22 Frozen Section
    • Ovary, left, frozen section — Malignant, clear cell carcinoma can be considered
  • 2022-09-21 ECG
    • Marked sinus bradycardia
    • Septal infarct, age undetermined
    • Nonspecific ST abnormality
  • 2022-08-20 Gynecologic Ultrasonography
    • Suspected LT ovarian mass with (papillary 24x23mm)
    • Uterine myoma
  • 2022-08-03 Mammography
    • Impression: Dense breast. No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
    • BI-RADS: Category 1: negative. - annual screening.

[surgical operation]

  • 2022-09-22
    • Surgery
      • Diagnosis: Left ovarian tumor suspected malignancy for staging surgery.    
      • Operation: Laparoscopic gynecologic oncology staging surgery (Laparoscopic hysterectomy + BSO + bilateral pelvic lymphadenectomy)   - Finding
      • Left ovarian tumor, suspected malignancy.
      • Frozen: clear cell carcinoma
      • Uterus: irregular shape due to multiple uterine myomas with size 9x8cm, there was dense adhesion with bladder, peritoneum due to previous endometriosis surgery before, adhesiolysis was performed smoothlt.
      • LOV: 6x7x5xcm , capsule intact , smooth surface, with yellowish mucus fluid content and necrotic tissues found within the ovary .
      • ROV: 3x3x2 cm , grossly normal
      • Fallopian tube: bilateral grossly normal
      • CDS: invisible due to tumor mass occupied
      • Ascites: bloody , about 10 ml
      • Bilateralpelvic lymph nodes: normal(+), enlarged(-), indurated(-)
      • Omentum: not seen
      • Liver: grossly normal & smooth
      • Appendix: grossly normal.
      • After the operation, check the bleeder and spray the arista on both pelvic lymph nodes lesion
      • Estimated blood loss: 300 ml
      • Blood transfusion: nil
      • Complication: nil  

[chemoimmunotherapy]

  • 2023-02-22 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2023-01-30 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-28 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-12-07 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-11-14 - paclitaxel 175mg/m2 270mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL
  • 2022-10-21 - paclitaxel 175mg/m2 260mg NS 250mL 8hr + carboplatin AUC 5 580mg NS 250mL 2hr (paclitaxel + carboplatin, Q3W)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famotidine 20mg + NS 250mL

==========

2023-02-23

  • The patient exhibited severely elevated blood pressure of 228/122 at 19:17 on 2023-02-22, which should be noted as it indicates that her blood pressure was unstable.
  • The patient’s 2023-02-22 lab results showed generally normal readings, and she is tolerating the treatment well.
  • The active prescription for the patient’s underlying conditions, including hypertension, chronic viral hepatitis B, and hypomagnesemia, has been prescribed without an issue.

2022-10-24

  • The patient has just undergone her first treatment with paclitaxel/carboplatin and her TPR and blood pressure are stable.
  • The active prescription does not present a problem.

701468007

230223

[past history] - 2023-02-22 admission note

  • The patient had no systemic diseases, including endocrine、CNS、CV
  • history of operation:
    • s/p abdominal total hysterectomy (ATH) for 20+ y/o ago
    • s/p Urethovesicopexy
    • s/p bilateral cataract
    • s/p rectal biopsy on 2023/02/01
    • s/p L’t port-A on 2023/02/15
  • Denied recent traveling history
  • Blood transfusion history: NIL
  • Occupational function (premorbid):OK。
  • Regular medications or herb:no            

[allergy]

  • NKDA

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[lab data]

  • 2023-02-12 HBsAg Nonreactive
  • 2023-02-12 HBsAg (Value) 0.44 S/CO
  • 2023-02-12 Anti-HBc Reactive
  • 2023-02-12 Anti-HBc-Value 7.26 S/CO
  • 2023-02-12 Anti-HCV Nonreactive
  • 2023-02-12 Anti-HCV Value 0.11 S/CO

[exam findings]

  • 2023-02-03 MRI - pelvis
    • CC: She sufferred from constipation for 2 months. This time, anal pain and anal bleeding after defecation developed recently. Digital examination: swelling anorectal region, 7 o’clock rupture.
      • 20230117 sigmoidoscopy: perianal swelling and extensive ulcerative lesion over 6-8 o’clock. Suspected anorectal ulcer
    • MR Imaging of the abdomen was performed on a 1.5 T superconducting magnet and phase arrayed body coil. Patient kept in supine position.
    • Scanning protocol:
      • Axial plane: spin echo T1WI, diffusion weighted images, Non-Fat-saturation FSE T2WI, and HASTE T2WI
      • Coronal and sagittal plane: Non-Fat-saturation FSE T2WI,
      • Dynamic study: Fat saturated T1WI with IV Gd-DTPA 0.1mmol/Kg and images were obtained at 70 second.
    • Findings:
      • There is circumferrential asymmetrical wall thickening at the rectum and aus, with right lateral exophytic growing measuring 4 cm in size. The cranial-caudal dimension of the rectal lesion is measured about 8 cm in length.
        • The fat plane between this mass and right levator ani muscle shows obliteration that is c/w direct invasion.
        • In addition, the rectal mass shows poterior extension to the perineum.
        • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion (T3) is highly suspected.
        • Please correlate with biopsy.
      • There are five enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w regional metastatic nodes.
        • The largest one measuring 1.3 cm.
        • In addition, There are several enlarged nodes in bilateral inguinal area that are also c/w regional metastatic nodes (N1a).
      • Others
        • There is no focal lesion in the urinary bladder and vaginal.
        • There is no evidence of ascites.
        • The visible artery and vein show unremarkable finding.
    • IMP:
      • Squamous cell carcinoma of the anorectum with right levator ani muscle invasion is highly suspected. Please correlate with biopsy.
      • According to American Joint Committee on Cancer (AJCC) staging system, 9th edition for anal cancer: T3N1aM0, stage:IIIC
  • 2023-02-02 CT - abdomen
    • History and indication: anorectal ulcer
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Wall thickening of rectum with adjacent tissue invasion, regional LAP and perforation. Colonic diverticula.
      • Some calcifications in bil. breasts.
      • Hyperplasia of left adrenal gland.
      • Some LNs at bil. inguinal regions.
      • S/P hysterectomy. Suspected left ovary cyst (1.8cm).
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • Addendum Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4b(T_value) N:N1a(N_value) M:M0(M_value) STAGE:IIIC(Stage_value)
  • 2023-02-02 Patho - colon biopsy
    • Anorectum, biopsy — squamous cell carcinoma, moderately differentiated
    • Section shows pieces of squamous mucosa with invasive squamous cell carcinoma.
    • The immunohistochemical stains reveal CK5/6(+), p40(+), CDX2(-), and CD56(-). The results are supportive for the diagnosis.
  • 2023-01-31 ECG
    • Sinus rhythm with Premature atrial complexes
    • Left axis deviation
    • Right bundle branch block
  • 2023-01-17 Sigmoidoscopy
    • Findings
      • 30cm to S colon, diverticulosis of S colon.
      • perianal swelling and extensive ulcerative lesion over 6~8 o’clock.
    • Diagnosis
      • anorectal ulcer, easily bleeding, pt complain better
    • Suggestion
      • repeat 1 month later.
    • Complication
      • No immediate complication
  • 2023-01-13 CXR
    • Cardiomegaly is noted.
  • 2023-01-13 ECG
    • Normal sinus rhythm with sinus arrhythmia
    • Left axis deviation
    • Right bundle branch block
    • Abnormal ECG

[SOAP]

  • 2023-02-10 Radiation Oncology
    • CCRT is indicated but old age. CT-simulation will be arranged on 20230215. Plan to deliver 45 Gy/ 25 fx to the pelvis (including inguinal, int & ext iliac lymphatic drainage area). Then boost the anal tumor and LAPs to 54 Gy/ 30 fx.

[chemotherapy]

[assessment]

  • The use of 5-fluorouracil/mitomycin or capecitabine/mitomycin in combination with radiation for the treatment of anal cancer was considered (2023-02-10). A population-based study found that capecitabine/mitomycin and fluorouracil/mitomycin given concurrently with radiation achieved similar disease-free survival (DFS) and anal cancer-specific survival (ACSS). As such, substituting capecitabine for infusional 5-FU may be a viable option for patients and healthcare providers who prefer to avoid the potential complications and inconvenience of a central infusional device. (Reference: “A comparison between 5-fluorouracil/mitomycin and capecitabine/mitomycin in combination with radiation for anal cancer.” J Gastrointest Oncol. 2016;7(4):665-672. doi:10.21037/jgo.2016.06.04)

  • The mitomycin and fluorouracil with concurrent radiation (FUMIR) regimen was ultimately chosen for the patient. There are multiple variations of this regimen. The standard administration of 5-FU involves a continuous infusion over 4 days, specifically on Day 1-4 and 29-32. (ref: Mitomycin and Fluorouracil With Concurrent Radiation (FUMIR) Regimen for Anal Cancer. Hosp Pharm. 2013;48(6):464-469. doi:10.1310/hpj4806-464). Due to the patient’s advanced age, a 3-day infusion was utilized during this hospitalization, with a weekend break in between.

  • Lab results 2023-02-22 revealed that the CBC, WBC DC, Na, K, liver and kidney function were grossly normal, indicating no significant abnormalities.

  • In the review of systems section of the admission note (2023-02-22, yesterday), it was documented that the patient had been experiencing constipation for a period of two months, as well as anal bleeding with pain. The prescription of sennoside has been appropriately made. If anal bleeding persists, the addition of tranexamic acid may be considered as a potential treatment option.

  • A summary of the compatibility of mitomycin with various intravenous solutions is listed as following: mitomycin is not compatible with D5W, Dextrose 3.3% in sodium chloride 0.3%, and Dextrose 5% in water. Compatibility with D10W, D5LR, D5NS, 1/2NS, D5W-1/2NS and Ringer’s Injection is untested. IV compatibility with Normal saline (Sodium chloride 0.9%) is variable; Lactated Ringer’s Injection, Sodium chloride 0.4%, Sodium chloride 0.6%, and Sodium lactate 1/6 M is compatible.

700348666

230221

This patient passed away at 10:19, 2022-11-03.

701470008

230221

[lab data]

2023-06-26 CMV viral load assay Target not detecetedIU/mL
2023-06-19 CMV viral load assay Target not detecetedIU/mL
2023-06-12 CMV viral load assay Target not detecetedIU/mL

2023-03-14 CMV IgM Nonreactive
2023-03-14 CMV IgM Value 0.57 Index
2023-03-14 CMV_IgG Reactive
2023-03-14 CMV_IgG Value 393.8 AU/mL

2023-02-16 FLT3-D835 Undetectable
2023-02-15 BCR/abl Undetectable
2023-02-15 PML-RARA Undetectable
2023-02-13 FLT3/ITD Undetectable
2023-02-13 NPM1 Undetectable

2023-02-04 Anti-HBc Nonreactive
2023-02-04 Anti-HBc-Value 0.21 S/CO
2023-02-04 Anti-HBs 1.78 mIU/mL
2023-02-04 Anti-HCV Nonreactive
2023-02-04 Anti-HCV Value 0.09 S/CO
2023-02-04 HBsAg Nonreactive
2023-02-04 HBsAg (Value) 0.36 S/CO
2023-02-04 Anti-HBc IgM Nonreactive
2023-02-04 Anti-HBc IgM Value 0.10 S/CO

[exam findings]

  • 2023-07-03 Patho - bone marrow biopsy
    • Bone marrow, iliac bone, biopsy — Compatible with AML with partial remission at least, see description
      • Immunohistochemical stains:
        • MPO: positive for myeloid series
        • CD117: negative for blast
        • CD34: positive for blast
        • CD61: positive for megakaryocyte
        • CD71: positive for erythroid series
        • CD68: positive for monocyte
    • MACROSCOPIC EXAMINATION
      • The specimen submitted consisted of one strip of bone marrow tissue measuring 2.2 x 0.2 x 0.2 cm in size, fixed in B-5 solution. Grossly, it was tan in color and bony hard in consistence. All embedded for sections after short decalcification.
    • MICROSCOPIC EXAMINATION
      • Hypocellularity for her age, 30%
      • M/E ratio about 1.5/1, largely normal maturation of myeloid and erythroid series
      • Adequate megakaryocytes with focal mononucleation and hyposegmentation
      • Some scatter large nucleated cells, which IHC shows CD34(-) / CD117(+) / CD68(+/-, equivocal), maybe residual blast or erythroid precursor
      • According to all histopathologic finding, it is compatible with acute myeloid leukemia with partial remission at least. Clinical or smear correlation is needed for conclusive diagnosis due to histologic limitation. Closely follow up.
  • 2023-02-09 CXR
    • Enlargement of cardiac silhouette.
  • 2023-02-06 Patho - bone marrow biopsy
    • Bone marrow, biopsy — Compatible with acute myeloid leukemia with maturation
    • The sections show hypercellular marrow (95%). M/E ratio = 3:1 in CD71 immunostain. The marrow space is partially replaced by a population of medium to large-sized immature cells with round to oval nucleus and prominent nucleoli.
    • IHC, increased CD34+ and or CD117+ blasts, constitue 40% of marrow cells. Most blasts are also positive for MPO and a few blasts are positive for CD68. The finding is compatible with acute myeloid leukemia with maturation. Suggest bone marrow smear evaluation and clinic correlation.
  • 2023-02-06 Gynecologic Ultrasonography
    • EM: 6.7mm.
  • 2023-02-02 CXR
    • Increase bilateral lung markings.

[MedRec]

  • 2023-07-06 Progression Note
    • Problem #1: Acute myeloid leukemia, 46,XX[20], status post induction chemotherapy with I3A7 on 2023/02/13-19, consolidation chemotherapy with hige dose Ara-C on 2023/04/12-15, 2023/06/02-05
      • Assessment: pending for bone marrow biopsy
    • Plan:
      • Followed bone marrow aspiration and biopsy on 2023/7/3 and pending
      • Family meeting on 2023/07/06 10:30, explained the current condition and further chemotherapy, alloPBSCT
      • closely monitor clinical condition
    • Medical team explained the current changes in the patient’s disease and future treatment direction:
      • The patient was diagnosed with Acute Myeloid Leukemia in 2023-02. Induction chemotherapy (I3A7) was given from 02/13 to 02/19. A follow-up bone marrow biopsy on 02/24 showed partial remission. Starting from 04/11/2023, the patient has been receiving consolidation treatment (High dose Ara-C) in two courses.
      • The initial white blood cell count was 100,000, indicating a poorer prognosis. The recent bone marrow biopsy during this hospitalization showed that complete remission has not yet been achieved. We discussed the subsequent treatments and the possibility of allogeneic peripheral blood stem cell transplant.
      • The patient’s sister will have HLA-ABC DR DQ typing performed for compatibility matching.
      • We explained and presented the consent form for matching from the Tzu Chi Stem Cell Registry.

[consultation]

  • 2023-02-06 Obstetrics and Gynecology
    • Q
      • This is a 29-year-old female with history of GERD. She denied systemic diseases, operation history or allergic history. She is ADL independent. This time, she suffered from abdominal distension for 1 months, accompanying with exertional dyspnea and bilateral lower limb edema for 5 days. Her dyspnea exacerbated during walking, and relieved during resting. She denied fever, chills, shortness of breath, dysuria, or abdominal pain. She visited local clinic first, and lab data revealed severe leukocytosis (92720) and anemia with HgB: 4.7. Then, she was transfered to Cardinal Tien Hospital. In order of further examination and survey, she was transfered to our ER due to leukocytosis, suspected leukemia. During ER, her vital sign showed BP:132/72, PR:123, BT:35.9 degree celsius, RR:18. Lab data showed severe leukocytosis (103.39 10^3/uL), anemia (HgB: 4.9 g/dL), thrombocytopenia (PLT: 52 10^3/uL). KUB and CXR showed negative findings. LPRBC 2U was transfused for her anemia.
      • Under the impression of anemia and abdominal distension, suspected acute leukemia, she was admitted for further hematological survey.
      • We strongely need your expertise for ceasing menstrural period due to severe thrombocytopenia (20230206 PLT: 78000/ul). Thank you very much.
    • A
      • S/O
        • SEX(+), LMP:2022/12/18 (moderate amount. irregular period, duration: 3~5 days)
        • NDKA
        • PHx: denied GYN history or family history GYN history. 2022/09 covid-19 infection.
        • Medication or hormone use: denied any hormone use before.
        • CC: for leukemia treatment.
        • PV: no lifting pain. clear discharge.
        • TVS (transvaginal ultrasound):
          • Uterus: AFV, 81X40 mm
          • EM:6.7 mm
          • ROV:27x12 mm
          • LOV:16x15 mm
      • Suggestion and plan:
        • Check pregnancy test. (Irregular menstrual cycle. )
        • Leuplin 3M 11.25 mg syringe SC ST for 1 dose
        • For long-acting Leuplin, one dose can last for three months, and at most two doses can last for six months. Patients have been informed that each dose will cost about TWD 10000 at their own expense.
        • The patient has been taught that Leuplin takes time to act, if there is still menstruation or heavy bleeding this month, oxytocin and transamin can be used (please contact obstetrics and gynecology).

[chemotherapy]

  • 2023-07-07 - [fludarabine 30mg/m2 46mg NS 500mL 30min + cytarabine 2000mg/m2 3000mg NS 500mL 4hr] D1-5 (FLAG Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-5
  • 2023-06-02 - cytarabine 3000mg/m2 4500mg NS 500mL 4hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-04-12 - cytarabine 1500mg/m2 2190mg NS 500mL 3hr Q12H D1-4 (HD Ara-C Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL] Q12H D1-4
  • 2023-02-13 - idarubicin 10mg/m2 14mg NS 100mL 30min D1-3 + cytarabine 100mg/m2 145mg NS 500mL 24hr D1-D7 (idarubicin/cytarabine 3+7 Q4W)
    • [dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL] D1-3

CYTARABINE (ARA-C) HIGH DOSE - Consolidation chemotherapy for AML in remission — https://nssg.oxford-haematology.org.uk/myeloid/protocols/ML-4-cytarabine-ara-c-3g-m2.pdf

ACUTE MYELOID LEUKAEMIA - CYTARABINE (3000mg/m2) — https://www.uhs.nhs.uk/Media/UHS-website-2019/Docs/Chemotherapy-SOPs1/AML/Cytarabine3000.pdf

==========

2023-07-07

  • In this hospital stay, the patient’s chemotherapy regimen has been augmented with the addition of fludarabine. I prepared information sheets for the patient on fludarabine and cytarabine and brought them to the ward. I visited her around 13:20 on 2023-07-07. Both the patient and her mother were present; the patient was standing and seemed to be reaching for something, and I observed that she was in good spirits. I highlighted the key points and potential side effects on the medication sheets with a colored marker, verbally informed both of them, and asked them to let our medical team know as soon as possible if they notice any suspected adverse drug reactions. I also left them with the contact information for the medication consultation window for their future reference.
  • During the visit, the patient’s mother asked about the results of the bone marrow biopsy performed on 2023-07-03. I informed her that questions regarding the patient’s condition and treatment strategy should be addressed to the attending physician. It is up to Dr Gao to disclose this information to the patient’s family as clinically necessary.

2023-02-11

  • Dr. Wan asked how long the stability of cytarabine lasts this morning. After calling the original supplier, the manufacturer said that the physical and chemical stability can be longer, but the microbiological stability is as shown in the package insert.
  • The content of this article “An 1H NMR study of the cytarabine degradation in clinical conditions to avoid drug waste, decrease therapy costs and improve patient compliance in acute leukemia” (Anticancer Drugs. 2020;31(1):67-72. doi:10.1097/CAD.0000000000000850) is the result of using Ara-C test instead of Cytosar.

700057920

230220

  • diagnosis - 2022-11-03 discharge
    • recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery, stage IV
    • Intrahepatic bile duct carcinoma status post laparoscopic S6-7 resection on 2020/09/30. ECOG:0, stage IV
    • chronic viral hepatitis B without delta-agent
    • liver cirrhosis, HBV related. Child A
  • exam findings
    • 2022-11-14 Ascites tapping
      • 2700mL
    • 2022-11-01 PTCD (Percutaneous Transhepatic Cholangial Drainage) revision
      • Obstruction of the PTCD catheter.
      • Revision of the catheter smoothly.
    • 2022-10-26 CT - abdomen
      • History and Indication:
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC 4.8 cm in S7 is suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 20201002 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
        • 20220330 CEA, CA199, and AFP: normal.
      • IMP:
        • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows stable disease.
        • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show stable disease.
          • Multiple metastatic nodes in the mesentery S/P C/T show partial response.
        • Carcinomatosis is highly suspected.
          • Please correlate with ascites cytology.
          • In addition, there is marked increased the volume of the ascites.
          • please correlate with clinical condition.
    • 2022-09-26 Endoscopic Retrograde CholangioPancreatography, ERCP
      • diagnosis
        • Failed to reach major papilla
        • CBD stricture s/p PTCD
        • Duodenal stenosis, proximal 2nd portion and SDA
        • Duodenitis and duodenal tumor with ulcer
      • suggestion
        • PPI
    • 2022-09-05 KUB
      • S/P PTCD catheter implantation via left lobe IHD approach and the tip located at S2/3 IHD?
      • Fecal material store in the colon. -Mild ascites is suspected. Please correlate with sonography.
    • 2022-08-24 CT - abdomen
      • Recurrent cholangiocarcinoma in S4 of the liver S/P C/T shows partial response.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, and aortocaval space S/P C/T show partial response.
        • Multiple metastatic nodes in the mesentery show progressive disease.
      • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
    • 2022-06-15 CT - abdomen
      • One recurrent cholangiocarcinoma measuring 1.6 cm in S4 of the liver is suspected.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery S/P CT show partial response.
      • There is ascites in the abdomen and pelvis with smuddgy appearance at the perihepatic omentum area.
      • Please correlate with ascites cytology to R/O carcinomatosis?
    • 2022-05-09 Endoscopic Retrograde CholangioPancreatography, ERCP
      • Failed Cholangiography due to inablity to reach major papilla
      • CBD stricture s/p PTCD
      • Duodenal stenosis, proximal 2nd portion and SDA
      • Duodenitis and duodenal tumor with ulcers
    • 2022-04-29 Percutaneous Transhepatic Cholangiography and Drainage, PTCD
      • Dilatation of the biliary tree (by US images).
      • Under local anesthesia, sono- and fluoroscopy guiding, a 8 Fr pig-tail catheter was inserted into the biliary tree smoothly.
      • No procedure-related complication during the whole procedure.
    • 2022-04-28 SONO - abdomen
      • Diagnosis
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • Dilated CBD & bilateral IHD
        • Lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-22 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver tumor, c/w recurrent cholangiocarcinoma, S3 and S7
        • suspicious,subphrenic abscess or biloma , S7 area.
        • Prominent bilateral IHD and MPD
        • suspiciosu, Renal stone, right
        • lymphadenopathy at pancreatic head area
        • Splenomegaly, moderate
        • Ascites, left retroperitoneal
        • CBD, GB, pancreatic body masked
      • Suggestion
        • ultrasound follow up ascites.
    • 2022-04-20 Patho - lymphnode biopsy
      • Lymph node, hepatic hilum, EUS FNB — Compatible with metastatic cholangiocarcinoma
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Extensive tumor necrosis and moderate neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with metastatic cholangiocarcinoma.
    • 2022-04-20 Patho - liver biopsy needle/wedge
      • Liver, EUS FNB — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma, recurrent
      • The sections show a picture of adenocarcinoma, composed of nests and cords of large pleomorphic neoplastic cells with focal glandular differentiation. Tumor necrosis, hemorrhage, and neutrophil infiltration are present.
      • IHC shows: CK7(+, focal), CK20(-), Arginase-1(-) and Hepatocyte(-). The finding is compatible with recurrent cholangiocarcinoma.
    • 2022-04-20 Endoscopic Ultrasonography, EUS
      • Diagnosis
        • Hepatic tumor, S4, s/p CH-EUS and FNB, suspect cholangiocarcinoma
        • Lymphadenopathy, hepatic hilum, s/p CH-EUS and FNB, suspect metaplastic lesion
        • Ascites
      • Suggestion
        • pursue pathological result
    • 2022-04-01 CT - abdomen
      • Three recurrent cholangiocarcinoma measuring 0.7 cm in S4, 0.9 cm in S8 and 1.2 cm in S3 of the liver are suspected. Please correlate with MRI.
      • Multiple Metastatic nodes in gastrohepatic ligament, hepatoduodenal ligament, para-aortic space, aortocaval space, and mesentery.
    • 2022-01-03 CT - abdomen
      • Liver tumor s/p operation with a biloma formation (3.5x7.9cm). A LN (1.5cm) at hepatic hilar region.
    • 2021-10-15 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • post partial right hepatectomy.
        • Calcified spot of liver, S4/7 area.
        • GB, pancreatic body and tail masked by gas.
        • Left hepatic lobe hypertrophy
        • Much colon gas.
      • Suggestion
        • semi-annual ultrasound follow up.
    • 2021-07-19 SONO - abdomen
      • Diagnosis
        • Liver cirrhosis
        • Status post S6/7 liver segmentectomy
        • Hepatic calcified spots
        • Fatty pancreas
      • Suggestion
        • keep follow up
    • 2021-04-30 CT - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT
        • 20080128 CT: HCC in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal, MRI:HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • 2020/10/02 Liver, S6-7 resection: cholangiocarcinoma
          • pT1aNx; Stage IA at least
      • IMP:
        • S/P near total right hepatectomy. There is no evidence of tumor recurrence.
        • Biloma in right surgical margin shows decreasing in size to 4 x 2.2 cm.
    • 2021-02-25 Hearing Test
      • Tymp bil type A
      • ART bil WNL
      • PTA:
        • Reliability FAIR
        • Average RE 11 dB HL, LE 13 dB HL
        • bil normal to mild SNHL
      • SRT RE 10 dB HL, LE 10 dB HL
      • WDS RE 96 % at MCL, LE 96 % at MCL
    • 2021-02-03 SONO - abdomen
      • Diagnosis
        • Liver cirrohis
        • Propable post op related biloma, right lobe
        • C/w post liver segmentectomy
      • Suggestion
        • keep follow up
    • 2020-12-30 Patho - soft tissue
      • Labeled as “an erythematous nodules with heat and itching on left chest for 1 months -> suspected cutaneous metastasis of HCC or cholangiocarcinoma”, skin biopsy — marked perivascular lymphocytic inflammation.
      • IHC stains: CD3 and CD20: no predominant subpopulation. No metastatic carcinoma.
    • 2020-12-09 SONO - abdomen
      • Diagnosis
        • C/w post liver segmentectomy
        • Propable post op related bilioma,right lobe
        • Poor assessment of biliary tract and PV
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • 2020-11-09 CT - abdomen
      • Impression: Liver tumor s/p operation with a biloma formation (3.5x7.9cm). No evidence of tumor recurrence.
    • 2020-10-02 Patho - liver partial resection
      • PATHOLOGIC DIAGNOSIS:
        • Liver, S6-7, segmental hepatectomy — Intrahepatic cholangiocarcinoma
        • Pathologic Staging: pT1aNx; Stage IA at least
      • MICROSCOPIC EXAMINATION
        • Histologic Type: Intrahepatic cholangiocarcinoma
        • Histologic Grade: Poorly differentiated (G3)
        • Tumor Growth Pattern: Mass-forming
        • Tumor Necrosis: Present
        • Tumor Extension: Tumor confined to hepatic parenchyma
        • Large Vessel Invasion: Not identified
        • Small Vessel Invasion: Not identified
        • Perineural Invasion: Not identified
        • Pathologic Staging (pTNM): Stage IA at least (pT1aNx)
        • Margins
          • Parenchymal Margin: Free, 2.5 cm from closest margin
          • Hepatic Capsule: Involved by invasive carcinoma
        • Additional Pathologic Findings: None identified
        • Hepatitis (specify type): Hepatitis B
        • Ishak Modified HAI Grading: Score=2 (interphase hepatitis=0/4, confluent necrosis=0/6, focal necrosis=0/4, portal inflammation=2/4) (Corresponding Metavir A1, mild activity)
        • Ishak Staging: F2 (Corresponding Metavir F2, periportal fibrosis)
        • Fatty Change: Present (<5%)
        • IHC: Hepa-1(-), Arginase-1(-), CK7(+), CK19(+), CD56(-)
    • 2020-09-21 Visceral Angiography 2 vessels
      • DSA of celiac trunk and common hepatic artery with post-angiography CTAP study via right common femoral artery puncture revealed:
        • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
        • Liver cirrhosis.
        • Patency of portal vein.
        • A hypervascular tumor at right hepatic lobe. A marginal enhancing nodule at S4 of liver r/o hemangioma. Some vascular blushes at right hepatic lobe r/o vascular shunting.
        • Post-angiography CTAP images also revealed a perfusion defect (5.9cm) at right hepatic lobe.
        • No procedure-related complication during the whole procedure.
      • IMP: Right liver tumor (5.9cm), HCC is first considered. Left liver hemangioma (1.1cm).
    • 2020-09-21 SONO - abdomen
      • Diagnosis
        • Liver tumor, nature?
        • Parenchymal liver disease
        • HCC s/p S5 resection
      • Suggestion
        • Please follow sonography in 3-6 mon
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2020-08-26 MRI - abdomen
      • History and Indication: FL + HCC + HBV , normal LFT and AFP
        • BWL 8 kg in 6 mon after exercise
        • 20080128 CT: HCCs in S6 S/P partial segmentectomy
        • 20200826 AFP and CEA: normal
      • Findings:
        • There is a well-defined, mild heterogeneous mass 4.8 x 3.5 cm in S7 of the liver. The main tumor shows hypointensity on T1WI, moderate hyperintensity on T2WI, and marked hyperintensity on DWI. During dynamic study, this tumor shows contrast enhancement in arterial phase and contrast washout in portal and delayed phase images.
          • The central area shows even higher intensity than the peripheral main tumor on T2WI and contrast enhancement in delayed phase images.
          • HCC is highly suspected.
          • The differential diagnosis include cholangiocarcinoma and neuroendocrine carcinoma.
        • S/P partial resection of S6 liver.
        • There are one enlarged node in hepatoduodenal ligament measuring 3 x 1.3 cm and several enlarged nodes in celiac trunk area, showing bright on DWI that may be metastatic nodes.
          • The differential diagnosis include benign reactive nodes.
    • 2020-07-28 Hearing Test
      • Reliabilty Fair
      • PTA
        • R’t: 13 dB HL
        • L’t: 11 dB HL
      • Bil WNL except L’t 8k Hz
      • Tymp
        • Bil Type A
      • ART
        • Bil WNL.
  • surgical operation
    • 2020-09-30
      • Surgery
        • S6-7 resection
        • laparoscope IOE
      • Finding
        • 5.5 x 5.0 x 5.0 cm well define tumor at S7
  • chemoimmunotherapy
    • 2022-11-22 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-11-02 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 725mg 2hr + fluorouracil 2400mg 4370mg 46hr
    • 2022-10-11 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-09-05 - nivolumab 100mg 1hr + oxaliplatin 80mg/m2 140mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr
    • 2022-08-16 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4380mg 46hr # The chemotherapy Q2W shift to Q3W due to neutropenia.
    • 2022-07-27 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-07-08 - nivolumab 100mg 1hr + oxaliplatin 70mg/m2 120mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg 4360mg 46hr
    • 2022-06-13 - oxaliplatin 60mg/m2 100mg 2hr + irinotecan 150mg/m2 270mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2200mg 3990mg 46hr
    • 2022-05-23 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-16 - fluorouracil 225mg/m2 400mg 24hr D1-5
    • 2022-05-10 - fluorouracil 225mg/m2 400mg 24hr D1-3
    • 2022-05-04 - fluorouracil 225mg/m2 400mg 24hr D1-3

==========

2023-02-20

  • The recently prescribed drugs that were disclosed in the NHI PharmaCloud System have been appropriately prescribed during this hospital stay.
  • No medication reconciliation issues have been found in the patient.

2022-11-22

  • The HGB level was 7.7 g/dL on 2022-11-21, and a transfusion of LPRBC 2U is scheduled.

700545433

230220

{DLBCL}

[diagnosis] - 2022-07-31 discharge diagnosis

  • Diffuse large B-cell lymphoma, lymph nodes of multiple sites
  • Diffuse large B cell lymphoma, Non-germinal center type,multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement,Lugano stage IV,IPI score:4,PS:2
  • Hypertension
  • Type 2 diabetes mellitus without complications
  • Hyperlipidemia

[lab data]

  • 2022-07-18 Amikacin <2.5 ug/mL
  • 2022-06-02 HCV RNA-PCR Target Not Detected IU/mL
  • 2022-06-01 EB VCA IgM Negative Ratio
  • 2022-06-01 EB VCA IgM Value 0.2
  • 2022-06-01 HBsAg Nonreactive
  • 2022-06-01 HBsAg (Value) 0.67 S/CO
  • 2022-06-01 Anti-HCV Reactive
  • 2022-06-01 Anti-HCV Value 2.98 S/CO
  • 2022-06-01 Anti-HBc Nonreactive
  • 2022-06-01 Anti-HBc-Value 0.18 S/CO
  • 2022-05-30 EB VCA IgG Positive Ratio
  • 2022-05-30 EB VCA IgG Value 7.2 Ratio
  • 2022-05-30 EBNA-IgG Positive Ratio
  • 2022-05-30 EBNA-IgG Value 2.5 Ratio
  • 2022-05-30 HSV 1 IgM Negative Ratio
  • 2022-05-30 HSV 1 IgM Value 0.18 Ratio
  • 2022-05-30 HSV 2 IgM Negative Ratio
  • 2022-05-30 HSV 2 IgM Value 0.04 Ratio
  • 2022-05-27 MTBC PCR NOT DETECTED
  • 2022-05-27 MTBC PCR Value <131 CFU/ml
  • 2022-05-26 CMV IgM Nonreactive
  • 2022-05-26 CMV IgM Value 0.21 Index
  • 2022-05-26 CMV_IgG Reactive
  • 2022-05-26 CMV_IgG Value 1701.6 AU/mL
  • 2022-05-26 HIV Ab-EIA Nonreactive
  • 2022-05-26 Anti-HIV Value 0.04 S/CO

[exam findings]

  • 2023-02-15 Whole body PET scan
    • There was increased FDG uptake in soft tissue in the upper and middle abdomen (SUVmax early: 18.32, delay: 27.37), and in the right lobe of the liver (SUVmax early: 17.88, delay: 26.98). In addition, increased FDG accumulation was also noted in bilateral kidneys and colon.
    • IMPRESSION:
      • The old lesions of glucose-hypermetabolism in bilateral neck and supraclavicular lymph nodes, bilateral axillary lymph nodes, mediastinal lymph nodes, pelvic lymph nodes, bilateral inguinal lymph nodes, and in multiple focal areas in bilateral lung fields disappear or come to very faint compared with the previous study on 2022-06-02.
      • However, old lesions of glucose-hypermetabolism in the upper and middle abdomen (Deauville score 5) become more evident, and there are several new lesions of glucose-hypermetabolism in the right lobe of the liver (Deauville score 5) in this study.
      • Increased FDG accumulation in bilateral kidneys and colon, probably physiological uptake of FDG.
      • Diffuse large B-cell lymphoma s/p treatment with dissociated response to current therapy, by this F-18 FDG PET scan.
  • 2023-02-13 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed a hot area in the sternum, and increased activity in the maxilla, mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees, in whole body survey.
    • IMPRESSION:
      • A hot spot in the sternum and increased activity in the maxilla, the nature is to be determined (post-traumatic change, lymphoma or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the mandible, some C-, T- and L-spine, sacrum, bilateral shoulders, S-I joints, hips, and knees.
  • 2023-02-10 Patho - liver biopsy needle/wedge
    • liver, CT-guided biopsy — Diffuse large B-cell lymphoma
    • The sections show a picture of diffuse large B-cell lymphoma with following features:
      • Specimen: Liver
      • Procedure: CT-guided biopsy
      • Tumor site: Liver
      • Histologic type: Diffuse large B-cell lymphoma
      • IHC: CD3(-), CD20(+), CK(-), and CD56(-)
  • 2023-02-01 CT - abdomen
    • History and indication: abdominal pain
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion. Some LNs at mesentery. A poor enhancing tumor (4.0cm) at right hepatic lobe.
      • Wall thickening of rectum.
      • Atherosclerosis of aorta, iliac, coronary arteries.
    • IMP:
      • A poor enhancing lesion (4.0cm) in pancreatic body with SMA, splenic artery and splenic vein invasion suspected malignancy. Liver and LNs metastases.
      • Wall thickening of rectum. Suggest coloscopy study.
  • 2023-01-30 KUB
    • Spondylosis of the L-spine is noted.
  • 2023-01-28 KUB
    • Calcified dot(s) is found at right paravertebral region, ureter stone(s) is most likely.
    • Stool impaction at the abdominal cavity is noted.
    • Phlebolith at pelvic cavity is also found.
  • 2023-01-27 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (39 - 13) / 39 = 66.67%
      • M-mode (Teichholz) = 66.7
    • Dilated aortic root
    • Concentric LV hypertrophy
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2023-01-26 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2023-01-26 KUB
    • Compression fracture of L2.
    • Stool retention in the bowel.
    • Atherosclerosis of the aorta.
  • 2023-01-18 KUB + AP & lat. LS-spine
    • Mild compression fracture of L1 vertebral body
    • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
  • 2023-01-02 CT - chest
    • Indication: malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases
    • MDCT (80-detector rows, Aquilion Prime SP, was performed with 0.5 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and abdomen-pelvic without & with contrast enhancement, coronal and sagittal reconstructed images shows:
      • Comparison was made with previous CT dated on 2022/09/04
      • Lungs: stationary of reticular opacities at Lt lung and a small noodule at RUL-S2 compared with CT on 2022/09/04.
        • mild paraspinal fibrosis of RLL, stable.
      • Mediastinum and hila: no enlarged LN or mass.
      • Vessels:
        • mild calcified plaques of the LAD coronary artery.
        • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers. minimal calcified aortic valves.
      • Pleura:no effusion.
      • Chest wall and visible lower neck: no enlarged lymphadenopathy.
      • Visible abdominal contents:
        • stationary residual of lymphadenopathy in mesentery root compared with CT on 2022/09/14.
        • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no bowel wall thickening in visible colonic segments and small bowel.
    • Impression:
      • post treatment change in lung and a a RUL 3mm nodule, and minimal residual small LNs at mesentery rootm as compared with CT on 2022/09/14
  • 2022-10-03, -07-14 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
  • 2022-09-14 CT - chest
    • near complete resolution of an irregular soft-tissue mass at LLL and multiple nodules in both lungs and significant regression of lymphadenopathy in both sides of diaphgram as compared with CT on 2022/05/30
  • 2022-07-29 ECG
    • Normal sinus rhythm
    • Septal infarct, age undetermined
    • Abnormal ECG
  • 2022-07-12 KUB
    • Radiopaque spot(s) at right renal region suspected renal stone(s).
    • Radiopaque density in left paraspinal portion suspected U/3 ureter stone.
    • Degeneration and spondylosis of L-S spine.
  • 2022-07-11 CT - brain
    • Brain atrophy.
  • 2022-06-30 ECG
    • Normal sinus rhythm
    • Anteroseptal infarct, age undetermined
    • T wave abnormality, consider lateral ischemia
  • 2022-06-28 CXR
    • Few nodular opacity projecting in both lung show mild resolving?
    • Spondylosis of the T-spine
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
  • 2022-06-02 Patho - lung wedge biopsy
    • Lung, side?, CT-guide biopsy —- diffuse large B cell lymphoma
    • Sections show alveolar lung tissue with infiltration of large pleomorphic tumor cells.
    • The immunohistochemical stains reveal CK(-), CD3(-), and CD20(+). The Ki-67 is about > 90%. The results are supportive for diffuse large B cell lymphoma.
  • 2022-06-02 Whole body PET scan
    • The FDG PET findings are compatible with lymphoma involving multiple lymph nodes on both sides of the diaphragm as mentioned above.
    • Prominently increased FDG uptake in multiple focal areas in bilateral lung fields. Lymphoma should be considered first.
    • Mildly to moderately increased FDG uptake in two focal areas in the region about left lobe of the thyroid gland. The nature is to be determined (some kind of benign or malignant thyroid lesion? lymphoma?). Please correlate with other clinical findings for further evaluation.
  • 2022-06-01 2D transthoracic echocardiography
    • Concentric LV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Aortic valve sclerosis.
    • Dilated aortic root and proximal ascending aorta (35 mm).
    • Prominent epicardial and pericardial fat.
  • 2022-05-30 CT - lung/mediastinum/pleura
    • malignant lymphoma in both sides of diaphram with lung involvement suspected LUL cancer with lung to lung metastases and
    • distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases, suggest tissue sampling.
  • 2022-05-30 SONO - abdomen
    • mild to moderate fatty liver (suboptimal exam of liver)
    • fatty infiltration of pancreas
  • 2022-05-27 Patho - lymph node region resection
    • Labeled as “Right level Ib lymph nodes”, excision biopsy — diffuse large B cell lymphoma. Non-germinal center type.
    • IHC stains: CD3 (focal +), CD20 (diffuse +), bcl-2 (diffuse +), bcl-6 (+, > 30%), MUM-1 (+, 90%), CD15 (+), CD30 (-), CD10 (-), c-myc: (+, <10%), Ki-67: 90%.
  • 2022-05-25 CXR
    • Multiple nodular opacities over both lungs. Suggest check CT scan to rule out metastases.
    • Degenerative joint disease of T-spine with marginal osteophytes.
  • 2022-05-16 Patho - lymphnode biopsy
    • Lymph nodes, L’t neck level V, excisional biopsy — Extensive coagulative necrosis with atypical B-cell proliferation
    • The large lymph node shows extensive, ring-like coagulative necrosis, 70-80% (unlikely geographic necrosis) with some nuclear debris, ghost cells, histiocytes and a few neutrophils as well as medium or large-size atypical lymphocytes in central, non-necrotic area. No granuloma is found. Immunohistochemistry of CK(-), CD3(+, scatter), CD20 (+) at subcapsular area and (-) at central area, CD68(+, scatter) and CD30(-). The three small lymph nodes show reactive change due to normal distribution of B and T-cell. The histopathologic finding and IHC stains is inconsistent with Kikuchi lymphadenitis, but infectious lymphadenitis or malignant lymphoma can not be excluded entirely due to suboptimal specimen with extensive necrosis. However, serology analysis (EBV or others) and repeat lymph node excision is advised for further evaluation. Closely follow up.
  • 2019-09-16 Knee Bilat. standing
    • Osteoarthritis change of both knees with joint space narrowing and marginal spur formation, more severe on right side. Osteopenia of visible bones.
  • 2019-01-26 CT - abdomen
    • Focal ileus of small and large bowel.
    • Wall thickening of gastric antrum. Distention of stomach.
  • 2019-01-24 SONO color transcranial, carotid phonoangiograph, CPA
    • Minimal atherosclerosis in bilateral CCA bifurcations.
    • Adequate total VA flow volume (107 ml/min).
    • Poor bilateral temporal windows for transcranial insonation.
    • Increased RI in bilateral VA, indicating distal stenosis.
    • Increased PI in right VA, indicating distal stenosis.

[consultation]

  • 2023-02-15 Psychosomatic Medicine
    • Q
      • The 77 y/o female patient with history of DM, HTN, hyperlipidemia. Under the diagnosis of Diffuse large B cell lymphoma, Non-germinal center type, multiple lymph nodes on both sides of the diaphragm as mentioned above and multiple focal areas in bilateral lung fields involvement, Lugano stage IV, IPI score:4, PS:2.
      • She received the C1 chemotherapy R-COP on 2022/06/08. C2 R-CHOP (Epirubicin 80mg/m2) on 2022/06/29-30. C3 R-CHOP (Epirubicin 80mg/m2) on 2022/07/29-30. C4 R-CHOP (Epirubicin 80mg/m2) on 2022/08/18-19. C5 R-CHOP (Epirubicin 80mg/m2) on 2022/9/11-12. C6 R-CHOP (Epirubicin 80mg/m2) on 2022/10/3-4.
      • The patient reported feeling very down lately, with physical discomfort and a lack of energy throughout the body. It has consulted with a psycho-oncologist who suggested a referral.
    • A
      • Psychiatric impression:
        • Acute depressive state
        • r/o adjustment recation with depressive features
        • r/o persistent depressive disorder, current major depressive episode
      • Symptoms and course:
        • This is a 77 y/o female patient admitted under the diagnosis of: Diffuse large B cell lymphoma, Non-germinal center type. We were consulted for her recent depressed mood.
        • According to the patient herself and the care-giver, since she was diagnosed of the disease about 1+ year ago, she had frequently visited the hospital with multiple treatment courses, that she developed depressed mood, preoccupied over her unfortunate, negative thinking, hopeless feelings. She claimed transient suicide ideation but not prominent without plan or attempt. When she was at home, she would try to relax herself and her mood would improve.
        • However, this admission, she suffered from greater pain, that she got more dysphoric with poor appetite, and also occaisonal sleep disturbance at night, sleepiness in the daytime.
      • Suggestion:
        • Suicide risk assessment: low to moderate: denied current ideation, without plan or attempt, care-giver(+), chronic disease
        • Provide psychoeducation for suicide prevention, and emotion catharsis, the patient and care-giver could understand
        • Brintellix (vortioxetine 10mg) 1# HS for the depressed mood
        • Arrange PSY OPD f/u
  • 2022-07-14 Infectious Disease
    • Q
      • The 77 y/o woman has diffuse large B cell lymphoma stage IV, who was admitted for neutropenic fever. Due to B/C yield Staphylococcus haemolyticus, so we need your help for antibiotic assessment. (20220714 WBC 14000/uL under GCSF 300 mcg treatment) Thanks!
    • A
      • Assessment:
        • Neuropenic fever with S. haemolyticus bacteremia
        • UTI
      • Suggestion:
        • Recommend antibiotic Rx with Targocid or Vancomycin + Amikin 500mg iv Qd
        • Check B/C from Port-A, if positive, may arrange echocardiography to rule out Infective Endocarditis (IE)
        • Monitor CRP
  • 2022-06-02 Radiation Oncology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to lung suspect a tumor, so we need your help for biopsy. Thanks!
    • A
      • This is a case of lung masses, suspected lung cancer or lymphoma. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • 2022-06-01 Gastroenterology
    • Q
      • The 76 y/o female, she has right neck mass post biopsy and report showed diffuse large B cell lymphoma. Due to postive of HCV, so we need your help. Thank you.
    • A
      • O
        • ALT 82
        • bil(t) 0.23
        • HbsAg(-)
        • anti-HbcAb(-)
        • anti-hcv ab(+)
        • abdominal echo: mild to moderate fatty liver(suboptimal exam of liver), fatty infiltration of pancreas
        • CT: normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
      • P
        • Check HCV viral load
          • If HCV RNA is detected, check HCV genotyping, and then discuss about treatment of direct antiviral agent.
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Well explained to the patient low incidnece of HCV reactivation during or after chemotherapy according to previous reports
        • GI OPD f/u for treatment
  • 2022-06-01 Hemato-Oncology
    • Q
      • for diffuse large B cell lymphoma
      • This is a 76 y/o female patient with history of DM, HTN, hyperlipidemia. This time, she came to our hospital due to right neck mass noted for 3 months. Other painful LNs were also noted at R’t level V , L’t level V and Bil. axillary, R’t inguinal region. Neck CT was done and revealed a nodular lesion (28mm) and another small one over right submandibular region, favor enlarged nodes. Also, due to lab data when admission showed elevated WBC and CRP, infection doctor was consulted, and antibiotic with ceftriaxone and Amikacin were suggested. Blood culture was also done and grew K.p. Abd. sono was done, and there’s no liver abscess noted.
      • She received right level Ib lymph nodes excision on 20220526, and the pathology showed diffuse large B cell lymphoma. She also received lung CT due to bil. lung nodules noted by CXR. Chest CT revealed an irregular soft-tissue mass (40 mm) at LLL, multiple nodules of variable sizes throughout both lungs, extensive lymphadenopathy in para-aortic region and mesentery root. Malignant lymphoma in both sides of diaphram with lung involvement or LUL cancer with lung to lung metastases and distant lymph nodes metastases or double cancer lymphoma and LLL cancer with lung to lung metastases were impressed. Therefore, we need your expertise for further evaluation and management.
    • A
      • Impression:
        • Diffuse large B cell lymphoma, non-germinal center type, triple hit, IPI score:3 (age, stage, extranodal)
        • Suspected LLL cancer with lung to lung metastases
      • Suggestion:
        • Arrange LLL lung CT guide biopsy for suspected lung cancer with lung to lung meta
        • Arrange PET scan for lymphoma work up, bone marrow is indicated
        • Check CEA, SCC, HbsAg, Anti Hbc, Anti HCV
        • Arrange Port A insertion
        • Arrange 2D heart echo
  • 2022-05-26 Infectious Disease
    • Q
      • According to the blood culture on 20220525 revealed GNB. General infection can not be rule out. We request your consultation for further management.
    • A
      • A patient of DM, HTN, hyperlipidemia. High fever developed and GNB sepsis was noted. In series of patients with immune-deficient fever, infection has been identified as the cause of the fever in 60% or more of cases. In at least some cases, however, the diagnosis has been presumptive, based on a favorable clinical response to antimircobial therapy, rather than on the result of definitive tests. Infection caused by pyogenic bacteria are the most common cause of fever. The generally respond well to antibiotic therapy, whether or not the etiologic microorganism is isolated. Anti-microbiologic coverage with parenteral Rocephin 2.0 gm qd or Fortum 1.0 gm q8h +- plus AMK 500 mg qd is recommended. The antimicrobial regimen can be modified once the results of the culture and susceptibility tests are available.

[chemoimmunotherapy]

  • 2022-08-18 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-07-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP, vincristine not available then)
  • 2022-06-29 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + epirubicin 80mg/m2 130mg 10min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-CHOP)
  • 2022-06-08 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 6tab BID D2-6 (R-COP)

701182757

230220

[exam findings]

  • 2023-02-17 SONO - chest
    • left lower lung consolidation
    • left side pleural thickening with trivial amount of pleural effusion, no thoracentesis wad done due to high risk
  • 2023-02-09, -02-02 KUB
    • Scoliosis of L-spine with convex to left side.
    • Fecal material store in the colon.
    • Calcified uterine fibroid in rihgt middle pelvis.
    • Ascites is highly suspected. Please correlate with sonography.
  • 2023-02-02 CXR
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear and nodular opacities on right lung are noted. please correlate with clinical condition or CT.
  • 2023-01-04 CXR
    • Cardiomegaly is noted.
    • Tortous aorta with calcification is noted.
    • S/p port-A placement with its tip at Superior vena cava.
    • Right pleural effusion is found.
  • 2022-12-26 Lower leg RT
    • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography.
  • 2022-12-26 L-spine AP+Lat. (including sacrum)
    • S/P nasogastric tube insertion
    • scoliosis of L-spine with convex to left side
    • Ueterine fibroid is noted.
  • 2022-12-26, -12-22, -12-15, -12-12, -12-08, -12-06, -12-05, -12-03 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
    • Linear infiltration on both lung are noted. please correlate with clinical symptom to rule out inflammatory process.
  • 2022-11-29 CT - abdomen
    • Clinical history: 75 y/o female patient with follicular lymphoma.
    • With and without contrast enhancement CT of abdomen - whole:
      • Diffuse multiple enlarged lymph nodes in the mediastinum, bilateral neck, right axillar regions, paraaortic regions and mesentery, progression
      • Paraspinal and prevertebral soft tissue with necrosis (T9-12 levels), could be due to lymphoma post treatment.
      • Focal soft tissue in right abdominal wall.
      • There are uterine tumors, some with dense calcifications, suspected uterine myomas.
      • Unremarkable change of the liver, spleen, pancreas and both kidneys.
      • Diffuse right pleural thickening.
    • Impression:
      • Diffuse right pleural thickening.
      • Diffuse lymphoma (from neck to chest and adomen) with progression.
      • Uterine tumors some with calcifications, suspected myomas.
  • 2022-11-29 SONO - chest
    • Right thorax: partial lung consolidation was noted; no pleural effusion
    • Left thorax: no pleural effusion.
  • 2022-11-28 CXR
    • S/P nasogastric tube insertion
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion ?
    • Linear infiltration over right lower lung zone is noted. please correlate with clinical symptom to rule out inflammatory process.
    • Prominence of right hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, Please correlate with CT.
  • 2022-11-08 SONO - chest
    • Right thorax: minimal amount pleural effusion; thoracocentesis was not performed.
  • 2022-11-07 CXR
    • S/P nasogastric tube insertion or S/P ventricular-peritoneal shunt insertion ?
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • There is scoliosis of the T-spine with convex to right side.
    • Right pleura effusion.
  • 2022-11-04 Peripheral Vascular Test - vein, lower limbs
    • Clinical diagnosis: edema
    • Doppler study: (N = Normal, A = Abnormal, T = Thrombus)
      • Lower limbs R_CFV R_SFV R_PV R_PTV R_SV L_CFV L_SFV L_PV L_PTV L_SV
      • Spontaneous signal N N N N N T T A T T
      • Respiratory changes N N N N N T T A T T
      • Cough response N N N N N T T A T T
      • Compression study N N N N N T T N N N
    • Report:
      • Right side:
        • SVC: 13.7 mmHg ; 15.1 mmHg ;
        • MVO/SVC: 100 % ; 99 % ;
        • Average MVO/SVC: 99 %
      • Left side:
        • SVC: 2.4 mmHg ; 4.5 mmHg ;
        • MVO/SVC: 100 % ; 98 % ;
        • Average MVO/SVC: 99 %
      • Thrombus at L’t CFV, SFV, PV, LSV
      • Varicose vein : None
    • Conclusion:
      • C/W acute to subacute DVT involved the left CFV, PFV, proximal SFV and proximal LSV with partial recanalization. The left middle to distal SFV, left popliteal vein and left PTV were patent with loss of respiratory change and cough response due to upstream outflow venous obstruction.
      • There was no evidence of DVT detected at right leg deep venous system.
      • The right saphenofemoral venous junction (LSV) and bilateral saphenopopliteal venous junction (SSV) were competent without venous reflux.
      • The measured MVO/SVC ratio at right leg was 99%, indicated no venous stenosis or obctruction at right iliofemoral venous system.
      • Although the measured MVO/SVC ratio at left leg was 99%, the SVC at left leg was very low, compatible with outflow venous obstruction.
  • 2022-11-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (53 - 9) / 53 = 83.02%
      • M-mode (Teichholz) = 83
    • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Mild aortic valve sclerosis.
    • Mild aortic root calcification with sessile atheromas.
    • Prominent epicardial fat.
  • 2022-11-02 CTA - chest
    • Indication: suspected Pulmonary embolism
    • Findings
      • Chest:
        • Pulmonary embolism at both sides of the main pulmonary artery and its branches more on right side is found.
        • Right pleural effusion is found.
        • Calcified coronary arteries is found.
        • Right pleural thickening is found and consolidation over right lower lobe is found.
        • Lymphadenopathy at right paratracheal region is found.
        • S/p port-A placement with its tip at Superior vena cava.
      • Visible abdomen:
        • The GB is well distended without soft tissue lesion
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
    • Imp: Pulmonary embolism at both sides of the pulmonary artery.
  • 2022-11-02 SONO - chest
    • pleural effusion, minimal, right
    • consolidation, RLL
  • 2022-10-31 ECG
    • Normal sinus rhythm
    • Possible Left atrial enlargement
    • Abnormal QRS-T angle, consider primary T wave abnormality
  • 2022-10-31 CXR
    • Consolidation in right lung
    • Right pleural fluid
  • 2022-10-17 MRI - brain
    • Indication: consciousness disturbance suspected brain mets
    • Findings
      • Generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
      • The interhemispheric fissure is centered on the midline.
      • Sella and pituitary are normal. The parasellar structures are unremarkable.
      • There are no abnormalities in the cerebellopontine angle areas on both sides.
      • There are no abnormalities in the calvarium.
      • A left temporal base tumor mass up to 15 mm, DDx: meningioma or lymphoma?
      • Well and heterogenous enhancement after contrast administration was noted of this tumor mass.
    • Imp:
      • Brain atrophy.
      • A left temporal base tumor mass, DDx: meningioma or lymphoma?
  • 2022-10-14 CT - abdomen
    • History and indication:
      • 20190604 PET: Lymphoma in right paraspinal retroperitoneal space
      • 20190613 CT; Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum. follicular lymphoma s/p C/T & R/T.
    • FINDINGS - Comparison: prior chest CT dated 2022/09/27.
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified left middle paraspinal soft-tissue mass around the descending thoracic aorta and thickening of Rt pericardium is noted again, stationary.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
      • Uterine tumors with some calcifications (up to 3.8cm) suspected myomas and fibroids.
      • Small renal cysts (up to 5mm).
      • Atherosclerosis of the aorta and coronary arteries.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, and pancreas.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the mesentery and omentum.
    • IMP:
      • Prior CT identified diffuse and marked thickening of Rt parietal and visceral pleura (involving hemidiaphgram) is noted again, mild increasing in size.
        • In addition, prior CT identified enlarged LNs in the paratracheal space and subcarinal space are noted again, increasing in size that is c/w progressive disease.
      • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, stationary.
  • 2022-10-03 Patho - pleural/pericardial biopsy
    • Pleura, right, decortication — high grade B-cell lymphoma (please see microdescription)
    • Specimen submitted in formalin consists of multiple tissue fragments measuring up to 7.5 x 3.2 x 0.2 cm. Representative sections are taken and labeled as A1-3.
    • Sections show fibroadipose tissue with diffuse infiltration of intermediate to large size lymphoid cells.
    • The immunohistochemical stains reveal CD3(-), CD20(+), BCL2(+), BCL6(+), CD10(+), cMYC(+), and MUM1(-). The Ki-67 is about 70%. The results are in favor of Grade 3B follicular lymphoma or GCB type diffuse large B-cell lymphoma.
  • 2022-09-28 Cell block
    • Right pleural effusion: Suggestive of lymphoma involvement
    • 7 cc red cloudy pleural effusion
    • The smears and cell block show small to intermediate size of lymphocytes with cleaved nucleus and nucleoli. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-27 CT - chest
    • Indication: Recurrent follicular lymphoma with right lung pleural effusion
    • Findings - Comparison was made with previous CT dated on 2022/09/20
      • diffuse and marked thickening of Rt parietal and visceral pleura (nvolving hemidiaphgram) with residual loculated effusion s/p pigtail drain placement (its pigtail segment is within lung parenchyma).
      • lungs compressive Rt lung volume loss (especially RML and RLL).
        • a subpleural lobular consolidation at S6 and minimal ground-glass opacities at basal segments of LLL.
      • Mediastinum and hila: enlarged LNs the visceral space especially subcarinal space and left middle paraspinal soft-tissue mass around the descending thoracic aorta.
        • small pericardial effusion and thickening of Rt pericardium.
      • Vessels:
        • extensive calcified plaques of the LAD and LCX coronary arteries.
        • Aorta: normal caliber, extensive atherosclerotic change of aortic arch and descending thoracic aorta.
        • Heart: normal in size of cardiac chambers.
      • Visible abdominal-pelvic contents: .
        • several small bilateral renal cysts.
        • unremarkable of the liver, spleen, both adrenal glands, pancreas, and no enlarged lymph node. .
        • Extensive atherosclerotic change of the abdominal aorta.
    • Impression:
      • recurrent follicular lymphoma with pleural, lung, hemidiaphgram, and descending aortic involvment, and mediastinal LAP.
      • regression of Rt pleural effusion with loculations, and malposition of pigtail drain.
  • 2022-09-26 Cell block
    • Suggestive of lymphoma involvement
    • 12 cc red cloudy right pleural effusion
    • The smears and cell block show mainly B lymphocytes with small to intermediate size of atypical lymphocytes with cleaved nucleus and nucleoli.
    • Immunocytochemistry shows CD20(+), CD3(-), Bcl-2(+), Bcl-6(+, focal) and CD10(+, focal) for lymphocytes. According to clinical information and cytomorphologic findings, it is suggestive of follicular lymphoma involvement.
  • 2022-09-20 CT - abdomen
    • Clinical history: 75y/o female patient with Recurrent follicular lymphoma at para-spinal region, Lugano stage II. Owing to poor appetite suspected peritonal seeding related.
    • Findings
      • Diffuse lobulated tumors in the pleura and pleural effusion with collapsed right lung, progression as compare with CT study on 2022-07-22.
      • R/O bilateral renal cysts, <1cm.
      • Unremarkable change of the liver, spleen, pancreas.
      • No enlarged lymph node in the paraaortic region.
      • No ascites.
      • There are uterine tumors, some with dense calcifications, up to 4cm, suspected uterine myomas.
    • Impression:
      • Progression of right plueral tumors and pleural effusion, right lung collapse, could be due to recurrent lymphoma with progression.
      • Uterine tumors, suspected uterine myomas.
  • 2022-09-16 MRI - T-spine
    • Indication: recurrent follicular lymphoma with low back pain
    • Findings
      • Abnormal enhancement in T10 and T11 vertebral body (esp T10), para-aoritc soft tissue lesions, right paraspinal soft tissue lesion at T9-12 levels, left paraspinal soft tissue lesionat T6-7 levels, and intraspinal lesion causing spinal cord compression at T7-10 levels (most severe at T10), indicating metastases.
      • Right massive pleural effusion.
      • End-plate degeneraiton, disc collapse with general bulging, posterolaterla osteophytes and enlarged facets causing diffuse spinal canal stenosis and neuroforaminal narrowing at at C2-3-4-5-6-7-T1.
      • No intramedullary lesion.
    • IMP: Bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10).
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • There is scoliosis of the T-spine with convex to right side.
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-09-13 Abdomen, standing (diaphragm)
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Scoliosis of L-spine with convex to left side
    • Fecal material store in the colon.
  • 2022-08-16 Whole body PET scan
    • Glucose hypermetabolism involving the upper abdominal right paraaortic area, pleura of right lower lung field, right paraspinal area and adjacent T10 spine. Recurrent lymphoma may show this picture.
    • A glucose hypermetabolic lesion in the wall of the descending aorta. The nature is to be determined (lymphoma? inflammatory process?). Please correlate with other clinical findings for further evaluation.
  • 2022-08-02 Patho - omentum biopsy
    • Pathologic diagnosis
      • Para-spinal tumor, CT-guided biopsy — Follicular lymphoma, compatible with recurrence
    • Macroscopic description
      • Operation procedure: CT-guided biopsy
      • Topology: Para-spinal tumor
      • Specimen size and number: one strip of tumor tissue measured 0.5 x 0.1 x 0.1 cm in size
    • Microscopic description
      • Histology type: follicular lymphoma
      • Histology description: B-cell lymphoma characterized by proliferative small lymphoid cells.
      • Immunohistochemistry shows CK(-), CD3(-), CD20(+), Bcl-2(+), CD10(+), Bcl-6(+), CD23(+) and Cyclin-D1(-) for tumor. According to all histopathologic findings and past history, it is compatible with recurrent follicular lymphoma.
  • 2022-07-22 CT - abdomen
    • Prior CT identified lobulated enhancing soft tissue tumors in right paraspinal area (right lower medial pleura space and right erector spinal muscle) are noted again, mild increasing in size.
  • 2022-01-24 CT - abdomen
    • History and indication: Follicular lymphoma grade I, lymph nodes of head, face, and neck
    • Impression:
      • Stationary condition of spleen lesions.
      • Total regression of retroperitoneal tumors.
      • Mild progression of right paraspinal lesions.
  • 2021-08-09 CT - abdomen
    • Stationary condition of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2021-02-19 CT - abdomen
    • Follicular lymphoma of right paraspinal area and retroperitoneal space s/p C/T & R/T show complete response.
    • Follicular lymphoma of the spleen s/p C/T & R/T show near complete response.
  • 2020-09-07 CT - abdomen
    • Much regression of spleen lesions.
    • Total regression of right paraspinal and retroperitoneal tumors.
  • 2020-03-03 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-31 CT - abdomen
    • Much regression of spleen, right paraspinal and retroperitoneal tumors.
  • 2019-12-12 MRI - C-spine
    • Indication:
      • 72 y/o, a pt of follicular lymphoma stage II Dx in May 2019 at TaiAn Hospital, s/p definitive C/T wt R-COP or R-CHOP IV Q3W x 6 finishing in Oct 2019 and R/T (15 frac) to paraspinal tumor bed from 20191113 to 20191203 by Dr JingMin Huang.
      • 20191203: right distal hand numbness for yrs with recent deterioration; neckpain also noted; clumsiness over rigth UE with weakness / eaasily lost holding things; no night pain
    • IMP:
      • Cervical spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, esp C7-T1 with right HIVD and compressive myelopathy.
  • 2019-09-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region come to significantly less prominent compared with the previous study on 2019/06/04, indicating partial response to current therapy.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary hilar regions, probably inflammatory process or physiological uptake of FDG.
  • 2019-06-13 CT - abdomen
    • Soft tissue tumors (up to 4.6x10.6cm) at spleen, right paraspinal region and retroperitoneum.
  • 2019-06-04 Whole body PET scan
    • Glucose hypermetabolic lesions in the abdomen as mentioned above with extension to the right lower back region, compatible with malignancy such as lymphoma. Please correlate with other clinical findings for further evaluation.
    • Mild and symmetric glucose hypermetabolism in bilateral pulmonary regions. Inflammatory process is more likely.

[consultation]

  • 2022-11-17 Rehabilitation
    • A
      • Assessment
        • Follicular lymphoma, stage II s/p chemotherapy
        • Pleural effusion in other conditions classified elsewhere
        • Shortness of breath
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation programs
        • Goal: recondition, improve endurance and muscle strength
  • 2022-11-04 Cardiology
    • Q
      • Consultation for management of pulmonary embolism.
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II, s/p definitive C/T wt R-COP or R-CHOP regimen finishing in Oct 2019 & R/T (15 fr) to paraspinal tumor bed completed in Dec 2019. This time, she was admitted due to dyspnea for 3 days. She appeared in general weakness and fatigue.
        • CXR done in ER : right-sided pleural effusion; however, chest echo showed only minimal fluid; therefore, tapping was not done.
        • PE : bilateral coarse breathing sound, swollen and cold left lower limb. SpO2 was able to be maintined by nasal cannula 3L for now.
        • Lab data : leukocytosis with neutrophilic predominance
        • WBC: 19.4 K
        • Neutrophil: 90%
        • D-dimer: >10000
        • NT-proBNP: 1896
        • Chest CTA was done on 20221102, which showed pulmonary embolim.
      • We have started 3 days of SC enoxaparin from 11/3, and have arranged lower limb Doppler sonography and cardiac echo. We need your expertise for this patient’s pulmonary embolism management.
    • A
      • This is a 75 year-old female patient with history of follicular lymphoma at para-spinal region, Lugano stage II,
      • This patient suffered from lobulated pleural effusion, s/p VATS decortication + close drainage. at 2022/09. According to this patient, she suffered rom dyspnea and also ntoed to have left lower limb swelling for 1~2 months. Currently, her left lower limb showed no obvious erythema or swelling or edema, however, the diameter was obvious larger than right side. She had history of cancer and also in semi-bedridden status.
        • Chest CT: right side pulmonary embolis, possible some small pulmonary embolism at left upper lobe branch, no RA dilatation
      • Impression:
        • compatible with pulmoanry embolism, beween submasive(trop-I) to low risk, suspected left chronic DVT related
      • Suggestion:
        • agree with Clexane Q12H use, ( BW 47kg, Creatine 1.10)
          • May transition to NOAC after 1 week of clexane injection
          • e.g. Apixaban 5mg 1# BID or Edoxaban 60mg 1# QD or Rivaroxaban 15mg 1# BID (EINSTEIN–PE study, higher dose and may go with higher bleeding risk in this patient)
        • Due to left lower limb swelling was noted, but clinical condition not favor acute DVT, may consider chronic DVT or may-thurner syndrome or retroperitoneal fibrosis
          • => please arrange lower limb echo (for DVT survey) and echocardiography (for pulmonary embolism PEPSI score)
        • This patinet had higher risk for recurrence (bed-ridden / cancer) and may consider long term NOAC use
          • If other cause was worry, may consider search for autoimmune and coagulation profile ( but might not change clinical decision)
          • => protein C/ protein S, anti-phospholipid antibody syndrome profile, C3,C4, lupus anticoagulant
  • 2022-10-18 Radiation Oncology
    • A
      • S: For radiotherapy due to high grade follicular lymphoma with brain metastasis.
        • PI: The patient suffered from change of personality during admission. Brain MRI (2022-10-17) showed a left temporal base tumor mass, suspicious meningioma or lymphoma? For radiotherapy.
      • A: Follicular lymphoma of the spleen, right paraspinal region and retroperitoneum, stage II, s/p chemotherapy, with partial response, s/p radiotherapy, with tumor progression including brain metastasis.
      • P: Radiotherapy is indicated for this patient with the following indicators: brain metastasis.
        • Goal: palliation
        • Treatment target and volume: brain
        • Technique: 2D and VMAT/IGRT
        • Preliminary planning dose: 1400cGy/7 fractions of the whole brain, and 3000cGy/15 fractions of the metastatic brain tumor.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her daughter. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy was already started at 1330, 2022-10-18.
  • 2022-10-06 Infectious Disease
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to rectal swab showed VRB, so we need your management.
    • A
      • Hx review as mentioned above and Lab data check
      • Suggestion:
        • May stop Targocid, shift to zyvox for this immunocompromised pt with increasing CRP
        • repeat B/C, monitor CRP
  • 2022-10-05 Psychosomatic medicine
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with right pleural effusion malignant. Due to several delirum with aggressive behavior, so we need your management. Thanks!
    • A
      • Psychiatric impression:
        • Acute agitated state
          • suspected adjustment reaction
          • suspected acute delirium
          • suspected dementia with BPSD
        • Depressive disorder
      • Symptoms and course:
        • This is a 75 y/o female patient with underlying lymphoma with right pleural effusion admitted for palliative C/T s/p 20220930 VATS decortication, and was just tranferred out from ICU at 20221005 afternoon. According to the patient, her family and side information collected:
        • Upon visit, she showed clear consciousness, alert, but very guarded and defensive attitude, irritable mood, angry, hostile attitude towards the medical team and her family. Speech were rather coherant and relevant, no obvious psychosis were noted currently.
        • Orientation:
      • Suggestion:
        • Anxicam 0.5amp IM/ Bini-U 0.5amp IM PRNQ6H if severe agitation
        • Add Utapine 1# HS, and give utapine 1# PRNHS if still irritable and sleep disturbance. Keep the xanax 1# BID for anxious mood.
        • Close monitor the vital signs, respiratory patterns after the PRN injection and medication, regularly follow up EKG
        • Further survey and treat her possible physical condition: infection, pain, urine retention…
        • Acute intervention, suicide risk assessment: moderate: denied past suicide idea or attempt; fair family support and accompany, but now in great distress and anger, impulsive
        • Suicide prevention is adviced.
  • 2022-09-29 Thoracic Surgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma, least stage III. Due to right pleural effusion with loculations, so we need help for chest tube insertion assessment. Thanks!
    • A
      • I have visited the patient and reviwed the images. I will arrange right VATS decortication this week. Thanks for your consultation!!
  • 2022-09-17 Neurosurgery
    • Q
      • The 75 y/o woman has recurrent follicular lymphoma with bony metastases at T10 and T11 vertebral body and bilateral paraspinal metastases (left T6-7 and left T9-12) with intraspinal invasion and cord compression (T7-10). We need your help for surgycal intervention. Thanks!
    • A
      • suggest medication treatment for the recurrent follicular lymphoma with bony metastasis first.

[chemotherapy]

  • 2022-11-30 - rituximab 375mg/m2 500mg NS 500mL 8hr D1 + bendamustine 70mg/m2 100mg NS 250mL 90min D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg + NS 250mL + acetaminophen 500mg PO

==========

2023-02-20

[tube feeding]

  • Keppra: In this hospital, there is a liquid form of Keppra oral solution (levetiracetam 100mg/mL, 300mL per bottle) that is suitable for tube feeding.

  • OxyNorm: Pour the small granules out of the OxyNorm (oxycodone 5mg/cap) capsules, dissolve them in drinking water, and administer them through a tube feeding.

  • OxyContin: OxyContin (oxycodone 10mg controlled-release tablet) is a long-acting formulation. Grinding the tablet will destroy the controlled-release design and cannot maintain long-lasting effects. Its use is not recommended for tube feeding.

2022-10-06

[drug interaction]

  • Morphine (8mg IVD PRNQ6H currently) is contraindicated when used concurrently with monoamine oxidase inhibitors (MAOIs, linezolid 600mg IVD Q12H currently).

  • There is a possibility that monoamine oxidase inhibitors may enhance the adverse/toxic effects of morphine. Please monitor any possible adverse reactions carefully.

700143756

230214

[diagnosis] - 2023-01-16 admission note

  • Synchronous cancer in the cecum and rectosigmoid colon, cT4aN2aM0, stage IIIC with partial obstruction and reginal lymph node metastasis s/p chemotherapy with FOLFOX from 2022/10/24 and status post robotic low anterior resection on 2022/12/20
  • Malignant neoplasm of sigmoid colon
  • Chronic viral hepatitis B without delta-agent
  • Hypokalemia
  • Constipation, unspecified
  • Cachexia
  • Insomnia, unspecified
  • Anemia due to antineoplastic chemotherapy

[past history]

  • Denied history of Hypertension, DM, asthma, cancer.
  • Denied any operation, accident and other medical history.                    

[allergy]

  • NKDA                     

[family history]

  • Father: colon cancer.
  • Mother: brain cancer.

[lab data]

  • 2022-08-23 Anti-HBc Reactive
  • 2022-08-23 Anti-HBc-Value 7.67 S/CO
  • 2022-08-23 Anti-HBs 1.00 mIU/mL
  • 2022-08-23 HBsAg Reactive
  • 2022-08-23 HBsAg Value 23.83 IU/mL

[exam findings]

  • 2023-01-03 CXR
    • staple line and hazy areas of increased opacity over Lt upper lung zone due to post op change
    • marginal spurs of multiple vertebral bodies due to spondylosis.
  • 2022-12-22 CXR
    • S/P Port-A infusion catheter insertion.
    • Right subphrenic air.
    • Presence of ileus.
    • S/P left side chest tube insertion.
    • S/P operation.
    • Right subcutaneous emphysema.
  • 2022-12-20 Patho - colon segmental resection for tumor
    • Diagnosis
      • Large intestine, rectum, robotic low anterior resection —- Adenocarcinoma, moderately differentiated, s/p CCRT
      • Resection margins: circumferential: involved
      • Lymph node, mesocolic, dissection —- Negative for malignancy (0/15)
      • Lymph node, IMA / SMA, dissection —- Not received
      • AJCC 8th edition Pathology stage: ypStage IIB, ypT4aN0(if cM0)
      • F2022-00614 Lung, LUL, wedge resection —- Negative for malignancy
    • Gross Description:
      • Operation procedure: robotic low anterior resection
      • Specimen site: rectum
      • Specimen size: 8.8 cm in length
      • Tumor size: 4.1 cm in length, annularly ulcerated
      • Tumor location: 2.7 cm and 2.0 cm away from the two resection margins, respectively
      • Depth of invasion grossly: visceral peritoneum
      • Mucosa elsewhere: congestion
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as: A1: colon, non-tumor; A2-6: tumor; A7-10: lymph node, mesocolic; B: proximal cutend; C: distal cutend.
      • F2022-00614 - The specimen submitted in fresh consists of a piece of lung tissue, measuring 9.3 x 2.0 x 1.4 cm and weighing 8g. On cutting, a fibrotic and calcified nodule measuring 0.5 x 0.4 x 0.3 cm is seen and 0.5 cm away from the resection margin. The parenchyma elsewhere is congested. The nodule is all for section in a cassette for frozen examination. After formalin fixation, additional sections are taken and labeled as: X1: resection margin; X2: lung, near nodule; X3-4: lung.
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the visceral peritoneum (including tumor continuous with serosal surface through area of inflammation)
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Involved
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Present
      • Tumor Budding: Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose: tubulovillous adenoma
      • Tumor Deposits: Not identified
      • Regional Lymph Nodes: 0/15
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply): y (posttreatment)
          • Primary Tumor (pT): pT4a: Tumor invades through the visceral peritoneum (including gross perforation of the bowel through tumor and continuous invasion of tumor through areas of inflammation to the surface of the visceral peritoneum)
          • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
          • Distant Metastasis (pM): if cM0
      • Additional Pathologic Findings (select all that apply): None identified
      • Tumor regression grading S/P CCRT: Modified Ryan scheme: Tumor regression score: 2, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response).
      • F2022-00614 - Sections show lung with a calcified and fibrotic nodule. No malignancy is seen.
      • Addendum: The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
  • 2022-12-19 CXR
    • Ground glass opacity in left lung.
  • 2022-12-19 Frozen Section
    • Preliminary diagnosis: Lung, LUL, biopsy — Calcified fibrotic nodule
  • 2022-12-19 ECG
    • Moderate voltage criteria for LVH, may be normal variant
    • Nonspecific T wave abnormality
  • 2022-11-29, -11-24 KUB
    • S/P intrauterine contraceptive device retention over the pelvis
    • Fecal material store in the colon.
  • 2022-11-24 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92 - 19) / 92 = 79.35%
      • M-mode (Teichholz) = 79
    • Indeterminated LV filling pressure and impaired RV relaxation.
    • Normal LV and RV systolic function.
    • Suspected bicuspid aortic valve with mild to moderate aortic stenosis (AVA= 1.45 cm2 by Doppler method); mild AR; mild MR; mild TR and mild PR.
    • Dilated aortic root and proximal ascending aorta ( 34 mm) with mild calcification.
  • 2022-11-22 CXR
    • Solitary pulmonary nodule at LLL.
  • 2022-11-22 CT - abdomen
    • History and indication: A case of RS cancer s/p CCRT
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
      • Small liver and renal cysts.
      • Atherosclerosis of aorta, iliac arteries.
      • An IUD in the pelvic cavity.
    • IMP:
      • Stable condition of R-S colon cancer and LAP. Some nodules in bil. lungs.
      • Wall thickening of cecum.
  • 2022-11-22 Colonoscopy
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-10-17 Bronchodilator Test
    • Rectosigmoid cancer partial obstruction s/p CCRT
    • The scope can’t pass through due to lumen narrowing
  • 2022-08-30 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-29 ECG
    • Normal sinus rhythm
    • Minimal voltage criteria for LVH, may be normal variant
    • Nonspecific ST and T wave abnormality
  • 2022-08-29 CXR
    • Atherosclerotic change of aortic arch
    • Tortuosity of thoracic aorta
    • Enlargement of cardiac silhouette.
    • Spondylosis of the T-spine
  • 2022-08-17 CT - abdomen
    • History: 76 y/o female
      • 20220726 FOBT positive at Far Eastern Polyclinic of Far Eastern Medical Foundation
      • 20220810 colonoscopy: An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion.
      • 20220816 pathological result: adenocarcinoma
    • Indication: Sigmoid colon cancer for staging
    • Findings:
      • There is segmental lobulated wall thickening measuring 6 cm in length and 1.8 cm in the maximal wall thickness at the rectal-sigmoid colon with irregular contour and lumen narrowing that is c/w adenocarcinoma (T4a) of the rectal-sigmoid colon with partial obstruction.
        • The fat plane between sigmoid colon lesion and the uterine cervix area shows obliteration that may be tumor invasion or attachment? Please correlate with MRI.
        • In addition, There are four enlarged nodes in left perirectal space that may be metastatic nodes (N2a).
      • Another lobulated soft tissue mass-like lesion in the cecum and proximal ascending colon is suspected.
        • Please correlate with colonoscopy to R/O Synchronous cancer.
      • There is a well-defined poor enhancing lesion 6 mm at S8 dome of the liver that may be cyst?
        • The differential diagnosis include metastasis?
        • However, it is too small to characterize. Follow up is indicated.
      • There is a well-defined ovoid-shaped poor enhancing lesion at right inguinal area, measuring 2.3 x 1.3 cm in size and 5HU in CT density.
        • Benign reactive node or cystic lesion is highly suspected. Please correlate with sonography.
      • There is a small nodule 4 mm at LUL of the lung.
        • Follow up is indicated.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)
  • 2022-08-11 Patho - colon biopsy
    • DIAGNOSIS: Intestine, large, RS colon, 10-15 cm from anal verge, biopsy — adenocarcinoma
    • Description: The specimen submitted consists of 4 pieces of tissues measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
    • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, tumor necrosis and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • NOTE: IHC stain for MSI will be followed.
  • 2022-08-10 Colonoscopy
    • Findings
      • Using Olympus CF-H260AL, endoscopic examination of rectum and colon was done and the scope is placed up to the level of RS junction. An annular tumor mass obstructs the lumen at this level about 10-15 cm from the anal verge and the scope cannot pass through this stenotic lesion. Bx x 4 done. Internal hemorroid is noticed.
      • Internal hemorrhoid was noted.
    • Diagnosis
      • Colon cancer, RS junction s/p Bx
      • Internal hemorrhoid
      • Incomplete CFS exam

[consultation]

  • 2022-11-25 Thoracic Surgery
    • Q
      • This is a 76 year-old woman who denied having any history. According the patient, she suffered from mucous stools was pink like, abdomen flatulence, and difficult defecation since half year ago. And she came to the local clinic (Far Eastern Polyclinic), the fecal occult blood test positive noticed, so referred to our GI OPD for further assessment.
      • Colonscopy (2022/08/10) showed: 1. Colon cancer, RS junction s/p Bx. 2. Internal hemorrhoid. Abdomen CT showed: 1. Adenocarcinoma of the sigmoid colon with suspicious uterine cervix invasion is suspected. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition for colon cancer: T4a(or4b)N2aM0, stage:IIIC. 2. Synchronous cancer in the cecum and proximal ascending colon is suspected on 2022/08/17. The RS colon biopsy — adenocarcinoma.
      • The radiotherapy starts from 2022/08/26, RT finished on 2022/10/12. CCRT with 5-FU (Covorin 20mg/m2, 5-Fu 225mg/m2) QW, (C1) on 2022/9/1-2022/9/2, 2022/9/5-2022/9/7, 2022/09/22-2022/09/23, 2022/09/26-2022/09/28. Chemotherapy with FOLFOX (Oxalip 85mg/m2, Covorin 400mg/m2, 5-Fu 400mg/m2、5-Fu 2400mg/m2) was given on 2022/10/24(C1D1), 2022/11/07(C1D15). Surgery will be arranged on 20221207 or later.
      • Due to CT image (2022/11/22) showed some nodules in bil. lungs, we need your consultation for evaluation. Thanks a lot!!!
    • A
      • LUL nodule was noted. I will arrange VATS LUL wedge resection.

[surgical operation]

  • 2022-12-19
    • Surgery
      • Robotic low anterior resection        
    • Finding
      • Advanced rectal cancer s/p CCRT with anterior pelvic peritoneal invasion
  • 2022-12-19
    • Surgery
      • VATS LUL wedge resection.
    • Finding
      • One small nodule was noted over LUL, size about 0.5cm in diameter.
      • Frozen section: benign lesion.
      • One 20 Fr. straight chest tube was inserted via left 6th ICS.

[radiotherapy]

  • 2022-08-26 ~ 2022-10-06 - 5040cGy/28 fractions (15 MV photon) to rectosigmoid tumor, LAPs and cecal tumor.

[assessment]

  • 2023-12-13 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr (w/o 5-FU bolus)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-01-16 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-11-07 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2023-10-24 - oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 400mg/m2 600mg NS 250mL 10min + fluorouracil 2400mg/m2 3500mg NS 500mL 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL + aprepitant 125mg D1-3
  • 2022-09-26 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-22 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2
  • 2022-09-05 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-3 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-3
  • 2022-09-01 [leucovorin 20mg/m2 30mg NS 100mL 10min + fluorouracil 225mg/m2 330mg NS 100mL 10min] D1-2 (CCRT)
    • [dexamethasone 4mg + metoclopramide 10mg + NS 250mL] D1-2

==========

2023-02-14

  • A leukocytopenia event was observed (2023-02-02 WBC 1.86K/uL, Neutrophil 42% => ANC 780/uL) and the previously scheduled chemotherapy was cancelled on that day. FOLFOX is being administered without a 5-FU bolus this time. It is important to monitor the patient’s WBC count to determine whether leukocytopenia recurs.

2023-01-17

  • Except for urticaria, the underlying conditions listed in the problem list are appropriately treated with corresponding medications.

  • As a premedication, a single shot diphenhydramine is used in the current chemotherapy regimen, however, the newer, second generation H1 antihistamines are recommended as first-line therapy for urticaria. These newer drugs are minimally sedating, are essentially free of the anticholinergic effects that can complicate use of 1st generation agents, have few significant drug-drug interactions, and require less frequent dosing compared with first-generation agents. It is recommended to initialize a 2nd generation antihistamine at standard therapeutic dose:

    • cetirizine, 10mg once daily
    • levocetirizine, 5mg once daily
    • fexofenadine, 180mg once daily
    • loratadine, 10mg once daily
    • desloratadine, 5mg once daily

2022-09-26

  • The CT of the abdomen on 2022-08-17 revealed possible synchronous cancer (rectal-sigmoid colon, cecum, and proximal ascending colon), a liver S8 dome lesion, and a LUL nodule.
  • Patients with synchronous colorectal carcinoma have a higher proportion of microsatellite instability cancer than patients with a solitary colorectal carcinoma. Also, limited data have revealed that in many synchronous colorectal carcinomas, carcinomas in the same patient have different patterns of microsatellite instability status, p53 mutation and K-ras mutation. (ref: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4051920/ ). Pathology (2022-08-11) IHC MSI results (for the rectal-sigmoid colon specimen) are not yet available.

701334097

230214

{not completed}

[exam findings]

  • 2023-02-08, -02-05, -01-31 CXR

    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Pleura effusion of right and left costal-phrenic angle S/P pigtail catheter implantation at right CP angle?
    • 2023-02-08 - Patchy consolidation of both lung zone are noted. please correlate with clinical condition to R/O Bronchopneumonia.
    • 2023-02-05 - Linear infiltration over both lung zone are noted. please correlate with clinical condition.
    • 2023-01-31 - Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2023-02-05 CT - brain

    • Brain atrophy
  • 2023-02-03 MRI - brain

    • No evidence of intracranial lesion.
  • 2023-02-03 Electroencephalography, EEG

    • This is an abnormal EEG suspecting bilateral central epileptogenic activities intermittent diffuse slow waves at bilateral central and temporal area
    • A few sharpy contour waves or spikes over bilateral central area.
    • Please correlate clinially
  • 2023-02-03 Peripheral Vascular Test - vein, lower limbs

    • No evidence of deep vein thrombosis at bilateral lower limbs (by color flow filling, direct compression, and distal augmentation response)
    • Bilateral long saphneous vein engorgement (from thigh to leg), left side more severe; connecting to bilateral engorged posterior tibial veins by perforator veins at leg level
    • 2022-01-06 Patho - colon segmental resection for tumor
      • pathology diagnosis
        • Rectum, Hartmann’s operation – Adenocarcinoma, moderately differentiated
        • Resection margins, Hartmann’s operation – Free of carcinoma
        • Lymph nodes, mesocolorectal, Hartmann’s operation — Metastatic adenocarcinoma (1/12)
        • Specime labeled pelvic tumor margin, biopsy — Necrosis and granulation tissue and free of carcinoma
        • T-colon colostomy, closure of colostomy — Free of carcinoma
        • Pathology stage: ypT3N1a(cM0); Stage IIIB
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: Moderately differentiated
        • Depth of invasion: Perirectal soft tissue
        • Angiolymphatic invasion: Not identified
        • Perineural invasion: Present
        • Tumor cell budding: Intermediate
        • Circumferential (radial) margin of rectum: Uninvolved, 2 mm from the margin
        • Lymph node metastasis, mesocolorectal: Metastatic adenocarcinoma (1/12)
        • Extranodal involvement: Absent
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • Primary Tumor (pT): ypT3 (Tumor invades pericolorectal tissues)
          • Regional Lymph Nodes (pN): ypN1a (one regional lymph node positive)
          • Distant Metastasis (pM): cM0
        • Type of polyp in which invasive carcinoma arose: Not identified
        • Additional pathologic findings: None identified
        • Tumor regression grading S/P CCRT: Partial response (score 2)
        • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
        • Specime labeled pelvic tumor margin: Necrosis and granulation tissue, and free of carcinoma
        • T-colon colostomy: Free of carcinoma
    • 2021-12-28 CT - abdomen, pelvis
      • Rectosigmoid colon cancer, size decreased.
      • Decreased size of pericolic lymph nodes.
      • Status post T-colostomy.
      • Right hydronephrosis and hydroureter.
      • Tiny subpleural nodules (<0.5cm) at basal LLL. Suggest close follow up.
    • 2021-12-28 Colonoscopy
      • compatible with colon cancer, 8cm AAV, with near lumen obstruction.
    • 2021-09-16 CT - abdomen, pelvis
      • Imaging stage: T3N2aM0, stage IIIB
  • lab data

    • 2022-02-24
      • All RAS mutation not detected
      • BRAF mutation not detected
  • surgical operation

    • 2022-01-05
      • surgery
        • Hartmann’s operation and closure of T-loop colostomy
      • finding
        • Advanced rectal cancer obstruction s/p CCRT and the tumor was firmly fixed to the pelvic cavity , clinically can’t be resected completely
    • 2021-09-17
      • surgery
        • T loop colostomy        
      • finding
        • Rectal cancer with obstruction, cT3N2aM0 stage IIIB
        • RUQ stoma with stent
  • radiotherapy

    • 2021-09-28 ~ 2021-11-04 - pelvis: 45 Gy/ 25 fx. R-S colon tumor and LAPs: 50.4 Gy/ 28 fx
  • chemoimmunotherapy

    • 2022-02-22 ~ undergoing - FOLFOX plus bevacizumab
    • 2021-11-29 ~ 2022-02-07 - FOLFOX
    • 2021-10-04 ~ 2021-11-01 - 5-Fu + LV (CCRT)

==========

2023-02-06

  • 2023-01-23 urine culture found Candidas abicans 50000 colony count CFU/cc. Treatment of candidemia and invasive candidiasis in nonneutropenic patients could be an echinocandin (1. caspofungin 70 mg IV loading dose, then 50 mg IV daily; 2. micafungin 100 mg IV daily; 3. anidulafungin 200 mg IV loading dose, then 100 mg IV daily. Items 2 and 3 are not necessary to be dose adjusted for any degree of kidney impairment and they are available in this hospital.) is recommended as initial therapy. (ref: https://www.uptodate.com/contents/image?imageKey=ID%2F87676)

  • 2023-01-13 anaerobic culture of the perineuim was found to contain Bacteroides thetaiotaomicron 3+ that was sensitive to metronidazole and ampicillin/sulbactam. It is not necessary to adjust dose for metronidazole if CrCl is greater than 10, while for ampicillin/sulbactam, CrCl is greater than 30. Keep metronidazole use is recommended.

  • If Keppra (500mg Q12H) is not demonstrated to be effective for seizure control, valproate (no dosage adjustment necessary if CrCl >= 10 mL/min) or carbamazepine (no dosage adjustment necessary for kidney impairment) might be added.

    • Depakine (valproic acid) is available in tabet, oral solution and injection forms.
    • Carbamazepine might cause hyponatremia, which might be a desired side effect to mitigate the patient’s hypernatremia (2023-02-05 Na 152 mmol/L).

2023-01-30

[compatible solutions to mitigate hypernatremia that do not rely on saline]

Following is a list of the selected injectable medications in the active prescription and their compatibility with non-saline-based solutions according to MicroMedex.

  • Benamine (diphenhydramine hydrocholoride)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Flucon (fluconazole)
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested
  • Furosemide
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV compatible
  • Metronidazole
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV not tested
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not tested

Use potassium supplements if necessary

  • Potassium phosphates
    • D5W (Dextrose 5% in water)
      • IV compatible
    • D10W (Dextrose 10% in water)
      • IV compatible
    • D5LR (Dextrose 5% in lactated Ringers)
      • IV not compatible

2022-04-08

  • Having been firmly embedded in the pelvic cavity, the tumor could not be surgically resected fully (2022-01-05).
  • The patient receives FOLFOX since 2021-11-29 (plus bevacizumab since 2022-02-22) s/p T loop colostomy (2021-09-17) and CCRT (late Sep to early Nov 2021).
  • According to laboratory data reported on 2022-04-06, there were no obvious abnormalities; however, elevations in ALT (60 U/L) and AST (64 U/L) should be addressed, as these two readings had been normal prior to the this last examination.
  • As metoclopramide is one of the potentially hepatotoxic drugs, some silymarin as supplementation might be an optional add-on to mitigate the potential hepatotoxicity.

701277175

230213

  • diagnosis - 20230105 admission note
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast invasive carcinoma with left axillary LN enlargement and bone metastasis, ER (+), PR (-), Her2 (+), stage IV, PS 1
    • Secondary and unspecified malignant neoplasm of axilla and upper limb lymph nodes
    • Secondary malignant neoplasm of bone
  • exam finding
    • 2022-10-17 CT - chest
      • Indication: left breast invasive carcinoma with left axillary LN enlargement and BONE Metases ER (+), PR (-), Her2 (+), stage IV, PS 1
      • MDCT (128 256-detector rows, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm (lung window),5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows: (Comparison was made with previous CT dated on 20220702)
        • Lungs: s/p RUL operative with septal line and surrounding opacity along the interalobar fissures, and septal thickening and subpleural edema along minor fissure. septal line and septal thickening at RML too.
          • there is subpleural and reticulation at basal segments of RLL.
      • Impression:
        • post op change in RUL and RML, in regression as compared with previous CT on 20220702.
        • suspect early fibrosis in RLL.
    • 2022-07-05 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/02/11, no prominent change is noted in the previous faint hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-07-04 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade A(minimal)
        • Superficial gastritis, body, s/p CLO test
        • Gastric erosions, antrum
        • Gastric polyps, fundus and AW site of high body, r/o fundic gland polyps
        • Duodenal shallow ulcer, bulb, AW site
      • Suggestion
        • Pursue CLO test result
    • 2022-07-02 CT - chest
      • S/P mastectomy at left side
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA
      • post op. change over right upper lobe
    • 2022-06-20 Abdomen - standing (diaphragm)
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • S/P Mastectomy, left.
    • 2022-06-14 MTBC (Mycobacterium tuberculosis complex) PCR
      • Undetectable
    • 2022-05-30, -05-27 CXR
      • Port-A catheter inserted into RA via right subclavian vein.
      • s/p right chest tube in place, its tip directed superiorly projecting over 5th rib
      • extensive hazy areas of increased opacity over Rt upper lung zone
    • 2022-05-27 Patho - lung wedge biopsy
      • DIAGNOSIS:
        • A: Lung, RML, wedge resection — organizing pneumonia
        • B: Lymph node, right, group 7, dissection — negative for malignancy (0/1)
        • C: Lymph node, right, group 9, dissection — negative for malignancy (0/1)
        • D: Lymph node, right, group 11, dissection — negative for malignancy (0/3)
        • E: Lymph node, right, group 12, dissection — negative for malignancy (0/1)
        • F2022-00248: Lung, RUL, segmentectomy — Non-necrotizing granulomatous inflammation with organizing pneumonia
    • 2022-05-26 Pulmonary Flow Volume Loop
      • Normal ventilation
    • 2022-04-22 CT - lung/mediastinum/pleura
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/P mastectomy at left side.
          • Spiculated nodule at right upper lobe up to 1.9cm in largest dimension is found. Another fissural based lesion at right middle lobe up to 1.4cm in largest dimension. In comparison with CT dated on 2021-12-17, the lesions are new. Suggest correlate with PET or other exam.
          • No evidence of bilateral pleural effusion.
          • S/p port-A placement with its tip at Superior vena cava.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • Non-specific bowel gas at abdominal cavity is found.
        • Imp:
          • S/P mastectomy at left side.
          • New spiculated nodule at right upper lobe and right middle lobe, the nature of the lesions should be further characterized or closely follow up. (mets is less likely but primary tumor or inflammation cannot be excluded.)
    • 2022-02-11 Tc-99m MDP whole body bone scan - In comparison with the previous study on 20210924, no prominent change is noted in the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones, suggesting stable condition. - Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2022-01-20 Patho - breast simple/partial mastectomy
      • Breast, left, simple mastectomy (s/p chemotherapy) — No residual tumor
      • Pathology stage: ypT0N0(if cM0)
    • 2022-01-19 Lymphoscintigraphy
      • No sentinel lymph node in the left axillary region or left ant. chest wall is delineated throughout the whole study.
    • 2022-01-11 SONO - breast
      • Clinical left breast s/p C/T.
      • Right breast cysts and fibroadenomas. Suggest follow up.
      • BIRADS 6 - proven malignancy
    • 2021-12-17 CT - chest
      • No evidence of recurrent/residual tumor at both sides of the breast and other region.
    • 2021-09-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210427, the previous hot spots in the skull, anterior aspect of bilateral rib cages, right S-I joint and bilateral iliac bones are less evident. Bone metastases with some resolution may show this picture. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla in stationary status. Dental problem and/or sinusitis may show this picture.
    • 2021-09-06 CT - chest
      • resolution of Lt breast tumor and metastatic axillary and supraclavicular lymphadenopathy as compared with CT on 20210423.
      • minimal paraspinal fibrosis in RLL of lung.
    • 2021-04-30 CT - brain
      • No intracranial lesion based on this study.
    • 2021-04-27 Tc-99m MDP whole body bone scan
      • Multiple hot spots in the skull, anterior aspect of bilateral rib cages and bilateral iliac bones. Bone metastases should be watched out if no definite traumatic event is noted. Please correlate with other clinical findings for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • 2021-04-26 Patho - lymphnode biopsy
      • Lymph node, left axilla, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6478): ER (+, strong intensity, 70%), PR(-), Her2/neu: positive(score=3+), Ki-67(50%), p53 (<5%).
      • Section shows fragments of tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 Patho - breast biopsy
      • Breast, left, core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains (using block S21-6477): ER (+, strong intensity, 70%), PR(+, weak intensity,5%), Her2/neu: positive(score=3+), Ki-67(80%), p53 (10%).
      • Section shows fragments of breast tissue with irregular neoplastic ducts infiltration.
    • 2021-04-26 SONO - breast
      • Left breast tumors with axillary lymph nodes, suspected malignancy with lymph nodes metastasis.
      • BI-RADS5
    • 2021-04-23 CT - nect
      • Suspect left breast tumor with left axillary lymphadenopathy. Several small lymph nodes at left supraclavicular region.
      • Suggest further breast ultrasound correlation and tissue proof if needed.
  • surgical operation
    • 2022-01-19 Simple mastectomy and SLNB (Sentinel Lymph Node Biopsy)
      • No palpable and visible tumor over L`t breast UOQ.
      • Sentinel nodes biopsy was done
      • Simple mastectomy was done.
      • L’t big toe nail bed redness & loosen wit hpus discharge.
  • chemoimmunotherapy
    • 2023-01-05 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-10-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-09-18 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-08-22 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-07-25 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-06-20 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 130mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2022-04-01 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 130mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-03-10 - docetaxel 75mg/m2 120mg 2hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-02-16 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-12-28 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-25 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-11-02 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-10-05 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-08-27 - trastuzumab 600mg SC 5min D1 + pertuzumab 420mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-07-29 - trastuzumab 600mg SC 5min + pertuzumab 420mg 1hr + decetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2021-07-02 - trastuzumab 600mg SC 5min D1 + pertuzumab 840mg 1hr D1 + decetaxel 75mg/m2 120mg 1hr D2
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + granisetron 2mg D2
    • 2021-06-01 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2021-05-05 - docetaxel 75mg/m2 120mg 1hr
      • dexamethasone 4mg + diphenhydramine 30mg
  • medication
    • Xgeva (denosumab) CXGEV01
      • 2022-09-01 120mg Q1M SC OPD
      • 2022-06-20 120mg ST SC IPD 2022-06-19
      • 2022-05-06 120mg Q1M SC OPD
      • 2022-04-01 120mg ST SC IPD 2022-03-31
      • 2022-02-25 120mg Q1M SC OPD
      • 2022-01-06 120mg Q1M SC OPD
      • 2021-12-02 120mg Q1M SC OPD

==========

2023-02-13

WBC returned to 5.05K/uL on 2023-02-12, neutropenia not observed.

2023-01-06

  • CT scan results from 2022-10-17 and bone scan results from 2022-07-05 indicate that the disease has remained non-progressive, indicating that the current regimen is still effective.
  • The lab results for 2023-01-05 were normal, and the vital signs during this stay in the hospital were stable.

2022-04-28

  • The patient was diagnosed with hormone receptor and Her2 positive breast cancer with bone mets. Mastectomy with SLNB was performed on 2022-01-19. Her chemoimmunotherapy with docetaxel began in May 2021, then trastuzumab and pertuzumab were added since July 2021.
  • She also received three denosumab injections for the bone mets on 2021-12-02, 2022-01-06, and 2022-02-25. Tc-99m MDP scan on 2022-04-22 showed that bone mets were stable.
  • The lab results of 2022-04-27 revealed no noticeable abnormalities. No issue with current prescription.

700380439

230210

[diagnosis] - 2022-12-02 admission note

  • Malignant neoplasm of lower third of esophagus
  • Bacteremia
  • Other specified bacterial agents as the cause of diseases classified elsewhere
  • Gastro-esophageal reflux disease with esophagitis
  • Secondary malignant neoplasm of other specified sites
  • Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes
  • Urinary tract infection, site not specified
  • Enterococcus as the cause of diseases classified elsewhere
  • Cardiomegaly
  • Rheumatic disorders of both mitral and tricuspid valves
  • Gastritis, unspecified, without bleeding
  • Pneumonia due to Pseudomonas

[past history]

  • denied systemic diseases
  • hyperthyroidism years ago? without follow up and medicine
  • SCC of esophagus of middle to lower third esophagus with gastric involvement, ycT3N1M1, stage IVB.   

[family history]

  • There is no family history of cancer, hypertension, mental diseases or asthma.
  • No members of the family with diabetes.

[exam findings]

  • 2023-02-10 CT - abdomen
    • History: esophageal cancer S/P C/T
      • 20210118 chest CT:interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is newly-developed massive ascites and omentum cake that is c/w carcinomatosis.
        • Please correlate with ascites cytology.
        • In addition, There are newly-developed ill-defined poor enhancing masses on both hepatic lobes that are c/w liver metastases.
      • Prior CT identified multiple lung metastases are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space are noted again, mild increasing in size that is c/w progressive disease.
      • Prior CT identified regional metastatic node in right lower para-esophageal mediastinum 2 cm is noted again, mild increasing in size to 2.5 cm.
      • There are several renal cysts on both kidney and the largest one measuring 2 cm in size at right umiddle pole.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery.
    • Impression:
      • Carcinomatosis and liver metastases (newly-developed).
      • Multiple lung metastases show progressive disease.
      • Metastatic nodes in the gastrohepatic ligament, celiac trunk and para-aortic space show progressive disease.
      • Metastatic regional node shows progressive disease.
  • 2023-01-18 CT - chest
    • Indication: esophageal cancer, S/P chemotherpaycheck chest C.T.
    • MDCT (128-detector rows, iCT Philips,was performed with 0.625 mm collimation & 2.5 mm (lung window), 5 mm (soft-tissue window), slice thickness) of the chest and upper abdomen without & with contrast enhancement, coronal and sagittal reconstructed images shows:
    • Comparison was made with previous CT dated on 2022/10/26
      • Lungs:
        • extensive, bilateral, upper lobes predominant, destructive centrilobular emphysema and subpleural paraseptal emphysema/bulla, in the lungs.
        • Multiple randomly distributed pulmonary nodules of varying sizes
        • due to metastases. reticular opacities at LLL and lingula.
      • Mediastinum and hila: a new necrotic lymphadenopathy in Rt paraesophageal region, subcarinal space.
        • Diffuse wall thickening from middle to lower third esophagus, in regression.
      • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Central pulmonary arteries: normal caliber.
      • Heart: normal in size of cardiac chambers.
      • Pleura: no effusion or nodule.
      • Chest wall and visible lower neck: regression mestatatic LAP at Rt supraclavicular fossa..
      • Visible abdominal contents: s/p percutsneous gastrostomy.
        • interval increase in size metastatic lymphadenopathy at para-aortic region near celiac trunk, with invasion to the pancreas.
        • multiple small hepatic cysts and small metastatic tumors are found. several small bilateral renal cysts.
    • Impression:
      • interval regression of esophageal tumor and metastatic LN at Rt supraclavivular fossa, but new regional metastatic mediastinal LAP, progression of retroperitoneal LAP and lung metastases, new hepatic metastasis, as compared with CT on 2022/10/28.
  • 2023-01-02 CXr
    • A nodular opacity projecting in the left lower lung is suspected. Please correlate with CT.
    • S/P port-A implantation.
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
  • 2022-11-02 Patho - esophageal biopsy
    • Labeled as “lower esophagus”, biopsy — Ulcer.
    • IHC stains: CK highlights surface squamous mucosa. P40 (-).
    • Section shows surface squamous mucosa, abundant cell debris and acute inflammatory exudates.
  • 2022-11-02 Patho - esophageal biopsy
    • Stomach, PW of upper body, biopsy — Ulcer, H pylori NOT present.
    • Section shows benign gastric mucosal tissue and ulcer debris with chronic inflammation. H. pylori NOT present.
    • NOTE: Since malignancy is clinically suspected, further work up or repeat biopsy might be considered.
  • 2022-11-02 SONO - abdomen
    • Liver cyst, both lobe
  • 2022-11-02 Miniprobe Endoscopic Ultrasound
    • Indication: Esophageal cancer, s/p CCRT, for restaging
      • Esophageal cancer staging
      • Symptoms: Nil
      • Dysphagia
      • Pre-EUS diagnosis: Esophageal cancer
    • Endoscopic findings:
      • With NBI-ME, no lesion nor brownish area was noted above epiglottis or at bilateral pyriform sinuses. With whitelight endoscopy, an easily touch-oozing scar was noted at 29cm below the incisors, causing luminal stenosis. The magnified endoscope could not pass through the stenotic site. With NBI-ME, non-specifc JES-IPCL pattern was noted over the scar and focal JES-IPCL B1 pattern was noted near the scar. We changed the scope to ordinary GIF scope and could pass through the stenotic site with resistance. A PEG tube was noted at AW of lower body. A healing ulcer with surrounding fold convergence was noted at PW of upper body, s/p biopsy(A). A kissing scar was noted at duodenal bulb. Chromoendoscopy with lugol solution showed circumferential LVL with pink-color sign from EC junction to 29cm below the incisors, s/p biopsy(B).
    • EUS findings:
      • With UM-2R, EUS showed 4th layer destruction, at least 3cm in length by miniprobe measurement. A 6.1mm hypoechoic lesion was noted near EC junction.
    • Diagnosis:
      • C/W esophageal cancer, middle to lower esophagus, EUS restaging at least cT3N1, s/p biopsy(B)
      • Gastric ulcer, PW of upper body, H2, Forrest III, suspected malignancy but improved, s/p biopsy(A)
      • PEG in situ
      • Duodenal ulcer scar, bulb
    • Suggestion:
      • Consider to correlate to other image studies and pursue pathology report
  • 2022-10-31 Tc-99m MDP whole body bone scan with SPECT
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, L-S junction, left sternoclavicular junction, bilateral shoulders, S-I joints, hips, and knees.
  • 2022-10-29 MRI - brain
    • Findings
      • mild dilated intraventricular and extraventricular CSF spaces
      • some white matter gliosis in the bilateral frontal lobes
    • IMP: no evidence of brain metastasis.
  • 2022-10-28 CT - chest
    • Indication: esophageal cancer
    • Findings
      • Chest:
        • Diffuse wall thickening from middle to lower third esophagus is found.
        • Severe Emphysematous change over both lungs is found.
        • Nodular lesion at subpleural region of right lower lobe up to 0.7cm and left lower lobe up to 0.5cm is found. These nodules are new.
        • S/p port-A placement with its tip at Superior vena cava.
        • Mild pericardial effusion is found.
        • No evidence of bilateral pleural effusion.
        • Lymphadenopathy at supraclavicular region is found. In regressionn.
      • Visible abdomen:
        • s/p gastrostomy. -Lymphadenopathy at retroperitoneum near celiac trunk is found. In enlargement. -The GB is well distended without soft tissue lesion -The liver, spleen, pancreas, both kidneys and adrenals are intact. -There is no evidence of paraarotic LAPs. -Suggest clinical correlation
      • Imp:
        • Severe COPD.
        • Esophageal cancer with regression.
        • NEw Right lower lobe and left lower lobe nodules. suspected lung meta.
        • Lymphadenopathy at supraclavicular region, in regression.
        • Lymphadenopathy at retroperitoneum, in enlargement.
  • 2022-10-28 Nasopharyngoscopy
    • Bil. few thick mucus and nasal cavity, suspected chronoic rhinosinusitis.
  • 2022-10-27 Body fluid cytology - bronchial washing
    • Atypia
  • 2022-10-27 Whole body PET scan
    • Glucose hypermetabolism involving the lower portion of the esophagus and cardia of the stomach, compatible with primary malignancy involving these regions.
    • Glucose hypermetabolism in multiple lymph nodes in the right lower neck, right paratracheal, precarinal, gastric cardiac and abdominal left paraaortic regions. Metastatic lymph nodes may show this picture.
    • A glucose hypermetabolic lesion in the segment IVb of the liver. Liver metastasis should be watched out.
    • Some glucose hypermetabolic lesions in bilateral lung fields. The nature is to be determined (inflammation? metastases?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake/accumulation in the left neck muscle, bilateral kidneys, ureters and colon. Physiological FDG uptake/accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2022-10-27 Bronchoscopy
    • nasal mucosa chronic inflammation
    • No evidence of trachea or LLL bronchus invasion of esophageal cancer
    • COPD AE during scopy
    • Diffuse proximal airways mucus impaction
  • 2022-10-26 CXR
    • Increased lung volume and areas of hyperlucency and decreased upper lung vascular markings due to severe emphysematous change of both lungs upper lung predominance
    • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
  • 2022-09-16 CXR
    • Atherosclerotic change of aortic arch
    • Fibrosis of right and left upper lung are suspected. Please correlate with clinical history to suspected old inflammatory process.
  • 2022-08-10 KUB
    • S/P gastrostomy.
    • Radiopaque spot(s) at left renal region suspected renal stone(s).
    • Intact bony structure(s).
  • 2022-08-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (134 - 43) / 134 = 67.91%
      • M-mode (Teichholz) = 67.8
    • Dilated LV, Ao
    • Adequate LV, RV systolic function with normal wall motion
    • LV hypertrophy, Impaired LV relaxation
    • Mild MR, TR
  • 2022-08-01 Tc-99m MDP whole body bone scan with SPECT
    • Several faint hot spots in the right rib cage, and increased activity in some T- and L-spine, and L-S junction, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for investigation.
    • Suspected benign lesions in the maxilla, left sternoclavicular junction, bilateral shoulders, and S-I joints.
  • 2022-07-30 CT - chest
    • Indication: esophageal tumor, lower esophagus
    • Findings
      • Chest:
        • Dilated upper esophagus with soft tissue occupying middle to lower esophagus about 10.3cm in largest dimension.
        • Lymphadenopathy at right lower neck, paratracheal, paraesophageal, gastric cardiac and retroperitoneal region.
        • There is no evidence of destructive bone lesion.
        • Severe Emphysematous change over both lungs.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Multiple hepatic cysts are found at both lobes of liver is found.
        • The spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
      • Suggest clinical correlation
    • Imp:
      • Esophageal cancer at lower third esophagus and extensive lymphadenopathy. Suggest further treatment.
      • Severe Emphysematous change over both lungs.
    • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-07-29 Patho - esophageal biopsy
    • Esophagus, 30-40 cm below the incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • Esophagus, 40-42 cm below the insicors, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation and tumor necrosis are evident.
    • Stomach, cardia, biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of gastric mucosal tissue with nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Keratin formation is evident.

[consultation]

  • 2022-10-28 ENT
    • Q
      • This 63-year-old man has squamous cell carcinoma of middle to lower third esophagus, with caria involvement, cT3N3M0, stage IVA. He underwent neoadjuvant CCRT and visited our oncologist OPD for regular follow-up. This time, he was admitted for cancer restaging. Due to nasal mucosa lesion noted during bronchoscope on 2022-10-27. Thus we need your professional evaluation and suggestion. Thank you very much.
    • A
      • Local finding via scope (PACS):
        • Bil. few thick mucus and nasal cavity, suspected chronoc rhinosinusitis
        • No obvious abnormal lesion was noted via this exam
      • Suggestion:
        • OPD f/u for his chronoc rhinosinusitis is enough
  • 2022-08-05 Radiation Oncology
    • A
      • A: Squamous cell carcinoma of the M-L/3 esophagus, with gastric involvement, stage cT3N3M0.
      • P: CCRT is indicated for this patient with the following indicators: esophageal cancer with gastric involvement, stage cT3N3M0.
        • Goal: palliation
        • Treatment target and volume: esophageal tumor, peripheral involved and regional involved nodal lesions.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5040cGy/28 fractions of the esophageal tumor, peripheral involved and regional involved nodal lesions.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-08-09.
  • 2022-08-02 Hemato-Oncology
    • Q
      • For CCRT surveillance
      • This is a 63 y/o male with history of hyperthyroidism (subclinical?) without medical treatment.
      • He was admitted for tumor work-up and treatment due to unintentional BW loss, esophageal and gastric tumor noted via PES on 20220728.
      • Pathological study showed squamous cell carcinoma. We sincerely need your expertise for CCRT evaluation and management.
    • A
      • This 63-year-old man was consulted and evaluated for esophageal cancer and CCRT
      • A:
        • esophagel cancer, with partial obstruction.
      • Recommendation:
        • CCRT is indicated for this patient
        • suggest port-A implantation and feeding jejumstomy for nutrition

[surgical operation]

  • 2022-08-08 laparoscopic gastrostomy and port-A implantation

[chemoimmunotherapy]

  • 2023-01-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-12-02 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-11-11 - pembrolizumab 200mg NS 100mL 30min + [NS 500mL 2hr + cisplatin 80mg/m2 130mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 800mg/m2 1300mg NS 500mL 24hr D1-D5
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-09-16 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2022-08-19 - [NS 500mL 2hr + cisplatin 75mg/m2 120mg NS 500mL 4hr + NS 500mL 2hr] + fluorouracil 1000mg/m2 1600mg NS 500mL 24hr D1-D4 (CCRT)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL

==========

2023-02-10

  • After the last round of chemotherapy (in early Jan 2023), he suffered from severe diarrhea for seven days and poor intake of food.
  • Chest CT images (2023-01-18) and abdomen CT images (2023-02-10) indicated that the disease is progressive.
  • A subsequent line treatment with paclitaxel 50 mg/m2 and carboplatin AUC 2 weekly for 5 weeks could be considered optionally.

2023-01-03

  • As part of the admission diagnosis, COPD with (acute) exacerbation is present, however, the Sp02 remains at no less than 94% according to vital sign records in this hospitalization.
  • Here are a few signs to watch for: diffuse wheezing, distant breath sounds, barrel-shaped chest, tachypnea, tachycardia, use of accessory muscles, brief and fragmented speech, inability to lie supine, profound diaphoresis, agitation, and an asynchrony between respiration and chest and abdominal movements.
  • In the event that exacerbations occur:
    • Inhaled beta agonist: Albuterol 2.5 mg diluted to 3 mL via nebulizer or 2 to 4 inhalations from metered dose inhaler (MDI) every hour for 2 or 3 doses; up to 8 inhalations may be used for intubated patients, if needed.
    • Short-acting muscarinic antagonist (anticholinergic agent): Ipratropium 500 micrograms (can be combined with albuterol) in 3 mL via nebulizer or 2 to 4 inhalations from MDI every hour for 2 to 3 doses.
    • Intravenous glucocorticoid (eg, methylprednisolone 60 mg to 125 mg IV, repeat every 6 to 12 hours).
  • A slightly low level of serum Na, K, and Mg was found in the 2023-01-02 lab result. Corresponding supplements were administered.

701463803

230210

[exam findings]

  • 2023-01-20 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, lower C-spine, middle and lower T-spines, some L-spines, bilateral shoulders, hips and knees in whole body survey.
    • IMPRESSION:
      • Increased activity in the lower C-spine, middle and lower T-spines and some L-spines. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
  • 2023-01-18 ECG
    • Possible Left atrial enlargement
    • Left axis deviation
    • Nonspecific T wave abnormality
  • 2022-12-30 SONO - abdomen
    • Findings:
      • The liver shows normal in size and echogenicity without focal lesion.
        • Portal vein flow: patent.
        • Bile ducts: not dilated.
      • The gallbladder appears normal in wall thickness and size.
        • There is no evidence of stone, polyp or sludge.
      • The pancreatic head and body shows normal in size and texture.
        • The pancreatic tail is obscured by overlying bowel gas.
      • The spleen shows normal in size and echogenicity without focal lesion.
      • Abdominal aorta and IVC show unremarkable finding.
      • There is no evidence of para-aortic lymphadenopathy or ascites.
      • Both kidney show normal echopattern and size.
        • There is no evidence of stone or hydronephrosis.
    • Impression:
      • Normal sonographic study of the hepatobiliary system.
  • 2022-12-23 Patho - breast mastectomy with regional lymph nodes
    • PATHOLOGIC DIAGNOSIS
      • Breast, left, modified radical mastectomy — Invasive carcinoma of no special type
      • Resection margin, breast, left, modified radical mastectomy — Free
      • Lymph node, level I and level II, left axilla, modified radical mastectomy — Metastatic carcinoma (1/12)
      • AJCC 8 th edition, Pathology stage: pT4bN1a(cM0); Anatomic stage IIIB; Prognostic stage IIIB
    • MACROSCOPIC EXAMINATION
      • Breast Size: 18 x 12 x 5.0 cm
      • Skin Size: 11.5 x 4.5 cm
      • Nipple: Not retracted
      • Tumor Size: 3.5 x 3.0 x 2.5 cm
      • Resection Margin: Free, 0.1 cm from the deep margin
      • Lymph nodes, left axillary: Level 1 and level 2
      • Representative parts are taken for section and labeled: A1=lateral margins, A2-A8= tumor, B1-B4= left axillary LN, level I, C= left axillary LN, level II
    • MICROSCOPIC EXAMINATION
      • Histologic type: Invasive carcinoma of no special type
      • Size of invasive carcinoma: 3.5 x 3.0 x 2.5 cm
      • Histologic grade (Nottingham histologic score): Grade 2 (score= 6)
      • Skin involvement with ulcer: Present
      • Ductal carcinoma in situ: Present; Extensive DCIS: Negative
      • Margins: Negative; Closest margin (1 mm from deep margin)
      • Nodal status: Positive (level I 1/11; level II 0/1)
        • number of lymph node examined: 11 (level I), 1 (level II)
        • number with macrometastases (>2mm): 1 (level I)
        • number with micrometastases (>0.2~2mm and/or >200 cells): 0
        • number with isolated tumor cells (<=0.2mm and <=200 cells): 0
      • Extranodal extension: Not identified
      • Treatment Effect: No presurgical neoadjuvant therapy received
      • Lymphovascular invasion: Presnt
      • Perineural invasion: Present
    • IMMUNOHISTOCHEMICAL STUDY (at Kaohsiung Armed Forces General Hospital)
      • ER (Ab): Positive (90%, 3+)
      • PR (Ab): Negative
      • HER-2/Neu (Ab): Negative
      • Ki-67: 5%
  • 2022-12-21 CT - chest
    • Indication: Malignant neoplasm of central portion of left female breast
    • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
    • Chest CT with and without IV contrast ehnancement shows:
      • Chest:
        • Lymphadenopathy at left axillary region is found.
        • Soft tissue mass at left breast up to 2.8cm is found.
        • Minimal atelectatic change at right middle lobe is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • The liver, spleen, pancreas, both kidneys and adrenals are intact.
        • There is no evidence of paraarotic LAPs.
        • There is no ascites accumulation at abdominal cavity.
    • Imp:
      • Left breast cancer with left axillary lymphadenopathy
  • 2022-12-21 ECG
    • Normal sinus rhythm
    • Left anterior fascicular block
    • Abnormal ECG
  • 2022-12-21 Spirometry
    • Mild restrictive ventilatory impairment
  • 2022-12-21 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (92.4 - 23.4) / 92.4 = 74.68%
      • M-mode (Teichholz) = 74.7
    • Adequate LV, RV systolic function with normal wall motion
    • Impaired LV relaxation
    • Mild MR, TR
  • 2022-12-20 External Eye Photography
    • cataract

[chemotherapy]

  • 2023-02-10 - Endoxan (cyclophosphamide) 600mg/m2 836mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • 2023-01-19 - Endoxan (cyclophosphamide) 600mg/m2 823mg NS 500mL 1hr + Lipo-Dox (liposome doxorubicin) 35mg/m2 48mg dextrose 5% 250mg 2hr
    • betamethasone 8mg + diphenhydramine 30mg + granisetron 1mg + aprepitant 125mg + NS 250mL
  • package insert
    • Endoxan: WBC > 2500
    • Lipo-Dox: ANC > 1500

[assessment]

  • 2023-02-09 WBC 1.74 *10^3/uL, Neutrophil 52.4%, Band 0.0% => ANC 912/mm3 grade 3 neutropenia. In the case of grade 3 neutropenia, chemotherapy is not recommended.
  • If the patient’s granulocyte count needs to be increased within a short period of time, 250ug of Granocyte (lenogastin) or 150ug of G-CSF (filgrastim) is recommended for two or three consecutive days. However, please do not administer G-CSF in the period 24 hours before to 24 hours after administration of cytotoxic chemotherapy because of the potential sensitivity of rapidly dividing myeloid cells to cytotoxic chemotherapy.
  • It is suggested to closely monitor any signs of infection.

700702162

230206

[diagnosis] - 20230203 admission note

  • Intrahepatic bile duct carcinoma
  • Malignant neoplasm of larynx, unspecified
  • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09), PD with spleen metastasis, stage IV on 2022/06/23 s/p plliative chemotherapy with FOLFOX from 2022/08/12 ~ 2022/10/21 for 5 cycles with liver metastasis s/p Target therapy with Lenvatinib (self pay) from 2022/11/16
  • Chronic viral hepatitis B without delta-agent
  • Essential (primary) hypertension

[past history]

  • Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at NTUHon 2017-04 ~ 2017-06
  • HBV under HBs(+) noted 30+ y/o, Hepatitis flare 2012-04 ~ (HBVDNA 1.36*7iu/ml) HBs(+>250iu/ml) HBe(-) antiHBe(+). PegIFN (Roche), 2012-09-12 ~ NHI 2012/09/14 ~ 2013/01 ETV NHI 2013/01/04 ~, self-paid 4/wk 2016/01/05 ~
  • DM with diet control 60 y/o~
  • Hypertension regular Olmetec 20mg 1# po QD tx 55 y/o~
  • Vocal cord SCC 28 y/o Cardinal Tien Hospital post R/T NTUH 2017/04 ~ 06    

[allergy]

  • Naproxen (KNAPO02): skin rash
  • Trimethoprim, Sulfamethoxazole (KBAKT01): slight ???

[exam findings]

  • 2023-02-03 KUB
    • Scoliotic alignment of the lumbar spine is found.
    • Phlebolith at pelvic cavity is also found.
  • 2023-02-03 CXR
    • Nodular lesion at right central lung is found.
  • 2023-01-31 CT - abdomen
    • History and indication: Intrahepatic cholangiocarcinoma
    • Findings
      • Some hypodense lesions (up to 3.3cm) in liver. A small enhancing tumor (1.6cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Multiple nodules in bil. lungs.
      • Wall thickening of A-colon. Minimal ascites.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
    • IMP:
      • A recurrent tumor (1.6cm) at liver dome.
  • 2022-10-24 CT - abdomen
    • Indication:
      • Intrahepatic bile duct carcinoma with splenic mets s/p OP and RFA
      • Malignant neoplasm of larynx, unspecified
    • Abdominal CT with and without enhancement revealed:
      • Abdomen
        • s/p right hepatic op.
        • Several low density lesions scattered at both lobes of liver is found up to 3.53cm at S4. Liver meta is considered. In comparison with CT dated on 2020-08-10, progession of the tumors are found.
        • Lymphadenopathy at hepatic hilum, mesenterric region and gastrohepatic ligment and paraaortic region is found.
        • MInimal ascites is found.
        • The GB is well distended without soft tissue lesion
        • The urinary bladder is well distended without soft tissue lesion.
        • The spleen, pancreas, both kidneys and adrenals are intact.
      • Visible chest
        • Normal heart size.
        • The lung fields are clear.
        • No pleural effusion is found.
    • Imp: Multiple liver meta with lymphadenopathy in the abdominal cavity.
  • 2020-08-10 CT - liver, spleen, biliary duct, pancreas
    • History and indication: cancer F/U
    • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
    • With and without-contrast CT of abdomen-pelvis revealed:
      • A small enhancing tumor (1.1cm) at liver dome with venous wash out pattern. S/P right hepatic lobe operation. Grade 4 fatty liver.
      • Normal appearance of spleen, pancreas, adrenals and kidneys.
      • Duodenal diverticulum.
      • Normal appearance of gallbladder.
      • Patency of portal vein.
      • Intact bony structures.
      • No ascites, nor enlarged lymph node.
      • No obvious extraluminal free air.
      • No abnormal density of heart.
      • Atherosclerosis of aorta, iliac arteries.
      • No abnormal density at bilateral basal lungs.
    • IMP:
      • A recurrent tumor (1.1cm) at liver dome. S/P right hepatic lobe operation. Grade 4 fatty liver.
  • 2020-06-03 Patho - liver partial resection
    • Diagnosis
      • Liver, S7, resection — Cholangiocarcinoma
    • Gross Description:
      • Procedure: S7 partial hepatectomy, 7 x 6 x 3 cm, 70 gms
      • Tumor Focality: Solitary
      • Tumor Site: Right lobe S7
      • Tumor Size: 2.2 x 2.0 x 1.8 cm , 2.0 cm away from closest margin
      • Non-tumorous part: cirrhotic
      • Gallbladder: size: not received.
      • Sections are taken and labeled as: A1-2: tumor with margins; A3-4: tumor; A5: non-tumor.
    • Microscopic Description:
      • Diagnosis: Intrahepatic cholangiocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Growth Pattern: Mass-forming
      • Tumor Extension: Tumor confined to hepatic parenchyma
      • Parenchymal Margin Uninvolved by invasive carcinoma
      • Bile duct Margin Uninvolved by invasive carcinoma
  • 2020-05-19 Visceral Angiography 2 vessels
    • DSA of celiac trunk, common hepatic artery and SMA with post-angiography CTAP study via right common femoral artery puncture revealed:
      • The necessarity and risks of the procedure was well explanined to patient family before the angiography. The patient family understood the risks of incomplete procedure, bleeding, infection, organ injury. Questions were answered, and all wished to procedure. Informed consent was obtained.
      • Patency of portal vein.
      • A faint enhancing tumor at right hepatic lobe.
      • Post-angiography CTAP images also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • No procedure-related complication during the whole procedure.
    • IMP: Right liver tumor, HCC is first considered.
  • 2020-05-15 CT - liver, spleen, biliary duct, pancreas
    • Indication:
      • 2015-08-14 HBV
      • 2020-05-12 US: susp tumor 17mm, > CT HBs(+) noted 30+y/o, HBe(-) antiHBe(+)
      • Vocal cord SCC 28y/o at Cardinal Tien Hospital and post R/T at NTUH 2017/4~6
      • FH: senior brother HBs + Cholangioca died 58y/o.
    • Findings:
      • There is an ill-defined hypodense mass lesion measuring 1.8 x 1.3 cm in S6 of the liver subcapsule area. During dynamic study, this mass shows mild contrast enhancement in arterial phase images and contrast washout in portal venous phase and delayed phase images.
        • HCC is highly suspected. The differential diagnosis include cholangiocarcinoma.
        • Please correlate with AFP and contrast enhanced dynamic MRI.
      • A hepatic cyst measuring 0.4 cm in S3 is suspected. Please correlate with sonography.
      • There is a diverticulum measuring 2.9 cm in the medial aspect of duodenum 2nd portion, near the ampulla of Vater area. Please correlate with clinical condition.
    • Imaging Report Form for Cholangiocarcinoma
      • Impression (Imaging stage): T:T1a (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IA(Stage_value)
  • 2020-05-04 SONO - abdomen
    • Diagnosis
      • Fatty liver, mild
      • Parenchymal liver disease, mild
      • Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe)
      • Suspected tiny GB polyps
    • Suggestion
      • Correlate with CT or MR
      • Check AFP
  • 2019-11-05 SONO - abdomen
    • Findings
      • Smooth liver surface. Small anechoic lesion about 0.5cm was noted at left lobe.
      • No gall stone. Small polyp about 0.2cm was noted on the gallbladder wall. No CBD dilatation.
    • Diagnosis
      • Liver cyst, left lobe
      • Gallbladder polyp
  • 2019-04-03 SONO - abdomen
    • Findings
      • Increased brightness, far attenuation and increased hepatorenal contrast
      • A few cysts were detected and the largest one 0.7 cm in size, was at S5
      • 2/3 pancreas was mask by bowel gas
      • Increased brightness of pancreas
    • Diagnosis
      • Fatty liver, mild
      • Fatty infiltration of pancreas
      • Liver cysts
  • 2018-09-19 SONO - abdomen
    • Findings
      • Increased brightness of echotexture. One 0.70cm anechoic cystic lesion with posterior enhancement at S5.
      • One 0.35cm hyperechoic lesion within GB lumen. No dilatation of CBD.
    • Diagnosis
      • Fatty liver, mild
      • Hepatic cyst, right
      • GB polyp
  • 2018-03-23 SONO - abdomen
    • Findings
      • Size normal; Surface smooth; Edge sharp; Vessel well-defined; Echotexture: increased hepatorenal echocontrast; One hypoechoic lesion about 0.8cm was found at the right anterior segment
      • One hyperechoic lesion about 0.4 cm in the GB; Normal GB wall thickness; No biliary tract dilatation
    • Diagnosis
      • Fatty liver,mild
      • Suspected liver cyst,right
      • Suspecetd GB polyp
      • Pancreas not shown
  • 2017-09-21 SONO - abdomen
    • Findings
      • bright echo appperance with increased hepatorenal contrast, mild
      • obliteration of portal tract; a 0.77-cm anechoic lesion at seg5
      • a 0.48-cm polyp in GB ; no biliary tract dilatation.
    • Diagnosis
      • mild fatty liver
      • liver cyst
      • GB polyp
  • 2017-03-22 SONO - abdomen
    • Indication: Hepatitis
    • Findings
      • Mildly bright liver echo comparing with renal cortex.
      • A 8-mm cyst in liver, right lobe.
      • A 6-mm polyp in GB. No biliary dilatation.
      • pancreas ~60% visible
    • Diagnosis
      • Mild fatty liver + Right Liver cyst
      • GB polyp

[consultation]

  • 2023-01-17 Dermatology
    • Q
      • This 64-year-old male patient has past history of 1) Larynnx cancer (SCC), stage Tis, diagnosis at Cardinal Tien Hospital s/p radiotherapy at National Taiwan University Hospital on 2017/04 ~ 2017/06; 2) HBV under ETV (4/wk) tx (self-paid), 3) Hypertension, he was regularly followed up at OPD. According for his statement, abdominal sonography on 2020/05/04 showed 1) Fatty liver, mild; 2) Parenchymal liver disease, mild; 3) Liver tumor, hypoechoic, nature indeterminate (1.7 cm, right lobe); 4) Suspected tiny GB polyps. Further Abdominal CT was perfromed on 2020/05/17 and revealed 1) HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Alpha-feto-protein (AFP) was 3.0ng/dl on 2020/05/04. Angio CT on 2020/05/15 also revealed a perfusion defect (2.5cm) at right hepatic lobe. Left liver cyst (5mm).
      • Cholangiocarcinoma s/p weekly chemotherapy with Gemzar/CDDP * 8 doses (4 cycles) in TP-VGH (last dose on 2022/06/09). Liver tumor biopsy on 2020/06/03 and pathology showed cholangiocarcinoma. PD in new lesion over spleen based on the findings of CT on 2022/06/24.
      • He was transfer to our hospital for further treatment. The patient has been informed again palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 and 5HT3 are not covered by NHI) on 2022/08/12. Palliative chemotherapy with FOLFOX (Oxalip 85mg/m2 self pay, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/8/12(C1D1), 2022/08/26(C1D15), 2022/09/13(C2D1), 2022/10/05(C2D15), 2022/10/21(C3D1). Abdominal CT on 2022/10/24 showed multiple liver metastases with lymphadenopathy in the abdominal cavity. Target therapy with Lenvatinib (self pay) from 2022/11/16. Now, he was admitted to ward for target therapy with Lenvatinib (self pay).        
      • For Lenvatinib related side effect of hand, we need your further evaluation and management.
    • A
      • The patient had sufferred from mutiple erythematous plaques with thick scales and erosion.
      • Under the impression of hand-foot syndrome after chemotherapy and target therapy.
      • The following sugeetion:
        • Tetracycline onit 2 tube topical bid use on the wound and erosive lesions first.
        • Sinphraderm cream (urea 100mg/gm) 1 tube topical QN use after body clean for skin mositurization and keratolytic effect.
        • If new erythema lesions development, consider Topysm cream (fluocinonide) 1 tube topical bid use for anti-inflammation.
  • 2020-05-18 Radiation Oncology
    • Q
      • for arrange angiography with CTAP (computed tomography arterial portography)
      • This 61 year-old male of DM, HBV.
      • Abdominal CT showed HCCs 1.8 x 1,3 cm in S6 of the liver is highly suspected. The differential diagnosis include cholangiocarcinoma. Please correlate with AFP and contrast enhanced dynamic MRI. According to American Joint Committee on Cancer (AJCC) staging system, 8th edition, CT staging of HCC: T1N0Mx, Staging: I.
    • A
      • According to the clinical condition and imaging findings, angiography with CTAP study is indicated.

[chemotherapy]

  • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + aprepitant 125mg D1-3
  • 2022-10-05 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-09-13 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-26 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
  • 2022-08-12 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg/m2 4000mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

[medication]

  • Lenvima (lenvatinib) KLENV02
    • 2022-11-16 ~ undergoing 10mg QD
  • Baraclude (entecavir) KBARA01
    • 2022-11-02 ~ undergoing 0.5mg QDAC
    • 2020-08-21 ~ + 84 days 0.5mg QDAC

==========

2023-02-06

  • 2023-02-06 lab data showed low Na, low K, low Mg, low Ca in the blood, Nako No.5 electrolyte solution has been provided appropriately.
  • Due to the patient’s blood pressure level staying at 90/50 for the past two days, it is not necessary to lower his blood pressure further. Please temporarily hold the self-carried Olmetec (olmesartan).
  • Please follow up with the patient to determine whether the hand-foot syndrome is improving, if not, topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) can be applied again.

2023-01-18

  • Because lenvatinib has a moderate to high emetic potential, the antiemetic agent metoclopramide has also been prescribed appropriately in combination with lenvatinib.
  • Lenvatinib’s dermatologic adverse reactions include: alopecia (12%), palmar-plantar erythrodysesthesia (27% to 32%), skin rash (14% to 21%). The developed hand-foot syndrome has been referred to a dermatologist and topical tetracycline, Sinphraderm (urea), and Topysm (fluocinonide) have been prescribed to mitigate the symptoms.
  • As the patient has a history of hypertension, and lenvatinib is also associated with hypertension (45% to 73%; severe hypertension: 3%), it is recommended that blood pressure be closely monitored.

700151650

230203

{not completed}

[exam findings]

  • 2023-02-02 Tc-99m MDP whole body bone scan
    • Mildly increased activity in the middle and lower T-spines, some L-spines and sacrum. Degenerative change may show this picture.
    • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
    • Increased activity in bilateral shoulders, right sternoclavicular junction, bilateral wrists, hip and right knee, compatible with benign joint lesion.
    • No prominent bone abnormality was noted elsewhere.
  • 2023-02-02 SONO - chest
    • Echo diagnosis:
      • pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
      • Check bleeding, if bleed from pig tail tube, please call Dr.
      • CxR follow up pig tail tube position.
  • 2023-02-01 Bronchoscopy
    • no endobronchial mass,
    • s/p bronchial washing via RML, sent for TB culture, TB PCR and cytology
  • 2023-01-31 SONO - thyroid gland
    • Normal size of the thyroid gland.
    • Some hypoechoic nodules (up to 0.67cm) in left thyroid gland.
    • Some LNs at bil. neck.
  • 2023-01-19 Cell block
    • PATHOLOGIC DIAGNOSIS
      • Positive for malignancy
      • Immunocytochemistry show TTF-1(+), CK7(+), Napsin-A(+), CK20(-) and CDX-2(-), compatible with metastatic pulmonary adenocarcinoma
      • The smears and cell block show lymphocytes, mesothelial cells and many hyperchromatic atypical epithelial clusters with focal tubular arrangement, compatible with metastatic adenocarcinoma.
  • 2023-01-19 SONO - chest
    • Echo diagnosis:
      • Pleural effusion
    • Suggestion:
      • Send pleural effusion for examination about cytology (cell block), biochemistry, culture, Gram stain, pH, cell count, and TB exam. TB PCR.
  • 2023-01-18 CT - chest
    • Findings
      • lungs:
        • a spiculated tumor at mediobasal segment of RLL (31mm in axial dimension) invading adjacent pericardium.
        • partial atelectasis of RML.
        • innumberable randomly distributed pulmonary small nodules of varying sizes due to lung to lung metastases.
        • moderate Rt pleural effusion.
      • Mediastinum and hila:
        • extensive lymphadenopathy in the visceral space, with central necrosis in subcarinal LAP.
      • Aorta:
        • normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
      • Heart:
        • normal in size of cardiac chambers.
        • mild calcified mitral annulus
      • Chest wall and visible lower neck:
        • suspect metastatic LAP aty Lt supraclavicular fossa.
      • Visible abdominal contents:
        • normal appearance of gall bladder.
        • a small Rt hepatic measurig 10mm.
    • Impression: RLL cancer T4N3M1a(E1)
    • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N3(N_value) M:M1a(M_value) STAGE:____(Stage_value)
  • 2023-01-17 CXR
    • diffuse miliary lesions in both lungs with xonsolidation and volume reduce over Rt lower lung zone and Rt pleural effusion, miliary tuberculosis or metastasis
    • Mild dextroscoliosis of the T-spine
    • Thoracic aortic arch calcified atheriosclerotic plaque
  • 2023-01-12 Merchant view (patella 45 0) Bil :
    • Lateral subluxation of the patella, Rt
    • Patellofemoral osteoarthritis
    • Sperner classification: 3, 3
  • 2023-01-12 Knee BIL standing AP and Lat
    • Moderate to severe osteoarthritis of both knees, Rt > Lt
    • Ahlback calcification: grade 4, 3
  • 2022-08-15 Peripheral Vascular Test - Vein, lower limbs
    • Significant venous reflux at left saphenofemoral junction with varicose change of left LSV from upper to lower leg level (Tortuous change at lower leg level). Slow venous return flow at left popliteal vein; atleast two perforator veins connecting the left PTV and LSV at left proximal to middle lower leg level were detected.
    • Slow venous return flow at left popliteal vein; atleast three perforator veins connecting the right PTV and LSV at right proximal to distal lower leg level were detected.
    • No evidence of venous thrombosis at bilateral lower limbs venous systems.
    • The ratios of MVO and SVC of bilateral legs were within normal limits.
  • 2022-08-02 ENT Hearing Test
    • Reliabilty Fair to Poor, 50dB
    • PTA
      • R’t : 73 dB HL, moderately severe to profound mixed type HL
      • L’t : 68 dB HL, moderately severe to profound SNHL
    • Tymp
      • R’t : Type A
      • L’t : Type As.
  • 2022-08-02 Nasopharyngoscopy
    • Findings
      • bil clear nasal cavity; smooth NPx, oropharynx, hypopharynx, no vocal lesion
      • a few whitish discharge coating on pharyngeal wall
    • Conclusion
      • chronic pharyngitis and rhinitis

701456943

230202

[diagnosis] - 2023-01-12 discharge note

  • Adenocarcinoma of rectosigmoid junction status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB
  • Constiplation

[Past History]

  • DM under metformin
  • Adenocarcinoma of rectosigmoid junction status, cT3N2bM0, status post laparoscopic low anterior resection on 2022/11/03, pT3N2aM0(6/17), stageIIIB, LVI(+), PNI(-), CRM(-), EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+) , stageIIIC    

[Family History]

  • His mother had colon cancer and DM
  • His younger brother had colon cancer; one of his elder sister had lung adenocarcinoma; one of his elder sister had gastric cancer
  • He denied other systemic diseases

[lab data]

  • 2022-10-20 HBsAg (NM) Negative
  • 2022-10-20 HBsAg Value (NM) 0.424
  • 2022-10-20 Anti-HBs (NM) Positive
  • 2022-10-20 Anti-HBs value (NM) 197
  • 2022-10-20 Anti-HCV (NM) Negative
  • 2022-10-20 Anti-HCV Value (NM) 0.0365

[exam findings]

  • 2022-12-02 Anoscopy
    • Mixed hemorrhoids with congestion
  • 2022-11-04 All RAS + BRAF mutation
    • ALL-RAS:
      • Detected (KRAS codon 12 GGT>GAT, p.G12D)
    • BRAF:
      • There was no variant detect in the BRAF gene.
  • 2022-10-28 Patho - colon segmental resection for tumor
    • Diagnosis:
      • Intestine, large, RS colon, Laparoscopic low anterior resection — Moderately differentiated adenocarcinoma
      • Distal cut-end: Free
      • Proximal cut-end: Free
      • Lymph node, regiona, dissection — Metatstaic adenocarcinoma (6/17)
      • AJCC 8th edition pathology stage: pT3N2a(if cM0); AJCC stage IIIB
    • Gross Description:
      • Procedure: Laparoscopic low anterior resection
      • Tumor Site: RS colon
      • Tumor Size: 5 x 4 cm.
      • Macroscopic Tumor Perforation: Not identified
      • Macroscopic Intactness of Mesorectum (if applicable): Complete
      • Sections are taken and labeled as:A:distal cut end, B1-3:LNs, B4-10:tumor, C:proximal cut end
    • Microscopic Description:
      • Histologic Type: Adenocarcinoma
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
      • Margins
        • Proximal margin: Uninvolved
        • Distal margin: Uninvolved
        • Radial or Mesenteric Margin: Uninvolved
        • Distance of tumor from margin: 4 cm
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Tumor Budding:
        • Number of tumor buds in 1 “hotspot” field (specify total number in area = 0.785 mm2)
        • Low score (0-4)
      • Type of Polyp in Which Invasive Carcinoma Arose:Not identified
      • Tumor Deposits: Not identified
        • Specify number of deposits: N/A
      • Regional Lymph Nodes:
        • Number of Lymph Nodes Involved/Examined: 6/17
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors (required only if applicable) (select all that apply)
        • m (multiple primary tumors) r (recurrent) y (posttreatment)
          • Primary Tumor (pT)
            • pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN)
            • pN2a: Four to six regional lymph nodes are positive
          • Distant Metastasis (pM):
            • N/A
      • Additional Pathologic Findings (select all that apply): None identified
      • Ancillary Studies: Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(+), MSH2(+), MSH6(+)
      • Comment(s): None
  • 2022-10-28 Sigmoidoscopy
    • Diagnosis
      • A fungating tumor lesion (3-4cm in size) is located at rectosigmoid junction (15cm AAV)
      • A middle rectal diverticulum
    • Suggestion
      • suggest operation
  • 2022-10-21 CT - abdomen
    • History: passage of bloody stool, change in bowel habit, decrased stool caliber for weeks. tumor of RS-colon at YongHe local clinics.
    • Findings:
      • There is segmental wall thickening of the recto-sigmoid colon, measuring 1.3 cm in the maximal wall thickness that is c/w adenocarcinoma (T3).
        • In addition, There are seven enlarged nodes in the perirectal space and sigmoid mesocolon that are c/w metastatic nodes (N2b).
      • There is a small poor enhancing lesion measuring 5 mm in S2 of the liver that may be cyst? Please correlate with sonography.
      • There is no focal lesion in both lung and mediastinum.
    • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T:T3 (T_value) N:N2b (N_value) M:M0 (M_value) STAGE:IIIC(Stage_value)

[surgical operation]

  • 2022-10-03
    • Surgery
      • Laparoscopic low anterior resection     
    • Finding
      • A fungating 4-5cm tumor is located at RS-colon. Some adhesions over small bowel and S-colon mesentery was found, and adhesiolysis was done.    
      • Radical proctectomy (low anterior resection) with total mesorectal excision was carried out smoothly. Blood loss was about 30ml.    
      • Anastomosis was achieved using endo GIA 601+ 451/ green, + CDH-33 + TISSEEL 4ml. Air test is ok.     
      • A drain in pelvis, 4DF 3g was applied for prevent adhesions.  

[radiotherapy]

  • 2022-12-05 ~ 2023-01-13 - completed RT to the pelvis: 45 Gy/ 25 fx. The rectal tumor bed: 54 Gy/ 30 fx.

[chemotherapy]

  • 2023-02-01 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2023-01-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 400mg/m2 680mg 2hr + fluorouracil 2400mg/m2 4100mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg
  • 2022-12-05 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 3mg + metoclopramide 10mg

[assessment]

  • The lab results (2023-02-01) were grossly normal.
  • Metformin (prescribed by a local clinic) is not included on the active medication list despite the fact that the patient has a history of diabetes.
  • If there are no contraindications, the addition of metformin is recommended to maintain stable blood sugar control.

700508887

230201

  • diagnosis
    • 2023-01-11 admission note - Acute lymphoblastic leukemia not having achieved remission
    • 2022-12-21 OPD assessment - MDS is considered with Karyotype: 45~46,XX,+1,der(1;16)(q10;p10)[cp7]/46,XX[7]
    • 2022-12-09 OPD assessment - MDS is considered
  • past history - 20230111 admission note
    • Myelodysplastic syndrome diagnosed on 2022-12-05 by BM biopsy
    • Hypertension for years, with medication (Aprovel) control and regular follow-up at Cardinal Tien Hospital
    • Hyperlipidemia for years, with medication (Livalo) control and regular follow-up at Cardinal Tien Hospital
    • Thrombocytopenia since 2015, and regular follow-up at Cardinal Tien Hospital
  • allergy
    • NKDA
  • family history
    • Mother: Hypertension.
    • Deny any cancer history
  • exam findings
    • 2023-01-11 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.
    • 2022-12-05 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Normal cellularity with presence of blasts; Suspicious for myelodysplastic syndrome
        • NOTE: Correlation with peripheral blood test, bone marrow smear, flow cytometry, molecular genetic study and clinical findings is recommended.
      • Microscopically, it shows normal cellularity for age (40%), 3:1 of M:E ratio and presence of trilineage marrowe component. Occasional megakaryocytes are seen. Blasts are highlighted by CD34 and CD117 (<20%).
      • Immunohistochemical stain reveals MPO (focal +), CD71(focal+), CD20(focal+), CD138(focal+), CD10(-) and TdT(-).
    • 2022-12-02 CXR
      • cardiomegaly; mediastinal widening

==========

2023-02-01

[potential drug interactions]

  • Flunarizine (patient-carried) is cocommitant with clonazepam, diphenhydramine, estazolam and fexofenadine currently.

  • According to the flunarizine product monograph (https://www.aapharma.ca/downloads/en/PIL/2021/Flunarizine_PM_EN.pdf), use of CNS depressants, including alcohol, should be avoided during treatment with flunarizine due to the risk of excessive sedation.

  • There is also an antivertigo preparation available in stock known as Nilasen (betahistine 24mg/tab), which has a lower risk of drug interaction than flunarizine and can be considered as a 1# daily dosage alternative.

2023-01-11

There is no specific pharmacist shift handover to follow in this patient.

[drug identification]

  • A request has been made for us to identify drugs for 3 items.
  • In total, 3 items have been identified as follows, with 0 item remaining unidentified.
    • Doxynin (doxycycline 100mg)
    • Welizen (famotidine 20mg)
    • Flamquit (diclofenac potassium 50mg)
  • These drugs will be sent back to ward by the in-hospital porter.

701352128

230201

[diagnosis] - 2023-02-01 discharge note

  • Gastric cancer with liver metastasis status post total gastrectomy with D2 and dissection, S2-3 left lateral segmentectomy, S6-7 partial hepatectomy and S4-8 alcohol injection on 2021-12-16, stage IV.
  • Chronic viral hepatitis B without delta-agent, 2022/12/23 Anti-HBc: postive

[lab data]

  • 2022-12-26 HBV-DNA-PCR Target Not Detected IU/mL
  • 2022-12-23 Anti-HBc Reactive
  • 2022-12-23 Anti-HBc-Value 4.82 S/CO
  • 2021-12-13 HBsAg Nonreactive
  • 2021-12-13 HBsAg (Value) 0.32 S/CO

[exam findings]

  • 2023-01-31 CT - abdomen
    • Clinical history: 70 y/o male patient with Gastric cancer (pathology showed poorly adenocarcinoma) with outlet obstruction.
    • Impression:
      • S/P total gastrectomy.
      • Ascites with pleural effusion and basal lung atelectasis, progression.
      • Minimal pericardial effusion.
  • 2022-10-12 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
      • 20211215 CT: gastric cancer & liver metas? cT4aN3aM1, csTAGE:IVB
      • 20211217 S/P total gastrectomy: pT4aN3bM1, pstage:IV
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings - Comparison: prior CT dated 2022/03/16.
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
        • S/P total gastrectomy.
        • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • Prior CT identified three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver are not noted again that are c/w metastases S/P C/T with complete response.
      • Prior CT identified A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is not noted again.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • There is ascites in pre-hepatic space, perisplenic space, and the pelvis.
  • 2022-06-23 CT - abdomen
    • History and indication: Gastric cancer with liver metastasis
    • IMP:
      • Gastric cancer s/p operation. Minimal ascites in pelvic cavity.
      • Much regression of liver lesions.
  • 2022-03-16 CT - abdomen
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • S/P total gastrectomy.
      • S/P total resection of S2-3 and tumor enucleation of S6/7 of the liver.
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
    • Impression:
      • There are three ill-defined poor enhancing lesions on S4, S8, and S5 of the liver that may be metastases? The largest one measuring 1.1 cm in S4.
      • A small ground-glass opacity in RUL-RML of the lung measuring 5 mm in lung window setting is noted.
        • Primary lung cancer is suspected.
        • The differential diagnosis include Metastasis.
        • Follow up is indicated.
  • 2021-12-20 Upper GI series
    • S/P gastrectomy. No evidence of contrast medium leakage.
    • Normal contour and mucosal pattern of the esophagus.
    • Right CVP inserted to SVC in position.
    • Compression fracture of spine.
  • 2021-12-17 Patho - liver partial resection
    • PATHOLOGIC DIAGNOSIS
      • Liver, S2-3, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
      • Liver, S6-7, partial hepatectomy — Metastatic adenocarcinoma, stomach origin
    • MACROSCOPIC EXAMINATION
      • Procedures: Partial hepatectomy of S2-3 and S6-7
      • Specimen Size: 12 x 5.0 x 4.0 cm and 130 gm (S2-3); 3.0 x 2.0 x 1.2 cm (S6-7)
      • Tumor Focality: Multiple; number: 3 (S2-3) and 1 (S6-7)
      • Tumor Site: S2-3 and S6-7
      • Tumor Size: 1.4 x 1.2 cm, 1.2 x 0.9 cm, 0.2 x 0.2 cm (S2-3), and 0.8 x 0.6 cm (S6-7), respectively
      • Large vessel involvement: Not identified
      • Non-tumorous part: Not cirrhotic
      • Sections are taken and labeled as: A1-A4= S2-3 tumors, B1-B2= S6-7 tumor
    • MICROSCOPIC EXAMINATION
      • Diagnosis: Metastatic gastric adenocarcinoma
      • Histologic grade: Poorly differentiated
      • Tumor growth pattern: Infiltrating
      • Tumor pseudocapsule: Absent
      • Tumor necrosis: Present
      • Parenchymal margin: Uninvolved by carcinoma
      • Vascular invasion: Present
      • Perineural invasion: Not identified
      • Non-neoplastic liver parenchyma: Mild lymphocytic portal
  • 2021-12-17 Patho - stomach subtotal/total (tumor)
    • PATHOLOGIC DIAGNOSIS
      • Stomach, total gastrectomy — Mixed tubular adenocarcinoma and poorly cohesive carcinoma
      • Margins, bilateral cutting ends, total gastrectomy — Free of tumor invasion
      • Lymph nodes, D2 LN dissection — Metastatic adenocarcinoma (46/60)
      • Omentum, omentectomy — Free of tumor invasion
      • AJCC Pathologic staging — pT4aN3bM1, stage IV
    • MACROSCOPIC EXAMINATION
      • Specimen type: Stomach, lymph nodes, omentum
      • Specimen size: (a) Stomach: 31.5 cm along the greater curvature and 16.0 cm along the lesser curvature (b) Omentum: 35 x 22 x 5 cm
      • Number of lesions: Solitary
      • Tumor site: Antrum to cardia, lesser curvature, 3.5 cm from distal margin
      • Tumor size: 12.5 x 11.0 cm
      • Tumor configuration: Ulcerative tumor
      • Representative sections as follows: A1= distal cut end, A2-A5= tumor with lesser curvature LNs, A6-A7= tumor at antrum, A8= tumor at body, A9-A10= tumor at fundus and cardia, B1-B2= omentum, C= esophageal margin, D1-D4= LN 1, E1-E2= LN 2, F1-F5= LN 4, G1-G2= LN 5, H1-H2= LN 6, I1-I4= LN 7,8,9,11,12a,16, J1-J2= LN 10, K1-K2= LN 14. F2021-00500FS= esophageal cut end received for frozen section
    • MICROSCOPIC EXAMINATION
      • Histologic type: Mixed tubular adenocarcinoma and poorly cohesive carcinoma (Lauren classification: mixed type)
      • Histologic grade: Poorly differentiation (G3)
      • Depth of tumor invasion: Tumor invades the serosa
      • Margins: All margins are uninvolved by carcinoma
        • Distance of invasive carcinoma from closest margin: <1 mm from radial margin
      • Perineural invasion: Present
      • Lymphovascular space invasion: Present
      • Regional lymph nodes: Metastatic adenocarcinoma (46/60) 8/8 (lesser curvature LNs), 0/1 (omentum LN), 12/14 (LN 1), 0 (LN 2), 14/14 (LN 4), 1/2 (LN 5), 4/5 (LN 6), 4/8 (LN 7, 8, 9, 11, 12a, 16), 0/1 (LN 10), 3/7 (LN 14) (Number of LN involved/Number of LN examined)
      • Extracapsular extension: Present
      • Omentum: Free of tumor invasion
      • Additional pathologic findings: Liver metastasis (S2021-18735)
      • Pathologic Staging: pT4aN3bM1, stage IV
      • IHC: HER2(Negative, score= 0)
      • Esophageal margin (including frozen section specimen): Free of carcinoma
  • 2021-12-15 CT - abdomen
    • History and Indication:
      • 20211206 Gastroscopy at Yonghe Cardinal Tien hospital: gastric cancer at the antrum induce gastric outlet obstruction.
      • 20211214 sono: A 1.7 cm hypoehcoic lesion at S2
    • Findings:
      • There is an ill-defined poor enhancing mass measuring 1.5 cm in S2 dome of the liver at portal venous phase images and suggestive enhancement in delayed phase images.
        • In addition, there are two lesions measuring 0.5 cm in S4 and 0.7 cm in S5, showing similar feature.
        • Metastases are highly suspected.
        • The differential diagnosis include hemangioma.
        • Please correlate with MRI.
      • There is wall thickening at the gastric antrum measuring 1.3 cm in wall thickness. Please correlate with gastroscopy.
        • In addition, there are seven enlarged nodes in the gastrohepatic ligament, celiac trunk, and hepatoduodenal ligament that may be metastatic nodes.
    • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T4a (T_value) N:N3a (N_value) M:M1 (M_value) STAGE:IVB(Stage_value)
  • 2021-12-15 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (84.4 - 24.6) / 84.4 = 70.85%
      • M-mode (Teichholz) = 70.9
    • Normal chamber size
    • Adequate LV and RV systolic function
    • Possibly impaired LV relaxation
    • AV sclerosis with mild AR, mild MR, TR and PR
    • No regional wall motion abnormalities
  • 2021-12-14 Patho - stomach biopsy
    • Stomach, prepyloric antrum, biopsy— poorly differentiated adenocarcinoma with focal signet-ring cell differentiation
    • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of neoplastic cells arranged in solid to glandular architecture, and focal signet-ring cell diffferentiation.
  • 2021-12-14 SONO - abdomen
    • Hepatic tummor, nature to be determinated
  • 2021-12-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Suboptimal study due to much semi-fluid residue retention
      • Ulcerative tumor, preplyoric antrum and probable low body, s/p biopsy x6
    • Suggestion
      • Pursue biopsy result
  • 2021-12-13 Spirometry
    • normal spirometry

[consultation]

  • 2021-12-24 Radiation Oncology
    • Q
      • This 69 y/o male with history of gastric with liver meta then s/p total gastrectomy with LN D2+ dissection and S23 resection + S6-7 partial hepatectomy + S4-8 alcohol injection on 2021/12/16. Pathology showed Mixed tubular adenocarcinoma and poorly cohesive carcinoma. pT4aN3bM1, stage IV. after well improved of general condition and well oral intake, further management of CCRT will plaining. We need your help for RT evaluation. Thanks you!!
    • A
      • A: Mixed tubular adenocarcinoma and poorly cohesive carcinoma of the stomach, AJCC Pathologic staging — pT4aN3bM1, stage IV, with liver metastases, s/p total gastrectomy with LN D2+ dissection, S23 resection, S6-7 partial hepatectomy, S4-8 alcohol injection.
      • P: Radiotherapy is indicated for this patient with the following indicators: stage pT4aN3bM1
        • Goal: palliation
        • Treatment target and volume: gastric tumor bed, peripheral involved including regional lymphatic area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 4500cGy/25 fractions of the gastric tumor bed, peripheral involved including regional lymphatic area
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 8:30, 2022-01-10.

[surgical operation]

  • 2021-12-16
    • Surgery
      • total gastrectomy with LN D2+ dissection
      • S23 resection
      • S6-7 partial hepatectomy
      • S4-8 alcohol injection
    • Finding
      • gastric ca lesser curvature cardia to lowewr antrum with multiple LN enlarge
      • serosa+
      • seeding-
      • multiple liver tumor
      • S2-3 at least 3 nodle 0.2, 0.8 1.2cmS6-7 0.8cm
      • S6-7 0.8 cm
      • S4-8 0,8 x 0.6cm in deep central parancyhma

[radiotherapy]

  • 2022-01-19 ~ 2022-03-02 - 4500cGy/25 fractions (15 MV photon) of the gastric tumor bed, peripheral involved including regional lymphatic area.

[chemotherapy]

  • 2023-01-30 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4775mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-22 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4770mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-12-09 - oxaliplatin 85mg/m2 140mg 2hr + leucovorin 400mg/m2 670mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-25 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4740mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-11-09 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-10-24 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-09-27 - oxaliplatin 85mg/m2 144mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4760mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-24 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-08-10 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-27 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-07-08 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-22 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-06-06 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-23 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-05-03 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-04-19 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-29 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-15 - oxaliplatin 85mg/m2 145mg 2hr + leucovorin 400mg/m2 680mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
    • dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
  • 2022-03-01 - fluorouracil 225mg/m2 380mg 24hr D1-2
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-21 - fluorouracil 225mg/m2 380mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-14 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-02-07 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-24 - fluorouracil 225mg/m2 390mg 24hr D1-5
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
  • 2022-01-19 - fluorouracil 225mg/m2 390mg 24hr D1-3
    • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg

701460262

230201

[diagnosis] - 2023-02-01 discharge note

  • Malignant neoplasm of cervix uteri, unspecified
  • Squamous cell carcinoma, keratinizing, moderately differentiated of the uterine cervix, stage pT1a2 (III), with negative margin (HPV related), s/p laparoscopic assisted vaginal hysterectomy, with local recurrence.
  • Type II diabetes mellitus

[lab data]

  • 2022-11-29 HBsAg (NM) Negative
  • 2022-11-29 HBsAg Value (NM) 0.775
  • 2022-11-29 Anti-HBc Nonreactive
  • 2022-11-29 Anti-HBc-Value 0.19 S/CO
  • 2022-11-29 Anti-HCV (NM) Negative
  • 2022-11-29 Anti-HCV Value (NM) 0.0347

[exam findings]

  • 2022-11-21 MRI - pelvis
    • Clinical history: 42 y/o female patient with cervical CIN 3 and ov tumor said s/p hysterectomy in Keelung CGMH in 2020 , patho revealed cervical cancer (SCC, stage Ia2, patho Number S2020G-15625A), 2021 stump revealed VaIN 3 (S2021G-12951) -> local LASER was done. 2022/11/10 vaginal bleeding, suggest IVRT (intravaginal radiotherapy) if residual cancer tissues noted. next – ask the patient to bring the reports from previous hospital, + MRI + SCC + CEA check.
    • Impression:
      • S/P hysterectomy.
      • Recurrent tumors in the vaginal stump with colon and urinary bladder adhesion/involvement.
      • Cystic lesions, 2.35cm in left pelvic cavity.
  • 2022-11-10 Gynecologic ultrasonography
    • s/p ATH
    • Suspcted Rt Ovarian cyst
  • 2021-11-04 Pathology - vagina biopsy (Keelung CGMH)
    • S2021G-12951A: vagina biopsy — vaginal intraepithelial neoplasia III (VaIn III) — P16(+), suggestive high risk HPV infection.
  • 2020-10-29 Pathology (Keelung CGMH)
    • S2020G-15625A: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a2, wth negative margin (HPV related)
  • 2020-10-26 Pathology (Keelung CGMH)
    • S2020G-15625: uterus, cervix, laparoscopic assisted vaginal hysterectomy — squamous cell carcinoma, keratinizing, moderately differentiated, pT1a1, wth negative margin (HPV related)

[surgical operation]

  • 2020 Laparoscopic Assisted Vaginal Hysterectomy, LAVH (Keelung CGMH)

[radiotherapy]

  • 2022-12-09 ~ - at 4500cGy/25 fractions (15 MV photon) of the pelvic area.

[chemotherapy]

  • 2023-01-30 - cisplatin 70mg/m2 115mg 4hr D1 + fluorouracil 1000mg/m2 1660mg 24hr D1 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1
  • 2022-12-15 - cisplatin 70mg/m2 115mg 4hr D1-4 + fluorouracil 1000mg/m2 1660mg 24hr D1-4 (CCRT)
    • dexamethasone 4mg D1 + diphenhydramine 30mg D1 + granisetron 2mg D1

700978478

230131

[diagnosis] - 2022-10-01 discharge

  • Squamous cell carcinoma of upper third esophagus cT2N2M0,stage IIA
  • Essential (primary) hypertension
  • Type 2 diabetes mellitus without complications
  • Unspecified viral hepatitis B without hepatic coma
  • Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
  • Hypomagnesemia
  • Constipation, unspecified

[exam findings]

  • 2022-12-23, -12-20, -12-19, -12-16, -12-15, -12-14 CXR
    • Port-A catheter inserted into cavo-atrial junction via left subclavian vein.
    • Right internal jugular central venous catheter with tip in the superior cavo-atrial junction
    • s/p right chest tube in place, its tip directed superomedially, projecting over hilar shadow
    • Rt shift of trachea s/p esophagectomy and gastric tube reconstruction s/p gastric tube placement
    • Platelike lung atelectasis over Lt lower lung zone
  • 2022-12-13 Patho - esophagus subtotal/total resection
    • Diagnosis
      • Esophagus, upper third, VATS McKeown esophagectomy —- Squamous cell carcinoma, moderately differentiated, s/p CCRT
      • Stomach, cardia, partial gastrectomy —- Negative for malignancy
      • Thoracic duct, right, excision —- Negative for malignancy
      • Resection margin: Negative for malignancy; cutend of proximal esophagus: Negative for malignancy
      • Lymph node, upper paraesophageal, specimen 1, dissection —- Negative for malignancy (0/1)
      • Lymph node, peri-gastric, specimen 1, dissection — Negative for malignancy (0/11)
      • Lymph node, right, group 2+4, dissection —- Negative for malignancy (0/15)
      • Lymph node, left, group 4, dissection —- Negative for malignancy (0/3)
      • Lymph node, right, group 7, dissection —- Negative for malignancy (0/3)
      • Lymph node, right, lower paraesophageal, dissection —- Negative for malignancy (0/0)
      • Left recurrent laryngeal nerve and lymph node, dissection —- Negative for malignancy (0/3)
      • Lymph node, left group 9, dissection —- Negative for malignancy (0/0)
      • AJCC 8 th edition pT N M Pathology stage: ypStage I, ypT2N0(if cM0)
    • Gross Description:
      • Procedure: VATS McKeown esophagectomy; Size: Esophagus: 10.0 cm in length with a portion of gastric tissue measuring 2.6 cm in length.
      • Tumor Site: upper esophagus
      • Relationship of Tumor to Esophagogastric Junction: Tumor is entirely located within the tubular esophagus and does not involve the esophagogastric junction
      • Tumor Size: 2.2 x1 .5 cm
      • Sections are taken and labeled as: A1-2: Distal gastric resection margin; A3: stomach; A4: esophagus;A5: EG junction; A6-9: tumor; A10: lymph node, upper paraesophageal; A11: lymph node, middle paraesophageal;A12: lymph node, lower paraesophageal; A13-14: lymph node, perigastric; B1-2: lymph node, right group 2+4; C: lymph node, left group 4; D1-2: lymph node, right group 7; E: right thoracic duct; F: lymph node, right lower paraesophageal; G: left recurrent laryngeal nerve and artery; H: proximal cutend of esophagus; I: lymph node, left group 9.
    • Microscopic Description:
      • Histologic Type: Squamous cell carcinoma, s/p CCRT
      • Histologic Grade: G2: Moderately differentiated
      • Tumor Extension: Tumor invades the muscularis propria
      • Margins: All margins are uninvolved by invasive carcinoma, dysplasia, and intestinal metaplasia
        • Distance of invasive carcinoma from closest margin (millimeters or centimeters): 1 mm
        • Specify closest margin: serosal
        • Proximal resection margin: 1.1 cm
        • Distal resection margin: 9.1 cm
      • Treatment Effect: Present, Residual cancer with evident tumor regression, but more than single cells or rare small groups of cancer cells (partial response, score 2)
      • Lymphovascular Invasion: Present
      • Perineural Invasion: Not identified
      • Regional Lymph Nodes: please see diagnosis
      • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
        • TNM Descriptors: y (posttreatment)
        • Primary Tumor (pT): pT2: Tumor invades the muscularis propria
        • Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis
        • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM0
      • Additional Pathologic Findings: Acute inflammation is seen on serosa.
  • 2022-11-26 MRI - brain
    • IMP: no evidenceof brain tumors.
  • 2022-11-25 Tc-99m MDP whole body bone scan
    • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the lower C-spine, lower T-spine, L4-5 spines, bilateral shoulders, sternoclavicular junctions, hips and knees in whole body survey.
    • IMPRESSION:
      • In comparison with the previous study on 2022/09/16, no prominent change is noted, suggesting no definite evidence of bone metastasis.
      • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
      • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-11-24 Bronchoscopy
    • Normal airways, no evidence of esophageal cancer invasion
    • COPD with some sputum in dependent airways
    • Chronic rhinitis
  • 2022-11-23 Patho - esophageal biopsy
    • PATHOLOGIC DIAGNOSIS
      • Esophagus, upper, 23 cm, biopsy — Squamous cell carcinoma, moderately differentiated
      • Esophagus, upper, 26 cm, biopsy — Chronic esophagitis
      • Esophagus, lower, 35 cm, biopsy — Chronic esophagitis
    • MICROSCOPIC EXAMINATION
      • The sections of specimen (1) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, basal cell hyperplasia, elongation of papillae, moderate inflammatory cells infiltration, and reactive atypia of epithelial cells.
      • The sections of specimen (2) show a picture of squamous cell carcinoma, moderately differentiated, composed of nests of polygonal to oval-shaped neoplastic cells with stroma invasion. Keratin formation is present.
      • The sections of specimen (3) show a picture of chronic esophagitis, composed of squamous epithelium with congestion, parakeratosis, basal cell hyperplasia, elongation of papillae, and mild inflammatory cells infiltration.
  • 2022-11-23 Miniprobe Endoscopic Ultrasound
    • Diagnosis
      • Esophageal cancer, 23cm, EUS staging at least cT2N2, s/p biopsy(C)
      • Lugol voiding area, r/o dysphagia, 35cm, s/p biopsy(A)
      • Lugol voiding area, r/o dysphagia, 26cm, s/p biopsy(B)
      • Gastric subepithelial lesion, fundus, r/o lipoma
    • Suggestion
      • Consider to correlate to other image studies and pursue pathology report
  • 2022-11-23 Cardiopulmonary Exercise Test
    • conclusion
      • maximal exercise
      • low exercise capacity (VO2 59%, WR 75%)
      • low stroke volume response during exercise
      • normal ventilatory function (FEV1/FVC, FVC 87%, FEV1 81%)
      • No SpO2 desaturation during exercise
      • normal respiratory muscle strength (MIP 101%, MEP 79%)
      • Health-related quality of life, CAT= 12, poor, cough, sputum, chest tightness predominant
    • suggestions:
      • treat underlying condition, treat cough, sputum, chest tightnes
      • survey and treat cardiac function
      • Adequate fluid intake to keep adequate stroke volume
      • suggest exercise training after operation
      • low risk for operation
  • 2022-11-22 PET scan
    • In comparison with the previous study on 2022/09/14, the glucose hypermetabolism in the upper portion of the esophagus and some bilateral paratracheal lymph nodes is less evident.
    • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, in bilateral shoulders and in the soft tissues around bilateral hips. Inflammation may show this picture.
    • Increased FDG accumulation in the colon and both kidneys, probably physiological accumulation of FDG.
    • No prominent abnormal focal FDG uptake was noted elsewhere.
  • 2022-09-20 Pure Tone Audiometry, PTA
    • Reliability FAIR
    • Average RE 36 dB HL; LE 39 dB HL
    • R’t normal to severe SNHL.
    • L’t normal to severe SNHL but have ABG at 1k Hz.
    • 4k Hz notch was noted in both ears.
  • 2022-09-17 MRI - brain
    • No evidence of brain metastases.
  • 2022-09-16 Tc-99m MDP
    • No definite evidence of bone metastasis.
    • Increased activity in the lower C-spine, lower T-spine and L4-5 spines. Degenerative change may show this picture.
    • Increased activity in bilateral shoulders, sternoclavicular junctions, hips and knees, compatible with benign joint lesions.
  • 2022-09-15 Cardiopulmonary Exercise Testing
    • Conclusion
      • maximal exercise
      • low exercise capacity (VO2 73%, WR 67%)
        • normal stroke volume response during exercise
        • normal ventilatory function (FVC 83%, FEV1 82%)
        • Health-related quality of life, CAT = 13, poor
    • Suggestions
      • treat underlying condition
      • suggest exercise training
      • low risk for operation
  • 2022-09-14 Whole body PET scan
    • A glucose hypermetabolism lesion in the esophagus, U/3, compatible with the primary esophageal cancer.
    • Glucose hypermetabolic lesions in bilateral mediastinal space, suspected cancer with regional lymph nodes metastases.
    • Glucose hypermetabolism in bilateral pulmonary hilar regions and in a right level II-III cervical lymph node, probably reactive nodes.
    • Glucose hypermetabolism in the right palatine tonsil, probably chronic inflammation process.
    • Increased FDG accumulation in the colon, probably physiological uptake of FDG.
    • Upper esophageal cancer with two regional lymph nodes metastases, cTxN1M0, by this F-18 FDG PET scan.
  • 2022-09-14 Bronchoscopy
    • no endobronchial lesion
  • 2022-09-13 ECG
    • Sinus rhythm with 1st degree A-V block
    • Incomplete right bundle branch block
  • 2022-09-13 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (80 - 26) / 80 = 67.50%
      • M-mode (Teichholz) = 66
    • Preserved LV and RV systolic function with normal wall motion
    • Grade 1 LV diastolic dysfunction
  • 2022-08-24 CT - chest
    • Imaging Report Form for Esophageal Carcinoma
    • Impression (Imaging stage): T:T2(T_value) N:N1(N_value) M:M0(M_value) STAGE:____(Stage_value)
  • 2022-08-23 Patho - esophageal biopsy
    • Esophagus, 22-30 cm below incisors, biopsy — Squamous cell carcinoma, moderately differentiated
    • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei with subtle desmoplastic stromal reaction. Keratin formation is evident.
  • 2022-08-22 SONO - abdomen
    • mild tomoderate fatty liver (suboptimal exam of liver)
    • mild gallbladder wall thickening
  • 2022-08-22 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Segmental esophageal lesion, suspected advanced esophageal cancer, 22-30 cm below incisors, s/p biopsy
      • Reflux esophagitis LA Classification grade A (minimal)
      • Superficial gastritis
      • The examination was suboptimal due to patient’s intolerance
    • Suggestion
      • Pursue pathology result
      • CT scan is indicated

[consultation]

  • 2022-09-21 Hemato-Oncology
    • Q
      • This is a 55 year-old male, with underlying disease of (1) diabetes mellitus (2) hypertension. He suffered from dysphagia and odynophagia for one month. According to himself, he could swallow solid food, but there were foreign body sensation while food intake. No body weight loss, no fever, no cough. He then came to our gastrointestine clinic for help. Panendoscopy was done and and showed segmental esophageal lesion, further biopsy proven squamous cell carcinoma. Chest CT also done and revealed left lateral esophageal wall thickening with luminal narrowing at upper third of thoracic esophagus. Therefore, he was refferd to chest surgery clinic for further evaluation. After admission, we arranged PET, EUS, brain MRI, WBBS, bronchoscope and CPET for cancer work-up. On 2022-09-19, he underwent port-A insertion.
      • Impression: Upper thoracic esophageal cancer, cT2N2M0, Squamous cell carcinoma, moderately differentiated
      • We need to consult you for CCRT. Thanks a lot!
    • A
      • Impression:
        • Upper thoracic esophageal cancer, cT2N2M0, stageIII, Squamous cell carcinoma, moderately differentiated
        • Occult hepatitis B (anti Hbc positive)
      • Suggestion:
        • We will discuss with patient about CCRT, thanks for your referal
        • May arrange 24hr urine CCR and PTA auditory test
        • May arrange our OPD after discharge or transfer to our ward
        • If there is any problem, please feel free to let us known

[surgical operation]

  • 2022-12-12
    • Surgery
      • 3D VATS esophagectomy + gastric tube reconstruction.
    • Finding
      • One tumor was noted over U/3 of esophagus, s/p CCRT
      • One 24 Fr. straight chest tube was inserted via right 9th ICS.

[radiotherapy]

  • 2022-09-26 ~ undergoing? at 3240cGy/18 fractions of the esophageal tumor, peripheral including regional nodal area.

[chemoimmunotherapy]

Esophageal and Esophagogastric Junction Cancers, NCCN Evidence Blocks, 2022-09-07, Version 4.2022, ESOPH-F 5 OF 17, p49 = Principles of Systemic Therapy > Regimens and Dosing Schedules > Other Recommended Regimens

  • Fluorouracil and cisplatin
    • Cisplatin 75-100 mg/m2 IV on Days 1 and 29
    • Fluorouracil 750-1000 mg/m2 IV continuous infusion over 24 hours daily on Days 1-4 and 29-32
    • 35-day cycle

Administration

  • 2023-01-30 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3 + [magnesium sulfate 10% 20mL + furosemide 20mg 10min] post cisplatin
  • 2022-10-21 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3
  • 2022-09-26 - cisplatin 75mg/m2 135mg 24hr + fluorouracil 1000mg/m2 1800mg 24hr D1-4 (PF4)
    • dexamethasone 8mg D1-2 + diphenhydramine 30mg D1 + palonosetron 250ug D1 + aprepitant 125mg D1-3

==========

2023-01-31

  • Despite MgO PO, MgSO4 IV supplementation during hospitalization, this patient had several months of hypomagnesemia according to lab data. It is recommended that supplementation continue following discharge.

2022-10-25

  • The current two-drug cytotoxic regimen (fluorouracil + cisplatin) is preferred for patients with advanced disease because of lower toxicity.
  • The underlying conditions of hypertension, type 2 diabetes, hyperuricemia are well managed with patient-carried medications based on blood pressure, finger stick measurements and lab data.
  • Hypomagnesemia (1.4mg/dL 2022-10-24) is treated with MgSO4 injection.
  • The active prescription is not subject to any issues.

700999046

230131

[assessment]

  • In response to anemia (2023-01-27 HGB 7.5g/dL), LPRBC 2U was transfused on 2023-01-28 to treat the condition.

  • Cold hemagglutination was observed in 2023-01-27 lab data.

    • Cold agglutinins regularly occur during the course of two infections: 1. M. pneumoniae (primary atypical pneumonia), 2. Epstein-Barr virus (infectious mononucleosis). Case reports have described cold agglutinins in the setting of other viral infections such as HIV, rubella virus, influenza viruses, COVID-19 infection, or varicella-zoster virus (chickenpox). Not all individuals with these infections who develop cold agglutinins will have clinically significant hemolysis. For those who do, it usually occurs approximately two weeks after onset of the primary infection, diminishes as the infection begins to resolve, and is gone within two to three months.
    • Cold agglutinins have also been described in individuals with autoimmune disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis.

701431422

230130

[exam findings]

  • 2023-01-28 CXR
    • S/P pace-maker implantation.
    • Enlargement of right hilum.
    • Atherosclerosis of the aorta.
  • 2023-01-27 CT - abdomen
    • Indication:
      • He received pancreatic ca stage I operation (Nov. 2022) at VGH.
      • He was recommended to receive TS-1
      • Night fever was noted since Dec. 16, 2022.
      • Fever, nature ? (20230113)
    • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Bi-phasic dynamic CT images were obtained during non-enhanced, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There is a lobulated cystic lesion with enhancing wall at left anterior subphrenic space, measuring 14 x 6 x 4 cm (width x depth x cranial-caudal length).
        • Pseudocyst is highly suspected.
        • The differential diagnosis include abscess.
        • please correlate with clinical condition.
      • There are two lobulated cystic lesion in right and left para-colic gutter space, measuring 1.9 x 2.6 x 3.2 cm and 1.7 x 2.3 x 3,8 cm, respectively.
        • Pseudocysts are highly suspected.
      • There is another cystic lesion with enhancing wall at the midline pelvis, measuring 5 x 4 cm.
        • Pseudocyst is also suspected.
      • There is ascites in right perihepatic space,
      • S/P Whipple operation and S/P cholecystectomy.
      • There is mild left Pleura effusion.
      • Others
        • There is no focal abnormality in the biliary system, spleen & both kidney.
        • There is no evidence of lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
    • Impression:
      • Pseudocyst (14 x 6 x 4 cm) in left anterior subphrenic space is highly suspected.
        • The differential diagnosis include abscess. please correlate with clinical condition.
      • Three lobulated cystic lesions in bilateral para-colic gutter space and midline pelvis are noted.
        • Pseudocysts are highly suspected.
  • 2023-01-16 ECG
    • Atrial-paced rhythm
    • Nonspecific ST and T wave abnormality
    • Abnormal ECG
  • 2023-01-13 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • Scoliosis of the T-spine with convex to right side.

[assessment]

  • Despite having a pacemaker implanted, the patient’s heart rate doubled from 64 (2023-01-29 20:03) to 144 (2023-01-30 08:50).

  • Runaway pacemaker occurs when the pacemaker’s pulse generator discharges at a rate above its preset upper limit. The malfunction lies entirely within the pulse generator. It should be suspected if pacemaker dysrhythmias occur at rates greater than 130 beats/min or the upper rate limit if this is known. ref: Tachycardia in the presence of a pacemaker. Postgrad Med J. 2004;80(940):119-122. doi:10.1136/pmj.2002.004036q

701433000

230130

[lab data]

  • 2022-07-21 Anti-HBc Reactive
  • 2022-07-21 Anti-HBc-Value 7.05 S/CO
  • 2022-07-21 Anti-HBs 10.17 mIU/mL
  • 2022-07-21 Anti-HCV Nonreactive
  • 2022-07-21 Anti-HCV Value 0.07 S/CO

[exam findings]

  • 2023-01-28 Elbow LT
    • Left elbow X-ray shows
      • Permeative change of proximal radius is found. Fracture line is also found. Pathological fracture is considered.
      • Regional soft tissue swelling is identified.
  • 2023-01-28 KUB
    • Phlebolith at pelvic cavity is found.
  • 2023-01-28 CXR
    • Cardiomegaly is noted.
    • Nodular lesion at both lungs is found.
    • The trachea is deviated to right side is found.
  • 2023-01-16, -01-10 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Borderline cardiomegaly
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Few nodular opacity projecting at both lung are noted that are c/w metastases after correlate with CT.
  • 2023-01-04 CT - chest
    • Findings - Comparison was made with previous CT dated on 20220624
      • Lungs:
        • multiple randomly distributed pulmonary nodules of varying sizes up to 26mm at RUL due to metastases.
        • septal thickening over medial Rt upper lobe.
      • Mediastinum and hila: resolution of M/3 esophageal tumor, with mild wall thickening.
        • extensive lymphadenopathy in the visceral space and left anterior prevascular space, with tracheal and thyroid gland invasion and encasing Ly common carotid artery
        • small pericardial effusion.
      • Pleura: minimal bilateral effusion.
      • Visible lower neck: metastatic LAPs in left deep cervical space,
      • Visible abdominal-pelvic contents:
        • normal appearance of gall bladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys.
        • no enlarged lymph node. no ascites.
      • Visualized bones: marginal spurs of multiple vertebrae due to spondylosis.
    • Impression:
      • m/3 esophageal cancer with resolution of primary tumor but pogression of lung and distant LNs metastases compared with 2022-06-24
  • 2023-01-03 Neck Soft tissue X-rays
    • Swelling of prevertebral soft tissue at C4-6 level.
    • Straightening alignment of cervical spine.
    • Degenerative change of the spine with marginal spur formation.
  • 2023-01-03 CXR
    • Pulmonary nodules at right lung.
  • 2022-10-26 Patho - lung transbronchial biopsy
    • Trachea, central, bronchoscopic biopsy —- acute and chronic inflammation — negative for malignancy
  • 2022-10-14, -09-21, -09-07, -09-01 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Borderline cardiomegaly
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
  • 2022-08-25 CXR
    • No active lung lesion.
    • No cardiomegaly.
    • T-spine spondylosis.
  • 2022-08-17, -08-10, -08-03, -07-29 CXR
    • Widening of the left upper mediastinum causing right lateral deviation of the trachea is noted. Please correlate with CT.
    • Enlargement of cardiac silhouette.
    • Increased lung markings on both lower lung are noted. Please correlate with clinical condition.
  • 2022-07-25 CXR
    • Port-A catheter inserted into SVC via left subclavian vein.
    • Crowding of vascular markings over Rt lower lung zone
    • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
    • enlarged cardiac silhoutte
    • A tracheostomy tube in place, proper position
  • 2022-07-22 Patho - esophageal biopsy
    • Esophagus, upper, biopsy — Squamous cell carcinoma, poorly differentiated
    • Section shows several pieces of squamous mucosa with infiltration of nests of poorly differentiated tumor cells.
    • The immunohistochemical stain of p40 is positive.
  • 2022-07-22 Miniprobe endoscopic ultrasound
    • Endoscopic findings
      • A fungating ulcerative tumor mass with easily touched bleeding is seen at the upper to middle esophagus 20cm to 35cm below the incisors. Biopsy *8 are done. The scope cannot pass through this stenotic site.
    • EUS findings
      • EUS using miniprobe (Olympus UM-DP-25R) showed whole layer thickening with loss of stratification and invading the surrounding structure. The tumor size is about 15 cm in length. There are three hypoechoic LNs found outside the esophagus.
    • Diagnosis
      • Esophageal cancer, T3N2, s/p Bx
    • Suggestion
      • Pursue biopsy result
  • 2022-07-20, -07-18, -07-12 CXR
    • Crowding of vascular markings over both lower lung zones
    • Displacement of the tracheal axis to right at thoracic inlet and superior mediastinum probably due to lymph node enlargement,
    • enlarged cardiac silhoutte
    • A tracheostomy tube in place, proper position
  • 2022-07-15 Patho - esophageal biopsy
    • Labeled as “esophagus, 20 cm to 35 cm”, biopsy — squamous cell carcinoma, poorly differentiated.
    • IHC stains: CK5/6 (+), P40 (+), CDX2 (weak +), CD56 (-).
  • 2022-07-14 Esophagogastroduodenoscopy, EGD
    • Diagnosis
      • Esophageal cancer, 20-35cm, s/p biopsy
      • Duodenal shallow ulcers, D1 to D2
      • Reflux esophagitis LA grade A
      • Superficial gastritis, s/p CLO test
    • Suggestion
      • Pursue results of pathology and CLO test
      • PPI use
  • 2022-07-13 Tc-99m MDP whole body bone scan
    • No strong evidence of bone metastasis.
    • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
  • 2022-07-13 MRI - brain
    • no evidence of brain metastasis.
  • 2022-07-12 Whole body PET scan
    • A glucose hypermetabolic lesion involving middle portion of the esophagus, compatible with primary esophageal malignancy.
    • Glucose hypermetabolism in some confluent upper left paratracheal lymph nodes with possible invasion to adjacent trachea, two right paratracheal lymph nodes and a lymph node in the upper abdomen just between the stomach and left lobe liver. Metastatic lymph nodes may show this picture.
    • Mild glucose hypermetabolism in the right lower lung field. Inflammation may show this picture.
    • Increased FDG uptake in the right vocal cord. The nature is to be determined (inflammation? physiological FDG uptake? other nature?). Please correlate with other clinical findings for further evaluation.
    • Increased FDG uptake in bilateral neck muscles and mucles of anterior abdominal wall. Physiological FDG uptake is more likely.

[consultation]

  • 2023-01-28 Orthopedics
    • A
      • Pat Bas Info
        • 62y/o male
        • Past history: Squamous cell carcinoma of middle third esophageus, cT4N3M0 stage IVA s/p jejunostomy, left Port-A implantation and tracheostomy on 2022/07/12
        • Allergy: NKDA
        • No current anti-platelet/anti-coagulation medication usage
        • 169cm, 66.5kg
      • Subjective: left proximal forearm tenderness after lifting motorcycle 3 days ago
      • Physical examination:
        • Inspection: left proximal forearm: mild swelling, no ecchymosis, no open wound
        • Palpation: left proximal forearm tenderness, aggravated when motion (supination/pronation)
        • Motion: elbow supination/pronation(+ but tenderness); wrist flexion/extension(+); finger motion(+)
        • Distal sensation: intact
        • Circulation: Capillary refill time <2sec, radial pulse(+)
      • X-ray:
        • Left proximal radius radiolucent density and permeative change, consider pathological fracture
        • No evidence of destructive bone lesion found on KUB.
      • Previous exam
        • 2022/07/13 Tc-99m MDP whole body bone scan
          • No strong evidence of bone metastasis.
          • Suspected benign lesions in the skull, maxilla, mandible, T-spine, right clavicle bone, bilateral shoulders, S-I joints, and hips.
        • 2023/01/28 CXR
          • Nodular lesion at both lungs is found.
      • Plan:
        • Long arm splint and triangular sling immobilization
        • Adequate pain control
        • Please arrange Tc-99m MDP whole body bone scan.
        • Conservative management was recommended first.
        • OPD follow-up and arrange further treatment
  • 2022-07-21 Hemato-Oncology
    • Q
      • This 62-y/o male who denied any systemic disease was diagnosed with esophageal cancer this year.
      • Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12, and brain MRI, whole body bone scan and PET scan were done.
      • His tumor staging was T4N3M0.
      • We would like to consult your expertise on arrangement of CCRT for the patient, thank you!
    • A
      • Impression:
        • Poorly differentiated Esophageal squamous cell carcinoma, with trachea compression and deviation cT4N3M0, s/p Tracheostomy + Prot-A + Jejunotomy were performed on 2022/07/12
        • Aspiration pneumonia
      • Suggestion:
        • CCRT is indicated in this case (PF4). Please check HbsAg, AntiHbc, Anti HCV. Arrange auditory PTA and 24 urin CCR

[surgical operation]

  • 2022-07-12 Feeding jejunostomy + port-A + tracheostomy

[radiotherapy]

  • 2022-07-29 ~ 2022-09-20 - 5040cGy/28 fractions of the esophageal tumor, peripheral involved, and regional lymphatic area.

[chemoimmunotherapy]

  • 2022-10-13 - cisplatin 80mg/m2 150mg 24hr D1 + fluorouracil 1000mg/m2 1900mg 24hr D1-4
  • 2022-09-14 - cisplatin 40mg/m2 75mg 2hr (CCRT)
  • 2022-09-07 - cisplatin 30mg/m2 60mg 2hr (CCRT)
  • 2022-08-17 - cisplatin 30mg/m2 60mg 2hr (CCRT)
  • 2022-08-10 - cisplatin 30mg/m2 50mg 2hr (CCRT)
  • 2022-08-05 - cisplatin 30mg/m2 50mg 2hr (CCRT)
  • 2022-07-29 - cisplatin 30mg/m2 50mg 2hr (CCRT)

==========

2023-01-30

  • When pulmonary symptoms limit the patient’s ventilation, oxygenation becomes more important.

  • Laboratory 2023-01-28: MCV 68.5fL, MCH 21.5pg, both below LLN since 2nd half 2022, there may be an iron deficiency. It is recommended that the patient’s body iron level be checked in order to determine whether iron supplements need to be added.

2022-10-14

  • There are no results for HER2 from the pathologies performed on 2022-07-22 and 2022-07-15. In the event that HER2 overexpression is confirmed, trastuzumab should be added to first-line chemotherapy. (NCCN 2022-09-07 version 4.2022)
  • The serum magnesium level has been no higher than 1.8mg/dL since 2022-08-05 (with oral MgO currently). Hypomagnesemia due to urinary magnesium wasting occurs in over one-half of cases of cisplatin-induced nephrotoxicity. It can occur without the presence of concomitant AKI. In patients who receive cisplatin for several months, urinary magnesium wasting may persist even after discontinuation of cisplatin therapy. In addition to its direct clinical manifestations, hypomagnesemia may exacerbate cisplatin toxicity. As always, please keep an eye on the related signs.
  • Hypokalemia (2022-10-13 3.1mmol/L) is managed with Radi-K (potassium gluconate) currently.
  • It is suggested a solution consisting of isotonic saline supplemented with KCl and MgSO4 rather than isotonic saline alone. Specifically, a solution consisting of 1000 mL of isotonic saline plus 20 mEq of KCl and 2 grams of MgSO4, and administer intravenously a minimum of 1000 mL of this solution over two to three hours prior to, and a minimum of 500 mL over the two hours following, the cisplatin administration. This fluid administration should be adequate to establish a urine flow of at least 100 mL/hour for two hours prior to, and two hours after, chemotherapy administration. The rationale for adding potassium and magnesium to the solution is to avoid the development of hypokalemia and hypomagnesemia that may occur with forced diuresis; in addition, magnesium supplementation may help to limit cisplatin nephrotoxicity. The addition of furosemide is generally not required, unless there is evidence of fluid overload. (ref: UpToDate https://www.uptodate.com/contents/cisplatin-nephrotoxicity )

700387653

230127

  • past history
    • Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
    • HTN
    • Hyperurecemia
  • exam finding
    • 2022-11-01 MRI - nasopharynx
      • The current study was compared to the prior one obtained on 2022/06/14.
      • Known a case of right oropharyngeal cancer S/P CCRT. Marked regression of prior shown soft-palate and tonsillar lesions. But progression of right sphenoid sinus lesion and more invasion of right masticator space.
      • Focal subcortical edema of right temporal lobe tip with abnormal enhancement, may be due to radiation necrosis. But direct invasion by adjacent tumor can not be ruled out. Suggest follow up.
      • Right-sided paranasal sinusitis.
      • Right otitis media and mastoiditis.
    • 2022-10-26 CT - abdomen
      • History: oropharyngeal cancer diagnosed in Mackey asked for further opinion and management
        • 2022-05-31 biopsy over right oropharynx (soft plate) MacKay Memorial Hospital: SCC
      • Findings:
        • There is mild dilatation of IHDs, CHD, and CBD.
          • Please correlate with serum alk-p and bilirubin level.
        • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla.
          • Please correlate with MRCP to R/O pancreatic divisum.
        • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images.
          • Spontaneous arterio-portal shunting are highly suspected.
          • Please correlate with sonography and MRI.
        • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum.
          • Metastasis is highly suspected.
        • S/P nasogastric tube insertion
        • Fecal material store in the colon.
      • Impression:
        • There is mild dilatation of IHDs, CHD, and CBD. Please correlate with serum alk-p and bilirubin level.
        • There is mild dilatation of the pancreatic duct and it seems directly drained into minor papilla. Please correlate with MRCP to R/O pancreatic divisum.
        • There are few enhancing nodules on right hepatic lobe at arterial phase images but isodensity in portal venous phase and delayed phase images. Spontaneous arterio-portal shunting are highly suspected. Please correlate with sonography and MRI.
        • There is a newly-developed lobulated poor enhancing soft tissue mass measuring 3.5 cm in left hilum. Metastasis is highly suspected.
    • 2022-09-09 CXR
      • Tortous aorta with calcification is noted.
    • 2022-09-09 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-08-27 CXR
      • S/P NG tube indwelling.
      • S/P Port-A infusion catheter insertion.
      • Ground glass opacity in LLL.
    • 2022-08-24 CXR
      • S/P port-A implantation.
      • S/P nasogastric tube insertion
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-08-13 CXR
      • Consolidation in left lower lung, stationary.
    • 2022-08-10 CXR
      • S/P port-A implantation.
      • S/P nasogastric tube insertion
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-08-03 Nasopharyngoscopy
      • Findings
        • Left nasal floor Tumor seen, partial obstruction,
        • NP smooth
        • PND+
        • Oropharynx partial occlusion by tumor
        • Bil vocal cord good motility, no paresis
        • Bil parapharyngeal wall tumor involvement
        • No saliva pooling in bil pyriform sinus
        • Vallecula/tongue base patent
        • NG in place
      • Conclusion:
        • orophayrngeal SqCC p16(+) cT4N0M0 Stage II under CCRT
        • OPD f/u
    • 2022-07-26 CXR
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Linear and nodular opacities projecting at left lower lung are noted. please correlate with clinical condition or CT.
    • 2022-07-21 CXR
      • Patchy consolidations at LUL-lingula and LLL due to pneumonia with pleural effusion still visualized
      • Thoracic aortic arch calcified atheriosclerotic plaque
    • 2022-07-20 Bronchoscopy
      • symptom:
        • dyspnea with much sticky sputum
      • clinical diagnosis:
        • SCC of the oropharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT, LLL pneumonia with much sputum
      • bronchoscopic diagnosis
        • Bronchitis, LLL, with pus like sputum over LLL bronchus and emerging from distal airway
    • 2022-07-16 CT - lung
      • LML and LLL consolidations, suspected pneumonia
      • A faint ehancing nodule(0.5cm) in S6 of liver. Suggest sonography correlation.
    • 2022-07-16 ECG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-07-16 CXR
      • Consolidation in left lung
    • 2022-06-15 Tc-99m MDP whole body bone scan
        1. A hot spot in the left 1st rib, probably normal variant, post-traumatic change, or other benign nature. Please keep follow-up for further evaluation.
        1. Probably benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, S-I joints, and hips.
    • 2022-06-14 MRI - nasopharynx
      • AJCC 8th edition Staging status: T4bN0M0
    • 2022-06-14 Patho - esophageal biopsy
      • A: Esophagus, lower, near EG junction, biopsy — Compatible with Barrett’s esophagus
      • B: Esophagus, upper, biopsy — Compatible with heterotopic gastric mucosa
    • 2022-06-13 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal mucosal lesion, lower esophagus near EG junction, suspected to be secondary mucosal change due to reflux esophagitis or heterotopic gastric mucosa; s/p biopsy (A)
        • Esophageal mucosal lesion, esophageal inlet, probable heterotopic gastric mucosa; s/p biopsy (B)
        • Superficial gastritis
        • Oropharyngeal cancer
      • Suggestion
        • No endoscopic evidence of metachronous esophageal cancer
        • Pursue biopsy result
    • 2022-06-09 Nasopharyngoscopy
      • orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation tongue base, hypopharynx, larynx: ok
    • 2022-05-31 Pathology (at Mackey Hospital)
      • Oropharynx, soft palate, right side, biopsy, squamous cell carcinoma.
      • The result of immunohistochemical study with p16 is positive for tumor cells.
      • Dr. DongYing Chen has reviewed the lesion slide and concurs with the diagnosis of carcinoma.
  • consultation
    • 2022-08-31 Dermatology
      • Q
        • This 56-year-old man patient is a case of squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for upper and lower limbs skin itch without redness rash. Now, for evaluate skin itch therapy. Thank you.
      • A
        • The patient had sufferred from SCC under chemoradiotherapy. Erythematous itchy papules with excoriative crust on the four limbs and turnk for days.
        • Under the impression of eczema with post-scretch wound and prurigo formation.
        • The following sugeetion:
          • Betason-N onit 3 tube topical bid use on the excoriative wound first
          • Topysm cream 2 tube topical bid use on the reddish itchy papule lesions.
          • add Cypromin lotion 10cc QID po for pruritus control.
    • 2022-07-28 Rehabilitation
      • Q
        • This 56 year-old man patient is a care of Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0, stage III s/p concurrent chemoradiotherapy. This time, for being unable to open mouth. Now, for evaluate mouth rehabilitation. Thank you.
      • A
        • This is a 56 y/o male patient with history of
            1. Squamous cell carcinoma of the orpharynx, p16(+), stage cT4bN0M0 (stage III) under CCRT
          • 2.) Hypertension
          • 3.) Hyperurecemia under medication control.
        • He was regular F/U at our oncologist OPD.He was just discharge form our ENT ward on 2022-06-16.
        • PE
          • Consciousness: E4V5M6
          • Cognition:could follow orders
          • Speech: no aphasia
          • Swallowing: NG (+)
          • limited mouth and tongue ROM
          • Functional status: could ambulates with CG
          • BADL: needs max assistance (NG +
        • Assessment
          • Squamous cell carcinoma of the orpharynx, p16(+),
        • Plan
          • Lip-mouth movement instruction
    • 2022-06-14 Oral and Maxillofacial Surgery
      • Q
        • This 56 y/o male patient with history of HTN and hyperurecemia under medication control. This time, he went to our hospital due to progressive sore throat for 1 year and dysphagia for 6 months. Poor appetite and weight loss 10 kg in 6 months were also noted. Intermittent headache was also complained. Due to odynophagia and dysphagia progressed, he went to Mackey Hospital for help.
        • Biopsy for right soft palate was done, and the pathology was SCC, P16 (+). He went to our ENT OPD for second opinion and further management. At Dr. Su’s OPD, Nasopharyngoscopy showed orophayngeal tumor involved bil. tonsils, soft palate with right soft palate perforation. Tongue base, hypopharynx, larynx were grossly normal. PE showed no obvious lymphadenopathy. Admission for cancer work-up was suggested, and the patient and family agreed after well explanation. Under the impression of oropharyngeal cancer, P16 (+). the patient was admitted to ENT ward for cancer work-up. We need your help for pre-CCRT dental evaluation and management. Thank you very much!!
      • A
        • This is a 56 y/o male who suffured from SCC of orophayngeal regioninvolved bil. tonsils, soft palate with right soft palate perforation. and is about to received radiotherapy.
        • O:
            1. Hopeless tooth 17 and 38 were noted.
            1. Chronic gingivitis of full mouth was noted.
            1. Poor oral hygiene was noted.
        • P:
            1. Take panoramin film for tooth evaluation
            1. Suggest extraction of tooth 17 and 38.
            1. OHI (oral hygiene instruction)
  • radiotherapy
    • 2022-07-13 ~ - 4400cGy/22 fractions of the oropharyngeal to nasopharyngeal tumor, peripheral involved, to bilateral neck.
  • chemoimmunotherapy
    • 2022-09-22 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-24 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-17 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-10 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-08-03 - cisplatin 40mg/m2 65mg 2hr (CCRT)
    • 2022-07-13 - cisplatin 40mg/m2 65mg 2hr (CCRT)

==========

2023-01-27

[tube feeding, drug interactions]

  • Scrat (sucralfate) should be administered on an empty stomach. Please shake suspension well before use and do not administer antacids within 30 minutes of administration of sucralfate. In general, it is recommended to separate administration of other oral medications and sucralfate by at least 2 hours. With Panzolec (pantoprazole) 40mg IVD QD (09:00) and Scrat 1g PO Q6H (05:00, 11:00, 17:00, 23:00), it should be less likely that there will be obvious interactions between the two. The adjustment does not need to be made.

  • Bromelain, the main active ingredient in Broen-C tablets, is sensitive to extreme conditions such as high temperature, gastric proteases in stomach juice, high acidity, and organic solvents, and thus, reduces its functionalities and bioavailability. Its instability under such stress conditions reduce its enzymatic activity, decrease its health benefits, and limit its pharmacological applications. The drug is therefore designed to be enteric coated. There is no alternative for this ingredient available in the hospital at present time.

2023-01-22

Management of vasogenic edema in patients with primary and metastatic brain tumors - glucocorticoids - ref: https://www.uptodate.com/contents/management-of-vasogenic-edema-in-patients-with-primary-and-metastatic-brain-tumors

  • 2023-01-11 brain MRI showed increased heterogeneous soft tissue enhacement in the right temporal lobe and right cavernous sinus with right cavernous ICA encasement. suspected radiation necrosis or tumors.

  • Systemic glucocorticoids are the mainstay of symptomatic therapy for peritumoral edema. They play a role in stabilizing patients awaiting definitive treatment of the tumor as well as in palliative management of edema related to treatment-refractory tumors.

  • Emergency management of increased ICP

    • A significant increase in intracranial pressure (ICP) causing drowsiness and other signs of impending herniation can be a medical emergency, and treatment should be undertaken as expeditiously as possible, typically in an intensive care unit setting. A bolus dose of dexamethasone (eg, 10 mg IV) should be given acutely, followed by 16 mg/day in divided doses. Doses as high as 40 mg/day may be given in the emergency setting for brain tumor-related edema and mass effect. Additional interventions during the first 24 to 72 hours may be required to lower ICP, such as hypertonic saline and mannitol.
  • Initiation of glucocorticoids

    • Systemic glucocorticoids should be considered in all patients who have symptomatic peritumoral edema. Depending on the location of the tumor and the extent of edema, symptoms may be generalized (eg, headache, nausea, vomiting) or focal (eg, aphasia, hemiparesis), or both.
    • Dexamethasone is the standard agent for peritumoral edema management because its high potency and relative lack of mineralocorticoid activity reduce the potential for fluid retention [15-17]. In addition, dexamethasone can be given orally or intravenously (IV) with a 1:1 conversion ratio.
    • For patients requiring low to moderate amounts of dexamethasone (eg, 4 to 6 mg daily or less), prednisone is sometimes used as an alternative to dexamethasone in patients with steroid myopathy or in those with a history of adrenal insufficiency, as it allows for a taper in smaller increments.
  • Dexamethasone dose and schedule

    • The antiedema effects of dexamethasone are dose dependent, and the starting dose should be individualized based on the extent of edema and the severity of symptoms [16,18,19]. Because most side effects are also dose dependent, the goal is always to use the lowest dose necessary to control symptoms.
      • In patients with moderate to severe symptoms (eg, severe headache, nausea and vomiting, significant focal neurologic deficits), the usual initial dexamethasone regimen consists of a 10 mg loading dose IV, followed by an initial maintenance dose of 8 to 16 mg daily in divided doses orally (or IV for patients not tolerating oral medications).
      • For patients with milder symptoms, a loading dose is usually omitted, and smaller total daily doses (eg, 2 to 4 mg divided once or twice daily) are usually adequate and less toxic.
      • Most patients who are asymptomatic do not require steroids, although clinical judgment is required in patients with large amounts of edema, particularly when antitumor therapy has the potential to worsen edema. Increased caution is also required for posterior fossa tumors and edema, which can be associated with rapid deterioration.
    • Although it has been customary to administer dexamethasone in four divided daily doses, its biologic half-life is sufficiently long (36 to 54 hours) to allow once- or twice-daily dosing, and this approach is preferred for maintenance therapy because it is easier for patients and has not been associated with diminished efficacy. We use once-daily morning dosing when possible and avoid late evening and middle-of-the-night dosing to help reduce insomnia caused by glucocorticoids. To minimize complications, subsequent dosing should be modified to use the lowest possible dose necessary to control peritumoral edema. (See ‘Complications and prophylaxis’ below and ‘Approach to taper’ below.)
    • Absorption of oral dexamethasone is excellent and is complete within 30 minutes of administration. Oral and IV dosing is equivalent. IV dosing may be necessary if oral absorption cannot be assured, or if oral intake is unsafe due to altered mentation or other deficits.
  • Response assessment

    • Management of peritumoral edema is largely empiric. Clinical response, rather than radiographic changes, should guide most decisions.
    • Most patients begin to improve symptomatically within hours and achieve a maximum benefit from a given dose of dexamethasone within 24 to 72 hours. In general, headaches tend to respond better and more quickly than focal deficits, in part because edema may not be the only cause of focal deficits. The maximum neuroimaging response lags behind clinical response by days to a week or two.
  • Inadequate response to initial dose

    • When patients fail to improve or improve only partially after several days on the initial dose, there are two main possibilities. Either a higher dose is required, or the residual symptoms are caused by factors other than peritumoral edema.
    • A trial-and-error strategy is often used to help distinguish between the two. For patients on submaximal doses, the dexamethasone dose is typically doubled for two to three days as a trial (usual maximum total daily dose, 16 mg). If the patient improves clinically, the higher dose is continued. The less a patient responds to a doubling of the dose, the less likely it is that symptoms are steroid responsive. If there is no response by 72 hours, the dose can generally be returned to the previous dose level without taper. This strategy helps to avoid excessive steroid dosing and toxicity in the absence of clinical benefit.
    • If a dexamethasone dose of 16 mg per day is insufficient, the dose may be increased further, although often with diminishing returns and excess toxicity. Alternative options for refractory edema should be considered in such cases.
  • Approach to taper

    • Once patients have responded and stabilized clinically on a given dose of dexamethasone, a gradual taper should be attempted, if possible. This is particularly important for patients on high initial doses of dexamethasone (eg, >8 mg daily), as weight gain and proximal weakness often emerge within weeks at such doses. The likelihood of success and the speed of the taper depend on multiple factors, including the status of the underlying tumor, concurrent therapies, and the duration of steroid therapy. Postoperative steroid tapers in patients who have undergone complete tumor resection can be relatively rapid, for example, whereas efforts to taper steroids in patients with residual or progressive tumors must be approached more cautiously.
    • Dexamethasone has a long duration of action, and therefore a period of at least three to four days should generally follow each dose decrement to establish clinical tolerance of the lower dose. For patients in good clinical condition whose tumor has been stabilized with recent treatment, a taper may entail a reduction in dose of up to 50 percent every four days. A more protracted taper and chronic treatment may be required for patients with active tumors and those who do not tolerate initial attempts to wean steroids. Patients and caregivers should be educated about signs and symptoms that may signal reaccumulation of symptomatic edema as dexamethasone is being tapered (ie, recurrent or worsening headaches, focal deficits).
    • Symptoms not caused by recurrence of brain edema may develop during the course of the steroid taper (steroid withdrawal syndrome). These include mild headache and lethargy that may mimic recurrence of brain edema as well as myalgias and arthralgias (steroid pseudorheumatism). All of the symptoms respond to raising the dose slightly and tapering more slowly.
  • Refractory edema

    • Management of chronic, symptomatic edema can be challenging. Many patients develop toxicities related to chronic glucocorticoids, which in some cases eventually outweigh the benefits. Surgical debulking of the associated tumor may be indicated in select cases, even when the goal is not curative, in order to help control the underlying cause of the edema. For certain tumor histologies, bevacizumab may be an option to help control edema. If globally elevated ICP is the main source of refractory headaches or symptomatic plateau waves, ventricular shunting may be an option in some patients.
    • Role of bevacizumab
      • Since vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of peritumoral edema, anti-VEGF monoclonal antibodies such as bevacizumab or inhibitors of VEGF receptors are useful in reducing edema. The steroid-sparing effects of bevacizumab were demonstrated in a randomized phase II study of bevacizumab with or without irinotecan in patients with recurrent glioblastoma, in which 30 to 50 percent of patients had a sustained reduction in glucocorticoid dose and approximately 20 percent achieved a complete taper. Other VEGF inhibitors have shown similar effects.
      • In patients with recurrent/refractory glioblastoma and symptomatic peritumoral edema, the clinical antiedema effects of bevacizumab can often be observed within days of the first dose. This effect tends to be persistent with ongoing therapy and can improve the likelihood of a successful dexamethasone taper.
      • Bevacizumab also finds selective use in the management of edema related to radiation necrosis.
  • Symptomatic plateau waves

    • Plateau waves are sustained pressure waves that normally occur within the brain and are caused by activities that transiently raise the ICP (eg, standing, sneezing, coughing). In the presence of a brain tumor, significant further increases in ICP can temporarily cut off cerebral perfusion, leading to loss of consciousness. The treatment of choice for such cases is glucocorticoids and neurosurgical intervention for cerebrospinal fluid (CSF) diversion, when appropriate.

2022-11-10

  • The level of SCC was high (2022-11-09 5.1 ng/mL) during the last half year.
  • According to 2022-11-01 MRI and 2022-10-26 CT, the disease has regressed in some areas while progressing in others. It appears to be heterogeneous, increasing the possibility of resistance.
  • As far as the active prescription is concerned, there is no problem.

2022-09-12

  • It is possible that this patient will require a transfusion of LPRBC due to HGB 6.7g/dL on 2022-09-12.
  • Newly developed oral candidiasis has been promptly managed with Mycostatin oral suspension (nystatin). The erythematous itchy papules that developed at the end of August 2022 are currently being treated with Cypromin (cyproheptadine).
  • Blood culture and urine culture were performed on 2022-09-09, but the results have not yet been released. Tapimycin (piperacillin + tazobactam) has been used as an empiric antibiotic since then.
  • Tube Feeding
    • Broen-C (bromelain + L-cysteine) is an enteric coated tablet and is not intended for use with a nasogastric tube. As of right now, there is no single ingredient bromelain item in stock, however, Actein (acetylcysteine 200 mg/pk) has also been prescribed and may act in part as cysteine.

2022-08-29

  • It is not recommended that Broen-C is peel-halfed or ground because it is enteric-coated.
  • There was a drop in blood pressure to 98/63 (2022-08-29 16:23), which should be noted.

701320382

230127

{drug interactions}

  • Pantoprazole prescribing information states no clopidogrel dose adjustments are required during coadministration with an approved dose of pantoprazole.

700412091

230119

[exam findings]

  • 2023-01-18 MRA - brain
    • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
    • IMP: Moyamoya disease. Acute infarct in right occipital lobe.
  • 2023-01-18 CT - brain
    • Indication: The patient said that he started to have blurred vision an hour ago, numbness in his left hand and left face, and he had this once before, a small stroke.
    • Findings
      • Small calcifications in pineal gland.
      • A small calcificaiton focus at left VA.
    • IMP: No evidence of intracranial lesion.
  • 2022-10-04 MRA - brain
    • Findings:
      • Focal subacute ischemic infarct over right posterior corona radiata (posterior water-shed area).
      • Old ischemic infarcts over both corona radiata (water-shed areas).
      • Engorgement of leptomeningeal vessels.
      • Total occlusion of right MCA and both ACAs. Near-total occlusion of left MCA. Markedly decreased flow of both MCA & ACA branches. Suggest check cerebral angiography.
      • Normal appearance of paranasal sinuses.
      • Normal appearance of both mastoids.
  • 2022-10-03 Neurosonology
    • Mild to moderate stenosis in right CCA bifurcation (35.8% stenosis).
    • Minimal atherosclerosis in right proximal ICA and ECA.
    • Smaller caliber with decreased flow in right VA, indicating possible right VA hypoplasia; adequate total VA flow.
    • Normal extracranial carotid, and intracranial cerebral, vertebral, basilar arterial flows.
  • 2022-09-11 ECG
    • Normal sinus rhythm
    • Nonspecific T wave abnormality
    • Prolonged QT
  • 2022-09-11 CT - brain
    • Findings
      • Low attenuation in right parietal region.
      • A retention cyst (2.1cm) in left maxillary sinus.
      • Degeneration and spondylosis of C-spine.
    • IMP:
      • Low attenuation in right parietal region.
  • 2022-08-30 C-spine AP and Lateral
    • Degeneration and spondylosis of C-spine.
  • 2017-09-15 KUB
    • Degeneration of bony structures.

701008324

230118

[tube feeding]

  • Harnalidge (tamsulosin, designed for extended release) 0.4mg PO QDAC should be replaced by Urief (silodosin) 8mg PO QD for tube feeding.

  • Concor (bisoprolol 5mg/tab) package insert recommends swallowing the medication with some liquid and not chewing it. For tube feeding, the simple suspension method (SSM) involves suspending tablets and capsules in warm water for decay and suspension prior to administration, which can be applied to the Concor tablets.

700754253

230116

{High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1}

  • diagnosis
    • 2022-08-31 admission
        1. Diffuse large B-cell lymphoma, unspecified site
        1. Pericardial effusion (noninflammatory)
        1. Essential (primary) hypertension
        1. Type 2 diabetes mellitus without complications
  • past history
    • diseases
      • Hypertension for more years with medication control
      • Type II diabetes mellitus with OHA control,
      • Hypertensive cardiovascular disease.
    • surgical operation
      • HIVD s/p op on 202201
  • family history
    • Mother: HTN, DM
    • No cancer history
  • exam finding
    • 2023-01-13 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-11-29 CT - abdomen
      • Moderate regression of prior seen lymphoma in paraaortic region as compare with CT study on 2022-07-26.
      • Suspected uterine myomas.
      • Prominent soft tissue densities along bilateral ovarian veins, varices or prominent lymph nodes? Suggest follow up.
    • 2022-11-26 ENT Hearing Test
      • Tymp RE type C, LE type A
      • ART bil absent
      • PTA:
        • Reliability FAIR
        • Average RE 58 dB HL, LE 53 dB HL
        • RE mild to moderately severe SNHL (sensory neural hearing loss)
        • LE normal to moderately seevre SNHL
      • SRT (speech recognition threshold)
        • RE 45 dB HL
        • LE 35 dB HL
      • WDS
        • RE 88 % at MCL
        • LE 92 % at MCL
    • 2022-10-26 ECG
      • Sinus tachycardia
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-08-22 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99.3 - 45.8) / 99.3 = 53.88%
        1. Normal AV/MV with no MR
        1. Concentric LVH, norma lLV wall motion
        1. Preserved LV and RV systolic function
        1. Mild PR, mild TR, normal IVC size
        1. Thickened peri-cardial fat
    • 2022-08-12 ECG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-08-12 CXR
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-08-05 Patho - peritoneum biopsy
      • Lymph node, retroperitoneum, CT-guide needle biopsy — High grade B-cell lymphoma
      • Sections show lymphoid tissue with infiltration of medium-size, monoclonal lymphocytes. Marked apoptosis and some small granulomas are seen.
      • The immunohistochemical stains reval CD3(-), CD20(+), CD10(+), BCL6(+), BCL2(-), Cyclin D1(-), cMYC(-), and MUM1(-). The Ki-67 is nearly 100%. The PAS and AFB special stains are negative.
    • 2022-08-04 Whole body PET scan
        1. The FDG PET findings are compatible with lymphoma involving multiple lymph nodes in the abdomen (on one side of the diaphragm).
        1. Mildly increased FDG uptake in the regions about the pericardium and pleura of left lower lung field. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
        1. Increased FDG uptake in a focal area in the left aspect of mandible. Dental problem may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
        1. Increased FDG accumulation in the colon. Physiological FDG accumulation is more likely.
    • 2022-08-03 CXR
      • Cardiomegaly is noted.
      • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
      • Left pleural effusion is found.
      • There is no evidence of destructive bone lesion.
    • 2022-08-01 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • Left pleural effusion is found.
    • 2022-07-28 CXR
      • Cardiomegaly is noted.
      • S/p central line catheter placement with its tip at Superior vena cava.
      • s/p chest tube placement at left hemithorax.
      • Increased pulmonary vasculature is found.
      • Faint aveolar opacity over LEFT LOWER LOBE is found.
    • 2022-07-27 Cell block
      • Positive for malignancy, compatible with malignant B-cell lymphoma
      • The smears and cell block show lymphocytes, reactive mesothelial cells and atypical individual lymphoid cells with enlarged nuclei, nucleoli and degenerative quality. Immunocytochemistry shows CK(-), CD20(+), CD3(-), Bcl-2(+, focal) and calretinin(-) for atypical cells.
      • According to cytomorphologic findings, it is compatible with B-cell lymphoma. Clinical correlation and confirmatory biopsy is advised for further evaluation.
      • The smears and cell block show lymphocytes, reactive mesothelial cells and many hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-07-27 CXR
      • Cardiomegaly is noted.
      • Status post endotracheal tube placement.
      • S/p central line catheter placement with its tip at Superior vena cava.
      • s/p chest tube placement with its tip at left hemithorax.
      • Increased pulmonary vasculature is found.
      • Faint aveolar opacity over right lower lobe and left lower lobe is found.
    • 2022-07-26 CTA - chest
      • Enlarged LNs (up to 3.6cm) at retroperitoneum.
      • Pericardial effusion.
    • 2021-12-23 SONO - kidney
      • CC: left flank pain
      • DX: left hydronephrosis
    • 2021-12-18 CT - abdomen, pelvis
      • Left lower ureter stones (up to 6.3mm) with obstructive uropathy. Grade 4 fatty liver.
    • 2021-11-23 Colonoscopy
      • Diagnosis
        • Colon polyp, transverse colon, s/p forcep polypectomy.
        • Mixed hemorrhoid
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
  • consultation
    • 2022-12-09 Infectous Disease
      • Q
        • Chest film disclosed Faint aveolar opacity over Right lower lobe is found. Patent airway is found.
        • MTB Infection Report showed Indeterminate,pending for PJP and Aspergillus Ag
      • A
        • CxR film showed no pneumonia.
        • IGRA inderterminate report.
        • Aspergillus Ag negative.
        • Recheck IGRA 3-4 months later.
    • 2022-11-16 Colorectal Surgery
      • Q
        • she complained of anal pain and fever also noted, highly suspect anal abscess, we need your expertise for further management        
      • A
        • S
          • The patient was consulted CRS for anal pain for weeks. No anal bleeding
          • She has the diagnosis of High grade B-cell lymphoma with left aspect of mandible, multiple lymph nodes in the abdomen and the regions about the pericardium and pleura of left lower lung field, Lugano stage IV, IPI score:3, High-intermediate risk group, PS:1
        • O
          • Abdomen: soft, no tenderness, no distended
          • DRE: no palpable mass, no tenderness, no abscess or fistula, no fissure or ulcer
          • Mixed hemorrhoids(+), mild-moderate without thrombus
        • A: Mixed hemorrhoids
        • P:
          • Alcos-anal oint bid use, Proctosedyl 1# supp HS for 2 weeks
          • Consider sigmoidoscopy if still anal pain or “rectal pain”
          • No surgical indication at present
          • Suggest CRS OPD follow-up
    • 2022-11-01 Infectious Disease
      • Q
        • Lab data showed WBC 240, CRP 3.76. Chest x-ray showed increased denisty in the left lower lung field. Under the impression of neutropenic fever, chemotherapy related she was admitted for further evaluation and treatment.    
        • After admission, empiric antibiotics with Cefepime and targocid was administered but fever with occasionally chills was still noted. the blood culture yielded Corynebacterium spp.
        • We need your expertise for antibiotics evaluation, thanks
      • A
        • This is a case of high grade B-cell lymphoma s/p C/T.
        • WBC: 2960/uL
        • Corynebacterium spp. in blood culture might be contamination.
        • Suggestion:
          • Please collect B/C when fever
          • Check CMV PCR, sputum PjP PCR, sputum culture and sputum TB culture/AFB stain
          • Agree with your current use of imipenem and targocid
          • Please adjust antibiotic according to culture results and clinical conditions.
    • 2022-08-04 Radiological Diagnosis
      • Q
        • A case of B-cell lymphoma of pericardial effusion,CK(-), CD20(+), CD3(-), Bcl-2(+,focal) and calretinin(-).
        • CT of chest to abdomen showed enlarged LNs (up to 3.6cm) at retroperitoneum.
        • we need your expertise for CT guide biopsy,thanks
      • A
        • According to the clinical condition and imaging findings, biopsy is indicated.
    • 2022-08-02 Hemato-Oncology
      • Q
        • This 71 year old female with HTN, dyslipidemia, and DM was within her usual healthy state till 2~3 weeks ago c/o progressive SOB, and DOE.
        • CT showed large amount of bloody pericardial effusion, impending cardiac tamponade. s/p urgent PP window. The effusion appeared bloody pattern, and also intra-op TEE showed there is a ill-defined mass around the RA.
        • CT showed a enlarged LN over retroperitoneal space.
        • cell block showed Malignant b cell lymphoma.
        • Therefore, we need your expertise to guide us for further treatment and workup
      • A
        • The 71 year old female presented with pericardial effusion with impendiac cardiac tamponade post PP window. The effusion cell block revealed B cell lymphoma. Imaging study also revealed enlarged LN over retroperitoneal space and ill-defined mass aroud RA were noted also.
        • Comorbidity: with HTN, dyslipidemia, and DM.
        • Please arrange port-A for her and I can take over this case for further study and treatment.
        • Thank you for your referral.
    • 2022-07-29 Rehabilitation
      • A
        • Assessment
          • Pericardial effusion post PP window on 20220726
        • Plan
          • Rehabilitation programs: Bedside PT cardiopulmonary rehabilitation programs + coach training
          • Goal: recondition, improve endurance and muscle strength
          • May arrange PM&R OPD follow-up for further phase 2 cardiac rehabilitation program as needed
    • 2022-07-26 Cardiac Surgery
      • A
        • for opinion regarding treatment options for large amount of pericardial effusion referered from OSH.
        • impending tamponade.
        • Previous Hx: HTN dyslipidemia, DM
        • CXR showed enlarged heart. compared to her CXR in 2021/12 there is significant interval change.
        • CT reviewed, showed large amount of pericardial effusion, heterogenous, suspect old hematoma? cause TBD.
        • also reported there is a enlarged LN at retroperitoneal space
        • S/S wise, she c/o progressive DOE during the past 2 weeks. and after previous trip 2 days ago, significant limitation of exercise was noted. and also reported decreased urine output.
        • LAB: WNL, no anemia,
        • SUGGESTION & PLAN:
          • I think we have reached a point where there is prudence in considering surgical intervention, PP window, given her developing symptoms.
          • PP window will be arranged. specimen will be sent for full workup. (pericardial-pleural window, PP window)
          • TEE (Transesophageal echocardiography, TEE)
          • SICU admission.
        • The patient and family are agreeable with my surgical consultation.
  • surgical operation
    • 2022-07-26 PP window via left minithoracotomy
      • pre-op CT and TEE showed large amount of pericardial effusion, also TEE found a heterogenous mass lying over RA, ~5cm in size.
      • 600cc bloody pericardial effusion was drained.
  • chemoimmunotherapy
    • 2023-01-05 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-12-12 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-10-17 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-09-22 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-08-31 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 + vincristine 1.4mg/m2 2mg 10min D2 + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
    • 2022-08-10 - rituximab 375mg/m2 600mg 8hr D1 + cyclophosphamide 750mg/m2 1200mg 30min D2 + liposome doxorubicin 30mg/m2 49mg 1hr D2 ( vincristine not available then ) + prednisolone 60mg/m2 5mg/tab 4# TID D2-6 (R-CHOP)
      • dexamethasone 4mg D1-2 + diphenhydramine 30mg D1-2 + acetaminophen 500mg D1 + palonosetron 250ug D2
  • G-CSF
    • Granocyte (lenogastin) CGRAN01
      • 2023-01-12 250ug QD SC D1-4 OPD
      • 2022-12-23 250ug QD SC D1-4 OPD
      • 2022-12-19 250ug QD SC D1-4 OPD
      • 2022-12-15 250ug QD SC D1-3 IPD 2022-12-08
      • 2022-10-20 250ug QD SC D1-3 IPD 2022-10-16
      • 2022-09-25 250ug QD SC D1-3 IPD 2022-09-22
      • 2022-09-09 250ug QD SC D1-3 OPD
      • 2022-08-22 250ug QD SC D1-3 OPD
    • G-CSF (filgrastim) CGCSF01
      • 2023-01-13 300ug QD SC D1-14 IPD
      • 2022-10-26 150ug ST SC IPD
      • 2022-10-26 150ug ST SC OPD
  • WBC
    • 2023-01-16 WBC 1.44 *10^3/uL
    • 2023-01-15 WBC 0.75 *10^3/uL
    • 2023-01-13 WBC 0.23 *10^3/uL
    • 2023-01-12 WBC 0.77 *10^3/uL
    • 2023-01-05 WBC 3.73 *10^3/uL
    • 2022-12-27 WBC 8.58 *10^3/uL
    • 2022-12-23 WBC 0.57 *10^3/uL
    • 2022-12-19 WBC 5.03 *10^3/uL
    • 2022-12-08 WBC 6.85 *10^3/uL
    • 2022-11-25 WBC 3.93 *10^3/uL
    • 2022-11-13 WBC 6.81 *10^3/uL
    • 2022-11-07 WBC 5.83 *10^3/uL
    • 2022-11-02 WBC 10.65 *10^3/uL
    • 2022-10-31 WBC 2.96 *10^3/uL
    • 2022-10-28 WBC 0.99 *10^3/uL
    • 2022-10-27 WBC 0.34 *10^3/uL
    • 2022-10-26 WBC 0.24 *10^3/uL
    • 2022-10-24 WBC 7.69 *10^3/uL
    • 2022-10-16 WBC 4.35 *10^3/uL
    • 2022-09-29 WBC 4.94 *10^3/uL
    • 2022-09-22 WBC 4.27 *10^3/uL
    • 2022-09-16 WBC 3.51 *10^3/uL
    • 2022-09-09 WBC 2.77 *10^3/uL
    • 2022-08-31 WBC 4.90 *10^3/uL
    • 2022-08-26 WBC 11.19 *10^3/uL
    • 2022-08-22 WBC 1.08 *10^3/uL
    • 2022-08-12 WBC 12.86 *10^3/uL
    • 2022-08-04 WBC 6.85 *10^3/uL
    • 2022-08-01 WBC 6.70 *10^3/uL
    • 2022-07-27 WBC 14.02 *10^3/uL
    • 2022-07-26 WBC 9.53 *10^3/uL
    • 2021-12-23 WBC 5.62 *10^3/uL
    • 2021-12-18 WBC 8.24 *10^3/uL
    • 2019-05-26 WBC 7.41 *10^3/uL

==========

2023-01-16

  • In late October 2022 and mid-Jan 2023, grade 4 neutropenia occurred approximately between 1-2 weeks after the patient’s receiving R-CHOP. As soon as neutropenia is identified, filgrastim and/or lenogastin has been appropriatedly administered. The WBC count returned to 1440 cells/uL on 2023-01-16.

  • Following a peak of 220mg/dL (2023-01-14 17:00), the patient’s serum glucose level returned to 114mg/dL (2023-01-16 05:17). It is not necessary to modify the patient’s antihyperglycemic agent immediately.

  • To treat neutropenic fever in this patient with hematologic malignancy, it is recommended to initialize an antipseudomonal beta-lactam agent, such as cefepime, meropenem, imipenem, or piperacillin-tazobactam. Since 2023-01-13, cefepime 2000mg IVD Q8H has been used.

  • Since the culture result has not been released, teicoplanin 600 mg IVD QD and fluconazole 300 mg PO QD have also been added in order to broaden the scope of coverage.

  • Based on 2023-01-13, 15, 16 lab data, there is no evidence that the patient’s liver or kidney function has declined. Therefore, no dose adjustment is required for the medication prescribed.

2023-01-06

  • Cimetidine may increase the serum concentration of metformin. The AUC of metformin increased 40% when combined with a single dose of cimetidine (400 mg) and increased 50% after treatment with cimetidine (400 mg twice daily) for 5 days in healthy volunteers. In an another study of 15 healthy volunteers, cimetidine administration decreased metformin renal tubular clearance by 18.7% to 48.2%, depending on the individual’s organic cation transporter 2 (OCT2) genotype. Participants carrying the OCT2 808G>T polymorphism had lower baseline tubular clearance of metformin and a correspondingly lower magnitude of interaction with cimetidine.

  • As the patient’s renal function still works (2023-01-05 Cre 1.08mg/dL, eGFR 53, BUN 14mg/dL), it is less likely to develop lactic acidosis, however, close monitoring might be necessary.

  • The historical time series lab data suggest that the roughly cyclic trough WBC level (neutropenia events) was frequently observed around 3 weeks following each R-CHOP treatment. It might be necessary to plan in advance for the possible neutropenia 3 weeks after this hospital stay in order to ensure the G-CSF is accessible to the patient during the Chinese New Year long holidays.

2022-09-01

  • Diagnosed T2DM. Glucose One Touch data: 228 (2022-08-31 17:05), 203 (2022-09-01 06:09), 256 (2022-09-01 11:12). No HbA1c records found.

  • This patient is taking self-carried gliclazide 15mg QD and metformin 500mg TIDCC.

  • Suggestion:

    • check HbA1c
    • add Forxiga (dapagliflozin 10 mg) 1# QD (preferred) or Trajenta (linagliptin 5 mg) 1# QD to achieve a fasting glucose level below 200 mg/dL.
    • please monitor for UTIs while the patient taking dapagliflozin.

701351712

230116

  • diagnosis - 20230111 discharge note
    • Malignant neoplasm of lower third of esophagus
    • Malignant neoplasm of prostate
    • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA status post percutaneous endoscopic gastrostomy and port-A catheter implantation on 2022-09-05
    • Prostatic adenocarcinoma, cT3bN1M1 cstage IVB
    • Chronic viral hepatitis B without delta-agent
  • past history - 20230103 admission note
    • Prostate cancer status post hormone therapy since 2022/03/16
    • Smoking (2 packs per day) and Drinking alcohol (over 1 bottled of whistsky) for 40 years, quited 20 years ago
    • Parkinsonism under follow up at our neurology outpatient department
    • Peptic ulcer disease status post medication about 20 years ago
    • Cervical herniated intervertebral disc status post surgery 30 years ago 
  • exam findings
    • 2023-01-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 13.4) / 93 = 85.59%
        • M-mode (Teichholz) = 85
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Poor echo window
    • 2023-01-04 CT - chest
      • Indication: Malignant neoplasm of lower third of esophagus Malignant neoplasm of prostate, T3(T_value) N:N3
      • Findings
        • Lungs: extensive, bilateral upper lobes predominant, centrilobular emphysema, in the lungs. minimal fibrotic change at RLL and several small granulomas at RUL.
        • Mediastinum and hila: interval disappearance an intraluminal heterogeneous tumor at distal thoracic esophagus compared with CT on 2022/08/31
          • small LNs in upper paratracheal spaces and A-P window. old calcified LNs in the visceral space and anterior prevascular space, may be sequela of previous TB infection.
        • Vessels: extensive calcified plaques of the LAD, and LCX, and right coronary arteries.
        • Aorta: normal caliber, moderate atherosclerotic change of aortic arch and descending thoracic aorta.
        • Pleura: Rt apical fibrothorax. moderate-sized Lt effusion.
        • Chest wall and visible lower neck: no LAP
        • Visible abdominal contents: s/p percutaneous gastrostomy.
          • regions of atrophic change of Lt kidney. multiple metastatic LAP at E-G junction, along the celiac axis, significant in regression. mild dilated extrahepatic bule duct.
          • normal appearance of gallbladder. unremarkable of the liver, spleen, both adrenal glands, pancreas, and Rt kidneys.
        • Visualized bones: no destructive lytic or blastic lesion.
      • Impression:
        • D/3 esophageal cancer T3N3, significant in regression compared with CT 2022/08/31
    • 2022-11-30 Patho - esophageal biopsy
      • Labeled as “esophagus”, biopsy — ulcer.
      • IHC stain: CK highlights regular mucosa.
      • Section shows bland squamous mucosa with abundant ulcer debris.
    • 2022-11-30 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal scar, C/W Hx of esophageal cancer, L/3, s/p biopsy
        • Reflux esophagitis LA Classification grade A
        • Hiatal hernia
        • Superficial gastritis
        • PEG in situ
      • Suggestion
        • Pursue the result of pathology report
    • 2022-10-25 Bladder sonography
      • PVR 290 mL
    • 2022-10-11, -10-04 CXR
      • S/P port-A implantation.
      • Emphysematous change of both lung field
      • Borderline cardiomegaly
      • s/p percutaneous endoscopic gastrostomy
    • 2022-09-12, -09-08 CXR
      • areas of hyperlucency and decreased lung vascular markings due to emphysematous change of both lungs upper lung predominance
      • mild enlarged cardiac silhoutte due to prominent cardiophrenic angle mediastinal fat pad
      • Coronary arterial calcification indicating CAD
      • Port-A catheter inserted into SVC via left subclavian vein.
      • small Lt pleural effusion?
    • 2022-09-07 ECG
      • Sinus tachycardia with Premature atrial complexes with Aberrant conduction
    • 2022-09-01 Whole body PET scan
      • Glucose hypermetabolism involving the lower portion of the esophagus, compatible with primary esophageal malignancy.
      • Glucose hypermetabolism in a subcarinal lymph node and possible some lymph nodes in the upper abdomen around the EG junction. Metastatic lymph nodes may show this picture.
      • Mild glucose hypermetabolism in bilateral pyriform sinuses. Inflammation is more likely. However, please correlate with other clinical findings for further evaluation and to rule out other possibilities.
      • Increased FDG accumulation in both kidneys, bilateral ureters and colon. Physiological FDG accumulaiton may show this picture.
    • 2022-09-01 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was moderately narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Oral and laryngeal mucosal candidiasis, diffuse.
    • 2022-09-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (21 - 7) / 21 = 66.67%
        • M-mode (Teichholz) = 65
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR and trivial TR
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
      • Dilated aortic root
      • A tumor size 3.97x3.2 cm external compress LA. It induce LA volume very smal, maybe low preload status.
    • 2022-08-31 Nasopharyngoscopy
      • Smooth oral cavity, oropharynx and nasopharynx
      • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
      • Post. pharyngeal wall protruding with smooth mucosal surface
    • 2022-08-31 Pulmonary Flow Volume Loop
      • Mild restrictive and mild to moderate obstructive pulmonary function impairment
    • 2022-08-31 CT - chest
      • Imaging Report Form for Esophageal Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-08-26 Patho - esophageal biopsy
      • Ulcerative tumor, from 35 cm below the incisors to EC Junction, biopsy — Squamous cell carcinoma
      • The specimen submitted consisted of three small pieces of esophageal tumor tissue measuring up to 0.4 x 0.3 x 0.1 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
      • Microscopically, the sections show a picture of squamous cell carcinoma, moderately differentiated of the esophageal tumor tissue characterized by some solid tumor cell nests show enlarged, hyperchromatic and pleomorphic nuclei infiltrate in the stroma with keratin formation. Besides, ulceration, bacteria (bacilli) and fungal spores and hyphae, which morphology compatible with candidiasis are also noted.
      • Immunohistochemical stains of CK(+), P63(+), P16(-), PSA(-) and P53 (+, focal) for tumor.
    • 2022-08-25 Esophagogastroduodenoscopy, EGD
      • Esophageal tumor with luminal narrowing, 35cm below incisor to ECJ, s/p biopsy
      • Whitish esophageal mucosa, 20cm to 35cm below incisor, suspected food coating
      • Deformed antrum and GU scar, antrum
      • Superficial gastritis
      • DU scar, bulb
    • 2022-08-03 Sinoscopy
      • Dysphagia, may be parkinsonism related
    • 2022-05-11 Bladder Sonography
      • PVR 100.09 mL
    • 2022-05-11 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2022-05-04 MRA - brain
      • Old cerebral and left cerebellar infarcts. Intracranial artherosclerosis. General brain atrophy.
    • 2022-03-23 Electroencephalography, EEG
      • This EEG study recorded background alpha rhythm (8-9 Hz) and beta activity.
      • No epileptiform discharge.
      • Please correlate with clinical features.
    • 2022-03-11 MRI - prostate
      • Imaging Report Form for Prostate Carcinoma
      • Impression (Imaging stage): T:T3(T_value) N:N1(N_value) M:M1(M_value) STAGE:IVB(Stage_value)
    • 2022-02-22 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture.
      • Increased activity in the lower portion of bilateral S-I joints. The nature is to be determined (degenerative change? other nature?). Please correlate with other clinical findings for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2022-02-10 Patho - prostate needle biopsy
      • Prostate, left and right, biopsy — Prostatic adenocarcinoma, Gleason grade 4+4 — 6 out of 6 tissues involved, occupying 50% of tissues
      • Microscopically, section shows Gleason-grade 4+4 adenocarcinoma composed of proliferation of crowded, fused and irregular neoplastic glands and infiltrative growth pattern. The neoplastic acini are lined by a single layer of epithelial cells and absent of basal layer. The epithelial cells are cuboidal and shows pleomorphic nuclei and hyperchromasia.
      • Immunohistochemical stain reveal AMACR(+) and 34BE12(-).
    • 2022-02-08 CXR
      • Post-op at C-spine.
      • No cardiomegaly.
      • Fibrotic infiltrates in right lung apex.
      • Thoracolumbar spondylosis.
    • 2022-02-08 ECG
      • Sinus rhythm with occasional Premature ventricular complexes
    • 2022-01-04 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2022-01-04 Bladder Sonography
      • PVR 179 mL
    • 2021-12-14 Transrectal Ultrasound of Prostate, TRUS-P
      • Prostate
        • Size of prostate: 4.77(T)cm x 3.94(L)cm x 4.83(AP)cm = 47.2cc
        • Size of adenoma: 4.18(T)cm x 3.19(L)cm x 3.14(AP)cm = 21.8cc
      • Diagnosis: Benign prostatic hyperplasia
    • 2021-12-14 Uroflowmetry
      • Q max: low
      • flow pattern: obstructive
    • 2021-12-08 Bladder Sonography
      • PVR 381 mL
      • TPV 41
      • irregular posterior wall
  • consultation
    • 2022-09-07 Gastroenterology
      • Q
        • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Further CCRT will be performed. Owing to anti Hbc positive, we need consult you for Entecarvir treatment before chemotherapy. Thanks a lot !
      • A
        • S
          • A case of newly diagnosis with squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
          • We are consulted of Entecarvir treatment before chemotherapy
          • Plan: schedule chemotherapy at next admission
        • O
          • HBsAg: Nonreactive (8/31)
          • Anti-HBc: Reactive (8/31)
          • Anti-HCV: Nonreactive (8/31)
          • Bilirubin total: 1.43 (8/31)
          • S-GOT/AST: 17 (8/30)
          • eGFR: 63.28 (8/30)
        • P
          • Baraclude 0.5mg (GFR >50 QD, GFR 30-49 QOD, GFR 15-29 Q3D, GFR<15 or HD QW)
          • HBV carrier (HbsAg(+) or HbsAg(-) but anti-Hbc ab(+))
          • Start the Baraclude treatment 1 week before chemotherapy until 6 months after the end of chemotherapy.
          • Due to patient scheduled chemotherapy at next admission, may arrange GI OPD for prescribe Entecarvir 1 week before starting chemotherapy
    • 2022-09-07 Radiatoin Oncology
      • Q
        • After admission, cancer work-up was completed. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA. We has well explaining with patient and his family about further treatment. Operation of port-A catheter implantation and PEG was done on 2022-09-05. Thus we need consult you for radiotherapy. Thanks a lot !
      • A
        • This 83-year-old male patient has Parkinsonism disease and prostate cancer T3bN1M1a, with pelvic LAPs, status post hormone therapy since 20220316. This time, he suffered from swallowing difficulty for 4 months. Biopsy was done on 2022/08/25 and showed squamous cell carcinoma. The cancer stage revealed squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA.
        • Due to he and his family refused surgery, CCRT is indicated. CT-simulation will be arranged on 20220908. Plan to deliver 45 Gy/ 25 fx to the whole esophagus and adjacent lymphatic drainage area (including bil. SCF). Then boost the esophageal tumor and LAPs to 54 Gy/ 30 fx. RT will start around 20220912. Thank you very much.
    • 2022-09-05 Hemato-Oncology
      • A
        • Impression
          • Squamous cell carcinoma of lower third of esophagus, cT3N3M0 cstage IVA
          • Parkinsonism disease and prostate cancer T3bN1M1a status post hormone therapy since 2022/3/16
        • Suggestion
          • Anti Hbc positive, consult GI doctor for entecarvir before chemotherapy
          • We will discuss with patient and family about further systemic treatment. Please consult RT for further evaluation.
    • 2022-09-01 Thoracic Surgery
      • Q
        • This is a 83-year-old man , newly diagnoised with esophageal cancer, T3N3M0, pending obstruction.
        • Apart from the melignancy, there’s no specific underlying diseases.
        • We’d like to consult to you, with your expertise, we will have a better idea of the futher treatment for the patient.
      • A
        • I have explained possible preoperative CCRT followed by esophagectomy and gastric tube reconstruction.
        • Due to the patient’s old age and emphysema, the patient’s family preferred conservative treatment. As a result, definitive CCRT is suggested.
        • I will arrange EUS to complete esophageal cancer staging. Also, I will perform port-A catheter implantation and PEG for further CCRT and enteral nutrition support.
        • I will take over this case. Thanks for your consultation.
    • 2022-08-31 ENT
      • Q
        • This is a 83 y/o male with past history of prostate cancer s/p ADT, peptic ulcer, Parkisonism, VC HIVD S/P. This time, he was admitted due to dysphagia for 4 month, which was further biopsied and proved to be squamous cell carcinoma. Staging survey is still ongoing and uncertain but will be done in the next few days. We need your expertise to evaluate the presence of head and neck cancer or not. Thank you.
      • A
        • Local finding via scope (PACS):
          • Smooth oral cavity, oropharynx and nasopharynx
          • Much saliva and sputum cumulation at bil. piriform sinus and esophageal inlet, cannot see mucosal surface well
          • Post. pharyngeal wall protruding with smooth mucosal surface –> C-spine HIVD?
        • No obvious abnormal lesion noted via this exam, but cannot see bil. piriform sinus and esophageal inlet mucosal surface well
        • For further confirmation may consider LMS tumor mapping with ETGA, if needed and without contraindication of general anesthesia (ETGA = endotracheal tube intubation general anesthesia)
  • SOAP
    • 2022-10-26 Hemato-Oncology
      • due to improved mood and body weight after increasing calorie and fluid, may consider C/T with biweekly HDFL 3 weesk later.
  • radiotherapy
    • 2022-09-13 ~ 2022-10-26 completed RT to the esophagus and adjacent lymphatic drainage area (including bil. SCF): 45 Gy/ 25 fx. The esophageal tumor: 48.6 Gy/ 27 fx.
  • chemotherapy
    • 2023-01-04 - leucovorin 300mg/m2 450mg 2hr + fluorouracil 300mg/m2 450mg 10min + fluorouracil 2400mg/m2 3600mg 46hr (HDFL for esophageal cancer)
      • dexamethasone 4mg
  • medication
    • Leuplin Depot (leuprolide) CLEUP03, CLEUP01
      • 2022-10-25 11.25mg Q3M SC OPD
      • 2022-08-03 11.25mg Q3M SC OPD
      • 2022-05-11 11.25mg Q3M SC OPD
      • 2022-04-13 3.75mg Q4W SC OPD
    • Androcur (cyproterone acetate 50mg/tab)
      • 2022-03-16 ~ 2022-03-23 1# BID OPD
    • Vemlidy (tenofovir alafenamide 25mg/tab)
      • 2023-01-11 ~ 2023-01-18 1# QDCC IPD
      • 2023-01-04 1# ST IPD

==========

2023-01-16

  • Compared to the image of 2022-08-31, the CT of 2023-01-04 showed significant regress of multiple metastatic LAP along the celiac axis. Considering that esophageal SCC was not treated with chemotherapy by the end of 2022, but prostate cancer has been treated with leuprolide for months, could there be a diminished likelihood that the LAP originates from the esophagus? <- this might not be the right question for the patient has completed radiotherapy during 2022-09-13 ~ 2022-10-26.
  • The CT of 2023-01-04 also revealed extensive calcified plaques in the LAD, LCX, and right coronary arteries. Cilostazol may be indicated. 2D transthoracic echocardiography 2023-01-05 revealed an LVEF of 85%, Cilostazol is not contraindicated.
  • The patient’s body weight decreased by 2 kg during the past week (2023-01-03 49.6kg, 2023-01-10 47.5kg), Nutritional assistance may be required on a more intensive basis
  • Gastrostomy tube feeding is possible for all oral medications listed on the active prescription.

2023-01-04

  • In accordance with ECOG PS 4, there has been no C/T for R/T. R/T has been completed as of 2022-10-26.
  • The patient’s body weight increased from 42.4 kg on 2022-08-30 to 51 kg on 2022-09-13. However, no additional weight gain has occurred since then, even a slight decrease to 49.3 kg on 2023-01-03.
  • Left ventricular end-systolic volume index = 7 / 1.45 = 4.8 mL/m2; LVEF 67% (2022-09-01). Cilostazol is not contraindicated.
  • Tube feeding is possible for all oral medications listed on the active prescription. The current medication does not pose any problems.

701355603

230116

{poorly differentiated squamous cell carcinoma of esophagu, cT3N2M0 stage III; poorly differentiated adenocarcinoma of stomach with liver metastases, cT3N0M1, stage IV}

  • exam finding
    • 2022-08-10 CT - chest
      • further decrease in size of several poorly enhanciing hepatic tumors up to 22mm as compared with previous CT on 2022/04/26
      • collapse of thoracic esophagus without obvious wall thickening or intraluminal enhancing nodule or mass based on CT exam.
    • 2022-07-19 ECG
      • Normal sinus rhythm
      • Leftward axis
      • Inferior infarct, age undetermined
      • Abnormal ECG
    • 2022-04-26 CT - lung/mediastinum/pleura
      • Findings
        • Lungs:
          • normal appearance of both lower lobes and RML.
          • mild centrilobular emphysema in both upper lobes.
          • Mediastinum and hila: no enlarged LN or mass.
          • a small intraluminal lesion at upper third of thoracic esophagus.
        • Vessels:
          • mild calcified plaques in left main coronary artery.
        • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
        • Central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace Lt-sided effusion.
        • Chest wall and neck: unremarkable.
        • Visible abdominal-pelvic contents:
          • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm compared with previous CT exam.
          • no obvious abnormal enhancing wall thickening or ulceration of stomach based on axial CT images
          • several small Rt renal cysts up to 5 mm.
          • normal appearance of gallbladder. unremarkable of the spleen, adrenal glands, and pancreas. no enlarged lymph node.
          • Extensive atherosclerotic change of the abdominal aorta and bilateral commonl iliac arteries.
        • Visualized bones: unremarkable.
      • Impression:
        • decrease in size of several poorly enhanciing hepatic tumors up to 30 mm as compared with previous CT on 2021/12/28
        • a small intraluminal tumor at upper third of thoracic esophagus and no visible sessile like intraluminal lesion at distal thoracic esophagus compared witH CT on 2021/12/28.
    • 2022-03-08 Spirometry and Bronchodilator Test
      • normal baseline without significant reversibility
      • FEV1/FVC = 79%, FVC = 156%, FEV1 = 151%
    • 2022-01-27 Patho - esophageal biopsy
      • Labeled as “35cm from incisor’, biopsy — poorly differentiated malignancy.
      • Section shows pieces of necrotic tissue, pieces of bland squamoius tissue, and neoplastic tissue with diffuse infiltrtion of nests of neoplastic basaloid cells with dysplastic polygonal shape neoplastic cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
      • IHC stains (S2022-1781):
        • CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma.
        • CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0).
    • 2022-01-27 Patho - stomach biopsy
      • Stomach, labeled as “high body, GC”, biopsy — poorly differentiated malignancy.
      • Section shows pieces of necrotic tissue, pieces of bland gastric glands tissue with diffuse infiltrtion of nests of markedly crushed neoplastic round blue cells. The differential diagnoses include, but not limited to, poorly differentiated squamous cell carcinoma, poorly differentiated adenosquamous carcinoma, poorly differentiated adenocarcinoma, and neuroendocrine carcinoma.
      • IHC stains (S2022-1782):
        • CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell.
        • CD56 (-), chromogranin (-): dis-favor neuroendocrine origin;
        • CK7 (-), CK20 (-), CDX-2 (-);
        • LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma.
        • Her2/neu: negative =0).
    • 2022-01-27 Miniprobe Endoscopic Ultrasound
      • Diagnosis
        • Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy
        • Gastric cancer, at least cT3, high body, GC, s/p biopsy
      • Suggestion
        • F/U patho
    • 2022-01-24 Patho - liver biopsy needle/wede
      • Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
      • The sections show poorly differentiated carcinoma, composed of a few viable large pleomorphic neoplastic cells in fibrous stroma with extensive tumor necrosis.
      • IHC shows: CK(+), CK7(-), CK20(-), and p40(-). Neither squamous nor glandular differentiation can be identified in the sections examined.
    • 2022-01-24 EKG
      • Left axis deviation
      • Low voltage QRS
    • 2022-01-20 CXR
      • Atherosclerotic change of aortic arch
    • 2022-01-20 KUB
      • Fecal material store in the colon.
      • Spondylosis of the L-spine is noted.
      • Disk space narrowing of L3-4 and L4-5 is suspected.
  • consultation
    • 2022-02-21 Radiation Oncology
      • Q
        • This 62 year old male has HBV, squamous cell carcinoma of esophagus suspected liver metastases, cT3N0M1 stage IV and adenocarcinoma of stomach suspected liver metastases, cT2N0M1 stage IV under FOLFOX for treatment since 2022-02. We need your help for RT assessment.
      • A
        • The patient’s history was reviewed and patient was examined.
        • S:
          • For radiotherapy due to esophageal and gastric cancer with liver metastasis.
          • PI: The patient was a case of poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0; and poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis. He suffered from body weight loss.
          • Family history: (father: gastric cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
          • Personal Hx: DM(-); HTN(+); HBV(+)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 0
          • PE: neck and bil SCF: neg; bilateral low limbs: no edema; no tenderness and knocking pain of the bone.
          • KUB (2022-01-20): Fecal material store in the colon. Spondylosis of the L-spine is noted. Disk space narrowing of L3-4 and L4-5 is suspected.
          • CXR (2022-01-20): Atherosclerotic change of aortic arch.
          • Pathology (S2022-01455, 2022-01-26): Liver, CT-guided biopsy — Poorly differentiated carcinoma with extensive tumor necrosis
          • Miniprobe endoscopic ultrasound for upper GI (2022-01-27): Esophageal cancer, at least cT3N2, 35 to 40cm from incisor, s/p biopsy; Gastric cancer, at least cT3, high body, GC, s/p biopsy
          • Pathology (S2022-01681, 2022-02-01): CK (diffuse strong +) and CK5/6 (+): compatible with poorly differentiated squamous cell carcinoma. CD56 (-), chromogranin (-), CK7 (-), CK20 (-), CDX-2 (-), Her2/neu: negative =0). DIAGNOSIS: Labeled as “35cm from incisor”, biopsy (B) — poorly differentiated malignancy.
          • Pathology (S2022-01682, 2022-02-01): CK (focal +) and CK5/6 (-): poorly differentiated carcinoma, NON-squamous cell. CD56 (-), chromogranin (-): dis-favor neuroendocrine origin; CK7 (-), CK20 (-), CDX-2 (-); LCA (focal +), CD3 and CD20 no monoclonality: dis-favor lymphoma. Her2/neu: negative =0). DIAGNOSIS: Stomach, labeled as “high body, GC”, biopsy (A) — poorly differentiated malignancy.
        • A:
          • Poorly differentiated squamous cell carcinoma of the esophagus, stage cT3N2M0.
          • Poorly differentiated carcinoma of the stomach, stage cT3N0M1, with liver metastasis.
        • P:
          • Radiotherapy is indicated for this patient with the following indicators: esophageal cancer, stage cT3N2M0.
          • Goal: palliation
          • Treatment target and volume: esophageal tumor, peripheral involved, and regional lymphatic area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, peripheral involved, and regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sister. They understand and would like to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-2-24
    • 2022-01-24 Gastroenterology
      • Q
        • This 62 year old male has history of 1) hypertention for two years under medication control 2) HBV without followed
        • The initial presentations were dizziness and abdominal fullness since Dec 2021. Therefore, he came to Chung Shan Medical University for help. EGD on 2021/12/08 which showed 1) Reflux esophagitis, LA grade A 2) esophageal poyps 1cam at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies. 3) Gastric ulcer, maligancy can not be rule out, GC side of upper body, s/p tissue biopies. EUS was performed on 2021/12/28 and biopsy of esophagus and stomach were sent. Pathology of esophgus proved squamous cell carcinoma and pathology of stomach proved adenocarcinoma. CT was performed on 2021/12/31 revealed 1) proven gastric and esophageal cancer 2) liver metastatic tumors. PET on 2022/01/11 showed cT3N0M1 disease for esophageal carcinoma and cT2N0M1 disease for gastric carcinoma. Owing to personal reason, he came to our ONC OPD for help.
        • Liver biopsy done on 2022/01/24 and pending, we need your expertise for further management.
      • A
        • Finding
          • 62M
          • EGD(2021/12/08):
              1. Reflux esophagitis,LA grade A
              1. Esophageal poyps 1cm at 35cm post lower esophagus suspected maligant polyp s/p tissue biopies.
              1. Gastric ulcer,maligancy can not be rule out, GC side of upper body, s/p tissue biopies
          • EUS(2021/12/28)
              1. Esophageal cancer, uT3N0
              1. Gastric cancer, EUS staging undefined (at least T2 according to the imaging pictures)
          • CT(2021/12/31)
              1. proven gastric and esophageal cancer
              1. Multiple liver metastatic tumors.
              • no signs of LC; arterial hypo-enhancement, favored mets
          • PET(2022/01/11)
              1. cT3N0M1 disease for esophageal carcinoma
              1. cT2N0M1 disease for gastric carcinoma
          • According to the previous report,
            • the endoscopy biopsy of the esophageal lesion: SCC, moderate differentiated
            • the endoscopy boipsy of the gastric lesion: poorly-differentiated adenocarcinoma in the specimen on 12/8, poorly-differentiated SCC in the specimen on 12/28
          • GI was consulted for further management
      • Impression:
        • Esophageal cancer, SCC
        • Gastric cancer, poorly-differentiated carcinoma; however, there was discrepancy between the two pathologic reports on 12/08 and 12/28 (SCC or adenocarcinoma)
        • Liver tumors, in favor of metastasis, s/p CT-guided biopsy
        • HBV carrier, without evidence of cirrhosis of liver
      • Suggestion:
        • Await biopsy result to determine the nature of liver tumor
        • Consider repeat EGD with EUS to re-staing and re-biopsy the gastric lesion
        • Check HbeAg, HBV DNA
        • Keep HBV prophylactic treatment
  • radiotherapy
    • 2022-03-07 ~ 2022-04-18 - 4500cGy/25 fractions (15 MV photon) of the esophageal tumor, peripheral involved, regional lymphatic, and 5040cGy/28 fractions of the esophageal tumor bed area.
  • chemotherapy
    • 2022-02-28 ~ undergoing - FOLFOX6

==========

2023-01-16

  • 2023-01-15 lab data
    • RBC 3.59 *10^6/uL
    • HGB 12.4 g/dL
    • MCV 104.2 fL
    • MCH 34.5 pg
    • MCHC 33.2 g/dL
  • MCV, MCH and MCHC
    • Anemia can be classified based on whether the MCV is low, normal, or elevated. A decreased MCV (usually less than 80 fL) indicates a defect in the synthesis of hemoglobin, which may be caused by an iron deficiency. And the presence of an increased MCV (>100 fL) is often attributed to asynchronous maturation of nuclear chromatin, although other factors may also contribute.

    • A low MCH is typically reflected in an enlarged area of central pallor in RBCs on the peripheral blood smear, which defines “hypochromia” on the blood smear. This may be seen in iron deficiency and thalassemia.

    • Very low MCHC values are typical of iron deficiency anemia, and very high MCHC values typically reflect spherocytosis or RBC agglutination.

  • The patient’s MCV and MCH were above normal limits, while his MCHC was within normal limits. There might be a lesser likelihood of an iron deficiency. Please confirm whether Foliromin (ferrous sodium citrate) is necessary.

2022-06-08

  • The survival outcomes of patients with synchronous primary esophageal squamous and gastric cancers were not worse than those of patients with isolated esophageal cancer or isolated gastric cancer. (Synchronous primary esophageal squamous cell carcinoma and gastric adenocarcinoma. https://www.nature.com/articles/srep13335 )
  • It was reported that cases of synchronous esophageal and gastric cancer were successfully treated by multimodal therapy or other methods. references:
  • The patient is able to tolerate the current FOLFOX6 regimen and lab data reported on 2022-06-07 were generally normal.

701458299

230116

[exam finding]

  • 2025-01-22 Bladder Sonography
    • PVR 4.73 mL
  • 2025-01-11 Sonography - urology
    • Findings
      • L’t Kidney :
        • Size: 11.3 x 4.97 cm
        • Cortex: 0.825 cm
      • R’t Kidney :
        • Size: 10.5 x 3.3 cm
        • Cortex: 1.18 cm
  • 2025-01-09 CT - abdomen
    • History and indication:
      • Malignant neoplasm of sigmoid colon
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S-colon cancer s/p operation.
      • Progression of liver metastases and peritoneal seeding with ascites.
      • Small LNs at retroperitoneum.
      • Some fluid collection in subcapsular region of right kidney. Right renal stone (1mm).
      • Splenomegaly.
      • Partial thrombosis of right portal vein.
    • IMP:
      • S-colon cancer s/p operation.
      • Progression of liver metastases and peritoneal seeding.
      • Partial thrombosis of right portal vein.
  • 2025-01-08 SONO - abdomen
    • Indication: Progression of jaudice
    • Symptoms: abdomen fullness
    • Findings
      • Liver:
        • Multiple tumors in bilateral lobes of liver. Large confluent tumor occupied in the right liver with calcifications in the central portion near the portal hepatis.
      • Bile duct and gallbladder:
        • No gallbladder stone. No CBD dilatation.
      • Portal vein and vessels:
        • Right portal vein was invisible, possibly compressed or invased by the tumors
      • Kidney:
        • Perirenal fluid accumulation (2.89*10.35 cm) with echo content of RK
      • Pancreas:
        • Some parts of pancreas blocked by bowel gas, especially head and tail
      • Spleen:
        • Splenomegaly
      • Ascites:
        • Moderate ascites
    • Diagnosis:
      • Liver tumors with calcifications, probable hepatic metastasis
      • Invisible right portal vein, possibly due to tumor compression or invasion
      • Perirenal fluid, r/o hematoma, RK
      • Splenomegaly, mild
      • Ascites, moderate
  • 2024-12-25 CXR
    • Consolidation in left lower lung.
  • 2024-12-19 SONO - abdomen
    • Findings
      • Liver:
        • Multiple nodules were noted at liver. Hepatic cyst was not identified during exam.
    • Diagnosis
      • Liver nodules, probable metastasis
      • Right portal vein compression
      • Mild to moderate ascites
      • Splenomegaly
  • 2024-12-09 SONO - nephrology
    • Findings
      • Size & Shape
        • R’t:10.5cm smooth
        • L’t:9.6cm smooth
      • Cortex
        • R’t: Echogenicity increased Thickness normal
        • L’t: Echogenicity increased Thickness normal
      • Pyramid
        • R’t: visible
        • L’t: visible
      • Sinus Not Dilated
      • Cyst None
      • Stone N
        • R’t: 0.97cm
      • Mass None
    • Interpretation:
      • Parenchymal renal disease, mild
      • UPJ stone with hydronephrosis, right
      • Ascites
  • 2024-12-02 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S-colon cancer s/p operation.
      • Stable of liver metastases and peritoneal seeding with ascites.
      • Small LNs at retroperitoneum.
      • Right renal cyst (0.8cm) and stone (1.0cm).
      • Splenomegaly.
      • R/O thrombosis of right portal vein.
    • IMP:
      • S-colon cancer s/p operation.
      • Stable of liver metastases and peritoneal seeding.
  • 2024-11-11 Abdomen - standing (diaphragm)
    • There are few amorphous calcifications in right lobe liver that are c/w colon cancer with liver metastases after correlate with CT.
    • A renal stone in right middle pole is highly suspected.
    • S/P metalic autosuture projecting at right lower abdomen.
  • 2024-08-27 CT - abdomen
    • With and without contrast enhancement CT of abdomen
      • Post-op at the colon.
      • Diffuse multiple liver tumors in both lobes of liver, could be due to liver metastasis.
      • Peritoneal nodule, could be due to carcinomatosis, stationary.
      • Liver cysts, up to 3.5cm in S8 liver.
      • Right renal stone.
      • Right upper ureteral wall edema/thickening.
      • There are stationary lymph nodes in paraaortic region.
    • Impression:
      • Post-op at the colon.
      • Diffuse liver metastasis, progression.
      • Peritoneal nodule, could be due to carcinomatosis, stationary.
      • Stationary lymph nodes in paraaortic region.
  • 2024-05-22 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/08/07.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, mild decreasing in size that are c/w multiple liver metastases S/P C/T with stable disease.
      • Prior CT identified a soft tissue nodule at right upper pelvis omentum and smudgy appearance of the middle omentum is noted again, stable in size that is c/w carcinomatosis S/P C/T with stable disease.
      • Prior CT identified right UPJ stone 9 mm is noted again, stationary.
      • S/P right hemicolectomy.
      • S/P LAR with autosuture retention over the rectum.
      • The spleen shows prominence in size (long axis: 11.5 cm).
    • Impression:
      • Multiple liver metastases and carcinomatosis S/P C/T show stable disease.
  • 2024-05-16 KUB
    • r/o a small right renal stone. Please correlate with sono.
  • 2024-05-14 KUB
    • Compression fracture of L1.
    • Radiopaque spots at RUQ and right abdomen.
  • 2024-02-29 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S-colon cancer s/p operation.
      • Stable of liver metastases and peritoneal seeding.
      • Small LNs at retroperitoneum.
      • Right renal cyst (0.8cm).
    • IMP:
      • S-colon cancer s/p operation.
      • Stable of liver metastases and peritoneal seeding.
  • 2024-02-02 SONO - abdomen
    • Diagnosis:
      • Liver tumor, right. Propable metastases
      • Suspected fatty infiltration of pancreas
      • Suboptimal examination of liver, especially the subcostal view due to poor echo window (disruption of the transmission of US waves by bowel gas and patient’s body habitus)
  • 2024-01-31 Pathology - duodenum biopsy
    • Duodenum, 2nd portion, near major papilla, biopsy — Duodenal ulcer
  • 2024-01-30 Esophagogastroduodenoscopy, EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, s/p CLO test
      • Duodenal ulcer, second portion, s/p biopsy
    • CLO test: Negative
  • 2023-11-17 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/08/07.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, mild decreasing in size that are c/w multiple liver metastases S/P C/T with stable disease.
      • Prior CT identified a soft tissue nodule at right upper pelvis omentum and smudgy appearance of the middle omentum is noted again, stable in size that is c/w carcinomatosis S/P C/T with stable disease.
      • Prior CT identified right UPJ stone 9 mm is noted again, stationary.
      • S/P right hemicolectomy.
      • S/P LAR with autosuture retention over the rectum.
      • The spleen shows prominence in size (long axis: 11.5 cm).
    • Impression:
      • Multiple liver metastases and carcinomatosis S/P C/T show stable disease.
  • 2023-10-24 KUB
    • Right UPJ stone is noted.
    • S/P metalic autosuture projecting at the rectum.
  • 2023-08-07 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/05/03.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, stable in size that are c/w multiple liver metastases S/P C/T with stable disease.
      • Prior CT identified mild peripheral IHDs dilatation on both hepatic lobes are noted again, stable in size.
      • Prior CT identified a soft tissue nodule at right upper pelvis omentum and smudgy appearance of the middle omentum is noted again, stable in size that is c/w carcinomatosis S/P C/T with stable disease.
      • Prior CT identified right UPJ stone 9 mm is noted again, stationary.
      • S/P right hemicolectomy.
      • S/P LAR with autosuture retention over the rectum.
      • The spleen shows prominence in size (long axis: 11.5 cm).
    • Impression:
      • Multiple liver metastases and carcinomatosis S/P C/T show stable disease.
  • 2023-05-03 CT - abdomen
    • Findings: Comparison: prior CT dated 2023/02/02.
      • Prior CT identified multiple metastases on both hepatic lobes are noted again, mild decreasing in size that are c/w multiple liver metastases S/P C/T with partial response.
      • Prior CT identified peripheral IHDs dilatation on both hepatic lobes are noted again, decreasing in size.
      • Prior CT identified a soft tissue nodule at right upper pelvis omentum and smudgy appearance of the middle omentum is noted again, decreasing in size that is c/w carcinomatosis S/P C/T with partial response.
      • Prior CT identified right UPJ stone 9 mm is noted again, stationary.
      • S/P right hemicolectomy.
      • S/P LAR with autosuture retention over the rectum.
    • Impression:
      • Multiple liver metastases and carcinomatosis S/P C/T show partial response.
  • 2023-02-02 CT - abdomen
    • With and without-contrast CT of abdomen-pelvis revealed:
      • S-colon cancer s/p operation.
      • Decreased size of liver metastases (up to 7.9cm) and peritoneal seeding (up to 0.7cm).
      • Small LNs at mediastinum and retroperitoneum.
      • Thyroid nodules (up to 0.7cm).
      • Right renal cyst (0.8cm).
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • S-colon cancer s/p operation.
      • Mild regression of liver metastases (up to 7.9cm) and peritoneal seeding (up to 0.7cm).
  • 2022-11-04 CXR
    • Atherosclerotic change of aortic arch
  • 2022-10-28 CT - abdomen
    • CC: jaundice, tea-colored urine and poor appetite for 2 weeks
    • histroy of sigmoid colon cancer with liver metastasis S/P operation on 2022/06/17 at MacKay Memorial Hospital
    • Indication: sigmoid cancer with liver metastasis
    • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
    • Findings:
      • There are multiple heterogeneous poor enhancing masses on both hepatic lobes that are c/w metastases. The largest one is measured 12.8 cm in size (the largest dimension).
        • In addition, both lobe portal vein show small size that are c/w passive compression and encasement by the liver metastases.
        • The peripheral IHDs on both lobes show dilatation that is c/w tumor compression.
      • There is ascites, a soft tissue nodule at right upper pelvis omentum, and smudgy appearance of the middle omentum.
        • Carcinomatosis is highly suspected.
        • Please correlate with ascites cytology.
      • There is right UPJ stone 9 mm causing minimal hydronephrosis but no evidence of delayed contrast excretion.
      • S/P right hemicolectomy.
        • S/P LAR with autosuture retention over the rectum.
      • There is mild right side Pleura effusion.
      • There are few enlarged nodes in paratracheal space. Follow up is indicated.
        • In addition, There are few poor enhancing nodules on both lobe thyroid that may be nodular goiter.
        • Please correlate with sonography.
    • Impression:
      • Multiple liver metastases on both lobes, causing total encasement of both lobe portal vein and dilatation of the peripheral IHDs.
      • Carcinomatosis is highly suspected.
      • Please correlate with ascites cytology.
  • 2022-10-27 SONO - abdomen
    • Diagnosis
      • Suspicious liver tumor with mucin production, both lobe
      • Hepatic cyst, right lobe
      • IHD dilation, left lobe
      • Ascites, mild
    • Suggestion
      • Please arrange other image to correlate clinical context
  • 2022-10-25 KUB
    • A calcified spot at RLQ.
  • 2022-10-25 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage.

[surgical operation]

  • 2024-12-11
    • Surgery
      • Right flexible ureteroscopic lithotripsy & double J stenting    
    • Finding
      • Right UO patent
      • A 1 x 0.6 cm yellowish stone at right renal lower moiety
  • 2022-11-04
    • Surgery
      • Port-A insertion, L’t after L’t cephalic vein exploration        
    • Finding
      • We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.   

[immunochemotherapy]

  • 2025-01-13 - ramucirumab 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 620mg NS 250mL 2hr + fluorouracil 2800mg/m2 4350mg NS 500mL 46hr (Cyramza + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-11-11 - ramucirumab 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 130mg D5W 250mL 2hr + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (Cyramza + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-10-21 - ramucirumab 400mg NS 250mL 1hr + oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (Cyramza + FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-09-23 - ………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-09-03 - ………………………….. oxaliplatin 85mg/m2 120mg D5W 250mL 2hr + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (FOLFOX)
    • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + NS 250mL
  • 2024-08-17 - ………………………………….. irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4170mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-07-20 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4170mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-07-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4170mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-05-31 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 267mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4160mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-05-09 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4250mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-04-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4210mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-03-12 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 610mg NS 250mL 2hr + fluorouracil 2800mg/m2 4270mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-02-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 267mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4160mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2024-01-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 268mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4180mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-12-28 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-12-06 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4200mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-11-02 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 265mg D5W 250mL 90min + leucovorin 400mg/m2 590mg NS 250mL 2hr + fluorouracil 2800mg/m2 4130mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-10-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 270mg D5W 250mL 90min + leucovorin 400mg/m2 600mg NS 250mL 2hr + fluorouracil 2800mg/m2 4215mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-09-18 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4100mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-08-28 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-08-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-21 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 260mg D5W 250mL 90min + leucovorin 400mg/m2 580mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-07-05 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-06-02 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-05-08 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-24 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-04-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 570mg NS 250mL 2hr + fluorouracil 2800mg/m2 4000mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-03-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-03-01 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-02-16 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-01-30 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-01-15 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2023-01-03 - bevacizumab 5mg/kg 200mg NS 100mL 90min + irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 560mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (Avastin + FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2022-12-19 - ………………………………….. irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2022-12-06 - ………………………………….. irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + palonosetron 250ug + NS 250mL
  • 2022-11-21 - ………………………………….. irinotecan 180mg/m2 250mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3900mg NS 500mL 46hr (FOLFIRI)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 3mg .. + NS 250mL
  • 2022-11-07 - ………………………………….. irinotecan 180mg/m2 190mg D5W 250mL 90min + leucovorin 400mg/m2 550mg NS 250mL 2hr + fluorouracil 2800mg/m2 3200mg NS 500mL 46hr (FOLFIRI. TBI 6.09mg/dL, irinotecan x 0.75, 5-fu x 0.8)
    • dexamethasone 4mg + diphenhydramine 30mg + atropine 1mg + granisetron 3mg .. + NS 250mL

==========

2025-02-11

Patient Summary

  • This 63-year-old female has advanced sigmoid colon adenocarcinoma with multiple liver metastases (T3N1M1a, Stage IVA), initially diagnosed in 2022-06-17, and has undergone extensive chemotherapy with FOLFIRI, FOLFOX, and targeted therapy (Bevacizumab, Ramucirumab). She also has chronic viral hepatitis B, hypoalbuminemia, and anemia.

  • Recent findings indicate progression of liver metastases and peritoneal seeding with worsening ascites (CT 2025-01-09). There is partial thrombosis of the right portal vein, contributing to hepatic dysfunction and worsening jaundice (TBI 4.48 mg/dL, 2025-02-10). Tumor markers CEA (3163.000 ng/mL, 2025-01-24) and CA-199 (947.000 U/mL, 2025-01-24) continue to rise, indicating disease progression. Symptoms include hand numbness, leg swelling (pitting edema 4+), and abdominal distension.

  • She was admitted for #4 cycle of Cyramza (ramucirumab) + FOLFOX chemotherapy but due to worsening performance status (ECOG 2) and poor albumin levels, chemotherapy was held while receiving albumin and Lasix (furosemide) for volume control.

Problem 1: Progressive Sigmoid Adenocarcinoma with Liver and Peritoneal Metastases

  • Objective:
    • Imaging: CT (2025-01-09) shows progression of liver metastases, peritoneal seeding, and partial thrombosis of the right portal vein.
    • Tumor markers: CEA 3163.000 ng/mL (2025-01-24), CA-199 947.000 U/mL (2025-01-24) - both increasing.
    • Symptoms: Abdominal distension, hand numbness, leg swelling, worsening jaundice.
    • Chemotherapy: Last cycle Cyramza (ramucirumab) + FOLFOX (2025-01-13), now chemotherapy held due to worsening condition.
  • Assessment:
    • Disease is progressing, as evidenced by rising tumor markers and worsening liver metastases and ascites.
    • The right portal vein thrombosis may be worsening hepatic congestion and impairing liver function.
    • Holding chemotherapy is reasonable given poor albumin levels (2.6 g/dL, 2025-02-10) and ECOG PS 2.
  • Recommendation:
    • Monitor albumin levels and hepatic function (AST/ALT, bilirubin) closely.
    • Consider anticoagulation if portal vein thrombosis worsens and bleeding risk is low.
    • Palliative approach should be discussed, as chemotherapy efficacy is uncertain given worsening liver function.

Problem 2: Jaundice and Hepatic Dysfunction

  • Objective:
    • Total bilirubin: 4.48 mg/dL, direct bilirubin elevated (2025-02-10).
    • AST 127 U/L, ALT 39 U/L, hypoalbuminemia (2.6 g/dL, 2025-02-10).
    • Imaging: Multiple liver metastases, peritoneal seeding (CT 2025-01-09).
  • Assessment:
    • Jaundice is likely due to worsening liver metastases, peritoneal carcinomatosis, and partial portal vein thrombosis.
    • No evidence of biliary obstruction on recent imaging (CT 2025-01-09, US 2025-01-08).
    • Hypoalbuminemia contributes to ascites and edema.
  • Recommendation:
    • Continue albumin supplementation.
    • Monitor for signs of hepatic encephalopathy (mental status changes, asterixis).
    • Consider palliative biliary drainage only if jaundice worsens and patient becomes symptomatic.

Problem 3: Volume Overload with Ascites and Edema

  • Objective:
    • Pitting edema 4+ (2025-02-10), progressive abdominal distension.
    • Hypoalbuminemia (2.6 g/dL, 2025-02-10).
    • Imaging: Moderate ascites, peritoneal seeding (CT 2025-01-09).
    • Lasix (furosemide) + albumin initiated.
  • Assessment:
    • Volume overload is likely secondary to hypoalbuminemia and progressive peritoneal carcinomatosis.
    • Diuresis with Lasix is working (urine output increased on 2025-02-11).
    • Paracentesis may be required if ascites worsens.
  • Recommendation:
    • Continue Lasix (furosemide) + albumin for 1 more day and reassess.
    • Consider therapeutic paracentesis if ascites worsens and respiratory distress develops.

Problem 4: Anemia

  • Objective:
    • Hemoglobin: 10.5 g/dL, HCT 32.0% (2025-02-10).
    • MCV 95.2 fL, normocytic anemia.
    • No active bleeding.
  • Assessment:
    • Likely anemia of chronic disease from advanced malignancy.
    • No acute blood loss.
  • Recommendation:
    • Monitor hemoglobin levels, transfuse if Hgb < 8.0 g/dL or symptomatic.
    • Consider transfusion, iron or erythropoiesis-stimulating agents if necessary.

Final Recommendations

  • Monitor hepatic function and consider palliative interventions (anticoagulation for portal vein thrombosis, biliary drainage if symptoms worsen).
  • Continue albumin and Lasix for volume control; consider paracentesis if ascites worsens.
  • Hold chemotherapy for now; reassess after albumin and symptoms improve.
  • Monitor anemia and transfuse if needed.
  • Discuss palliative care and long-term goals with the patient and family.

2023-01-16

  • As bilirubin total (0.67 mg/dL) and bilirubin direct (0.16 mg/dL) were both within normal ranges, no dose adjustment is required for irinotecan.

700169401

230113

  • exam findings
    • 2023-01-02 Patho - breast biopsy (no need margin)
      • Breast, right, core biopsy — invasive lobular carcinoma
      • Microscopically, it shows invasive lobular carcinoma composed of infiltrative neoplastic cells arranged in linear or single-file pattern in a sclerotic background. The tumor cells display uniform, small atypical cells with round nuclei and inconspicuous nucleoli and intracytoplasmic vacuolations.
    • 2022-12-31 CT - chest
      • Indication: Secondary malignant neoplasm of bone
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Diffuse lytic change at spine, long bones, bilateral ribs and pelvic bony structure is found. MM is compatible.
          • Minimal pleural effusion at bilateral basal lungs is found.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
          • Minimal soft tissue enhancement at right breast, r/o breast cancer.
          • Left breast enhanced nodule. Bilateral breast cancer is favored.
        • Visible abdomen:
          • Hypervascular heptic tumor at S6 of liver measuring 0.8cm in largest dimension is found. Hemangioma is favored.
          • The GB is well distended without soft tissue lesion
          • Soft tissue mass at myometrium measuring 4.1cm in largest dimension. Myoma is favored.
          • Right ovarian cyst measuring 3.05cm in largest dimension.
          • There is no ascites accumulation at abdominal cavity.
          • There is no evidence of destructive bone lesion.
          • Suggest clinical correlation
      • IMp:
        • Diffuse lytic change at bony structures. Bone meta is favored.
        • Suspected right breast cancer and left breast enhanced nodule. Bilateral breast cancer is favored. T2N0M1, Stage IV.
    • 2022-12-30 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in the maxilla, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, scapulae, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, bilateral humeri, femurs and possible the bone of right forearm.
      • IMPRESSION:
        • The scintigraphic findings suggest multiple bone metastases.
        • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture. Please correlate with other clinical findings.
    • 2022-12-29 Femur RT
      • There is osteolytic lesion in right femoral head, right intertrochanter, and bilateral pubic bone that may be bony metastases. Please correlate with CT.
    • 2022-12-29 CXR
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion?
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Bony metastases are suspected.
    • 2022-12-29 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — metastatic carcinoma.
      • IHC stains: GATA-3 (+); E-cadherin (-): in favor of invasive lobular carcinoma of the breast. ER: (+, 95%, stron gintensity), PR (+, 95%, strong intensity), Her2/neu: Negative (score=0), Ki-67: 10%.
      • Section shows piece(s) of bone marrow with 50% cellularity and marked desmoplasia. There is a predominant round blue neoplastic cell population arranged in file or trabeculae pattewrn.
    • 2022-02-24 Gynecologic ultrasonography
      • ut: 91x28mm
      • Myoma: 36x22mm, 37x31mm, 27x24mm, 19x11mm, 30x23mm,
      • EM: 19.5mm
      • ROV: 27x15mm
      • LOV cyst: 19x18mm
      • IMP:
        • suspected Mild Adenomyosis
        • suspected Lt Ovarian cyst
        • Multiple myomas
  • medication
    • Zoladex (goserelin 3.6mg/syringe) CZOLA01 (10.8mg/syringe CZOLA02)
      • L02AE03. L02AE Gonadotropin releasing hormone analogues (See also H01CA - Gonadotropin releasing hormones). A combi-pack containing leuprorelin (L02AE02) injection and bicalutamide (L02BB03) tablets indicated for prostate cancer is classified in L02AE51.
      • 2023-02-02 3.6mg SC Q4W
      • 2023-01-05 3.6mg SC Q4W
    • Nolvadex (tamoxifen citreate 10mg/tab) KNOLV01
      • L02BA Anti-estrogens
      • 2023-01-05 ~ 2023-01-20 1# BID
    • Kisqali (ribociclib 200mg/tab)
      • L01EF02. L01EF Cyclin-dependent kinase (CDK) inhibitors. L01E PROTEIN KINASE INHIBITORS This group comprises protein kinase inhibitors used for neoplastic diseases. Substances are classified according to their main target. Substances which are multi-targeted without a clear main target are classified in L01EX. Lipid kinase inhibitors (phosphatidylinositol-3-kinase (Pi3K) inhibitors) are classified in L01EM.
        • The recommended dose of KISQALI is 600 mg (three 200 mg film-coated tablets) taken orally, once daily for 21 consecutive days followed by 7 days off treatment resulting in a complete cycle of 28 days. KISQALI can be taken with or without food.
      • 2023-01-05 ~ 2023-01-25 #3 QD

[assessment]

  • The patient was with her husband, who might be the primary caregiver, at the time of my visit approximately 08:45 on 2023-01-13. I gave the patient the Kisqali (ribociclib) empty package along with the insert inside.
  • It has been explained to the patient that they should be alert for any signs of adverse reactions of the drug such as interstitial lung disease, pneumonitis, cutaneous adverse reactions, prolonged QT intervals, hepatobiliary toxicity, and neutropenia; and to comply with the doctor’s instructions and cooperate with the regular lab tests.
  • A small amount of redness and itching can be seen on the back of the patient’s neck, and there appears to be a small break in the mouth near the lips. Please follow up.
  • There might be an increased QT prolongation with concomitant use of tamoxifen and ribociclib. KISQALI is not indicated for concomitant use with tamoxifen.
    • In MONALEESA-7, the observed mean QTcF increase from baseline was > 10 ms higher in the tamoxifen plus placebo subgroup compared with the non-steroidal aromatase inhibitors (NSAIs) plus placebo subgroup. In the placebo arm, an increase of > 60 ms from baseline occurred in 6/90 (7%) of patients receiving tamoxifen, and in no patients receiving an NSAI. An increase of > 60 ms from baseline in the QTcF interval was observed in 14/87 (16%) of patients in the KISQALI and tamoxifen combination and in 18/245 (7%) of patients receiving KISQALI plus an NSAI.
    • Data from a clinical trial in patients with breast cancer indicated that tamoxifen Cmax and AUC increased approximately 2-fold following coadministration of 600 mg ribociclib.
  • Following coadministration of ribociclib with anastrozole, letrozole, exemestane, and fulvastrant, clinical trial data indicate that there are no clinically relevant drug interactions between ribociclib and these drugs.
  • Palbociclib and abemaciclib are two other kinase inhibitors that are compatible with aromatase inhibitors and both are available in the stock.
  • Please monitor ECG and electrolytes very closely if the combination of ribociclib and tamoxifen cannot be avoided.

700126908

230112

[tube feeding]

Current administration routes are IVD and TPN; there is no tube feeding at this time.

700510940

230110

{not completed}

  • exam findings
    • 2022-12-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (52 - 10) / 52 = 80.77%
        • M-mode (Teichholz) = 82
      • Normal LV filling pressure.
      • Normal LV and RV systolic function.
      • Degenerative changes of mitral and tricuspid valves and marked posterior mitral annulus calcification with mild MR; trivial TR.
    • 2022-12-20 SONO - abdomen
      • A hepatic cyst 8 mm in S6 is noted.
      • A renal stone 0.51 cm in right kidney is suspected.
    • 2022-11-21 ECG
      • Normal sinus rhythm
      • Right atrial enlargement
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-09-27 Patho - breast mastectomy with regional lymph nodes
      • Diagnosis
        • Breast, right, simple mastectomy (S2022-16451) — Invasive carcinoma. No special type. NST.
        • Resection margin: free.
        • Lymph node, right, sentinel lymph node biopsy with frozen section (F2022-454FSB) — free (0/1)
        • Lymph node, right, Non-sentinel lymph node biopsy with frozen section (F2022-454FSA) — fibroadipose tissue; no lymph node, no malignancy.
        • pT1a pN0 (if cM0); anatomic stage: IA; pathology prognostic stage: IB
      • Gross Description
        • Procedure
          • right, simple mastectomy (S2022-16451): 12 x 8 x 3 cm with intact skin: 8 x 3 cm. Nipple present not retracted. Grossly tumor-like lesion: 1.8 x 1.2 x 0.4 cm, located at > 1 cm from all side margins. (Microscopiccaly, invasive component is 1.5 x 1 mm).
          • Lymph node sampling (if lymph nodes are present in the specimen)
          • sentinel lymph node biopsy with frozen section (F2022-454FSB)
          • Non-sentinel lymph node biopsy with frozen section (F2022-454FSA)
        • Specimen laterality- right
          • Sections are taken and labeled as:
            • Tissue for frozen section: F2022-454 FSA: SLN; FSB.
            • Tissue for formalin fixation: S2022-16451A1: four side margin: A2-4: tumor with deep margin (inked); A5: nipple.
      • Microscopic Description
        • For Invasive Carcinoma
          • Histologic type:
            • Invasive carcinoma, no special type, NST
          • Size of invasive carcinoma (mm): largest focus: 1.5 x 1 mm
          • Histologic grade (Nottingham histologic score): grade II (score 6,7)
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Absent
            • Chest wall invasion deeper than pectoralis muscle: no chest wall tissue submitted.
        • For Ductal Carcinoma In Situ-
          • Tumor size (mm): largest focus 10 x 2 mm
          • Nuclear grade: 2
          • Architectural pattern: Comedo
          • Tumor necrosis: Present
        • Margins:
          • Negative, Closest margin (4 mm from deep margin)
        • Nodal status: Negative
          • No. examined: 1
          • No. macrometastases (>2 mm): 0
          • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
          • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received) - no presurgical (neoadjuvant) therapy.
        • Immunohistochemical Study: result of biopsy specimen: S2022-15368: ER (-), PR (-), Her2/neu: negative (0/1+), Ki-67 inedex: < 10%.
    • 2022-09-20 PET
      • Mild glucose hypermetabolism in a focal area in the right breast, compatible with breast malignancy of low FDG uptake.
      • Glucose hypermetabolism in the nasopharynx. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions. Inflammation may show this picture.
    • 2022-09-13 Patho - breast biopsy (no need margin)
      • Breast, right, core needle biopsy — Invasive carcinoma of no special type
      • Microscopically, section shows invasive carcinoma composed of infiltrative neoplastic nests arranged in ductal architecture and stromal fibrosis. The neoplastic cells have hyperchromatic nuclei, pleomorphism,and increased N/C ratio.
      • Immunohistochemical study demonstrates ER (-), PR (-), Her2/neu: negative (0/1+), p53( complete -, aberrant-type), p63(-), Ki-67 inedex: < 10%.
  • chemoimmunotherapy
    • 2022-12-14 - fluorouracil 500mg/m2 570mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 570mg 1hr
      • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg
    • 2022-11-22 - fluorouracil 500mg/m2 564mg 30min + liposome doxorubicin 30mg/m2 34mg 2hr + cyclophosphamide 500mg/m2 564mg 1hr
      • diphenhydramine 30mg + betamethasone 8mg + famotidine 20mg + granisetron 1mg

==========

2023-01-10

  • As of 2023-01-10, no neutropenia was detected in the lab result.
    • 2023-01-10 WBC 3.60 *10^3/uL
    • 2023-01-04 WBC 1.53 *10^3/uL

[duplicate note]

  • Please disregard this duplicate note generated by the system.

2023-01-05

  • Lab data on 2023-01-04 indicated that WBC was 1.53 K/uL. It was therefore decided to cancel the scheduled admission for FAC regimen treatment.

700736705

230110

  • diagnosis - 2023-01-10 discharge note
    • Squamous cell carcinoma of left mandibular gingiva, cT4aN2bM0, stage IVA
    • Infection of the left mandibular gingiva and bone
    • Agranulocytosis secondary to cancer chemotherapy
    • Encounter for antineoplastic chemotherapy
    • Essential (primary) hypertension
  • exam findings
    • 2022-11-23 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed one hot spot in the left aspecr of mandible, faint hot spots in both rib cages, and increased activity in the maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees, in whole body survey.
      • IMPRESSION:
        • One hot spot in the left aspecr of mandible, the natur eis to be determined (advanced cancer or other nature ?), suggesting PET scan for further investigation.
        • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, bilateral shoulders, elbows, right S-I joint, hips, and knees.
    • 2022-11-22 MRI - nasopharynx
      • Indication: Squamous cell carcinoma of left mandibular gingiva, cT2N2bM0, stage IVA. For tumor survery
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
        • Thin left anterior low gingiva tumor mass, extending to anterior mouth floor, and highly suspect of genioglossus muscle invasion, up to 15 mm measured on the coronal images.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • Multiple enlarged left level I-II LNs.
      • IMP:
        • Left low gingiva-mouth floor CA, T4AN2BM0 stage IVA.
      • Imaging Report Form for Oral Cavity Carcinoma
        • Impression (Imaging stage) : T:T4A(T_value) N:N2B(N_value) M:M0(M_value) STAGE:IVA (Stage_value)
    • 2022-11-22 SONO - abdomen
      • Tiny gallbladder polyp
    • 2022-11-09 Patho - gingival/oral mucosa biopsy
      • Lingual gingiva (from #31 to #34) , left, incisional biopsy — Squamous cell carcinoma, moderately differentiated
      • The sections show a picture of squamous cell carcinoma, composed of nests of moderately differentiated neoplastic squamous cells with pelomorphic nuclei and stromal invasion. Rare keratin formation is present. Mucosal ulcer and tumor necrosis can be found also.
    • 2022-11-08, -08-16, -07-26 KUB
      • Lumbar spondylosis.
    • 2022-08-02 SONO - kidney
      • Right renal stone
    • 2022-08-02 SONO - kidney
      • Right hydronephrosis
  • chemotherapy
    • 2023-01-06 - docetaxel 36mg/m2 60mg 1hr + cisplatin 36mg/m2 60mg 2hr + [leucovirin 90mg/m2 150mg + fluorouracil 900mg/m2 1500mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-27 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-13 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-12-06 - docetaxel 40mg/m2 70mg 1hr + cisplatin 40mg/m2 70mg 2hr + [leucovirin 100mg/m2 170mg + fluorouracil 1000mg/m2 1700mg] 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
  • medication
    • UFT (tegafur 100mg + uracil 224mg) KUFT01
      • 2022-11-29 ~ 2022-12-03 2# BID 20221129 OPD
      • 2022-11-25 ~ 2022-11-29 2# TID 20221121 IPD
    • Zinga (zinc gluconate 78mg/tab) KZING
  • zinc supplement related ref:
    • Hoppe C, Kutschan S, Dörfler J, Büntzel J, Büntzel J, Huebner J. Zinc as a complementary treatment for cancer patients: a systematic review. Clin Exp Med. 2021;21(2):297-313. doi:10.1007/s10238-020-00677-6
    • Abt E. Zinc Supplementation May Reduce the Effects of Oral Mucositis for Patients With Cancer Receiving Either Chemotherapy or Radiotherapy. J Evid Based Dent Pract. 2020;20(4):101494. doi:10.1016/j.jebdp.2020.101494
    • Chaitanya NC, Shugufta K, Suvarna C, et al. A Meta-Analysis on the Efficacy of Zinc in Oral Mucositis during Cancer Chemo and/or Radiotherapy-An Evidence-Based Approach. J Nutr Sci Vitaminol (Tokyo). 2019;65(2):184-191. doi:10.3177/jnsv.65.184

[assessment]

  • As of 2023-01-10, WBC is 2.87K/uL, neutrophil is 53%, and ANC is greater than 1500 cells/uL.

  • However, there is a trend downward in WBC count which should be noted.

    • 2023-01-10 WBC 2.87 *10^3/uL
    • 2023-01-06 WBC 7.22 *10^3/uL
    • 2023-01-03 WBC 3.43 *10^3/uL
    • 2022-12-31 WBC 5.11 *10^3/uL
    • 2022-12-27 WBC 5.52 *10^3/uL
    • 2022-12-17 WBC 3.83 *10^3/uL
    • 2022-12-13 WBC 4.57 *10^3/uL
    • 2022-12-10 WBC 8.21 *10^3/uL
    • 2022-12-04 WBC 7.02 *10^3/uL
    • 2022-11-21 WBC 6.61 *10^3/uL
    • 2022-08-02 WBC 5.71 *10^3/uL

700842151

230110

  • diagnosis - 20230109 admission note
    • Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection(LAR) on 2021/12/02
    • Chronic viral hepatitis B without delta-agent anti-Hbc: positive
  • past history
    • C3-6 spondylosis with spinal stenosis s/p laminoplasty on 2006-12-21.
    • Squamous cell carcinoma of upper third esophageal, T3N2M0, stage IIIB since Oct 2014, post Port-A on 2014-10-23, complete CCRT until Feb 2015. Post VATS esophagectomy with RLND, laparoscopic gastric tube reconstruction and feeding jejunostomy on 2015-03-09, ypT3N0M0, Stage IIB.
    • Esophageal stenosis s/p ballon dilation on 2015-05-21 and bilateral pleural effusion, chyothorax post close drainage on 2015-05-21.  
  • family history
    • There is no family history of diabetes, hypertension, mental diseases or asthma.
    • No members of the family with cancer.
  • exam finding
    • 2022-12-22 MRI - brain
      • Clinical information: Adenocarcinoma of rectosigmoid junction colon, cT3N2M0, stage: IIIB with with intussusception and partial obstruction status post Laparoscopic low anterior resection (LAR) on 2021/12/02
      • Findings:
        • Mild periventricular small vessel disease. NO acute ischemic infarct.
        • One old lacuna infarct over right internal capsule.
        • Prominence of cerebral cortical sulci, gyri atrophy and proportionate ventricular dilatation.
        • Left mastoiditis.
      • Impression:
        • No evidence of brain metastasis.
    • 2022-12-13 Chest PA + Lat LT
      • Few linear and nodular opacities projecting at bilateral middle lung zone are noted. please correlate with clinical condition and CT.
      • Atherosclerotic change of aortic arch
    • 2022-12-08 Peripheral Vascular Test - Vein, lower limbs
      • Conclusion:
        • Both arm MVO/SVC is normal
        • Left jugular vein is small and patency
        • There is no thrombus was seen in both upper arm
      • Suggestion
        • dupplex of vein could not scan proximal subclavian vein and central vein lesion, if consider central vein lesion, IVDSA or CT with contrast is indication.
    • 2022-12-07 CT - abdomen
      • History:
        • 20211111 CT: Adenocarcinoma of RS junction colon, cT3N2M0, stage: IIIB with intussusception and partial obstruction
        • 20211203 S/P LAR:pT3N2a(if cM0); stage IIIB
        • Past Hx: Eso. ca. s/p op,
      • MD CT (iCT 256 slices) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • S/P LAR with autosuture retention over the rectosigmoid junction.
        • S/P esophagectomy with gastric tube reconstruction via retrosternal space.
        • There are several hepatic cysts in both lobes and the largest one 1.4 cm in size at S5.
        • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
          • In addition, patchy areas of consolidations and ground-glass opacities in perihilar lungs, with tree-in-bud and centrilobular nodules in peripheral of RUL as well as subsegmental ground-glass opacity in superior segment of LLL, stationary.
        • Others
          • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
        • Prior CT identified several enlarged nodes in paratracheal space, right hilum, and subcarina space are noted again, mild decreasing in size that may be Metastatic nodes S/P C/T with partial response. please correlate with clinical condition.
    • 2022-12-06, -11-13 KUB
      • Spondylosis of the L-spine is noted.
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L3-4, L4-5 and L5-S1.
      • S/P metalic autosuture at the rectum.
    • 2022-12-06, -11-28, -11-25, -11-24 CXR
      • Atherosclerotic change of aortic arch
      • Nodular opacity projecting in the bilateral middle lung are suspected. Please correlate with CT.
    • 2022-10-26, -10-12 CXR
      • Atherosclerotic change of aortic arch
    • 2022-09-08 CT - abdomen
      • S/P colon operation.
      • S/P gastric tube reconstruction.
      • Liver cysts (up to 1.2cm). A hypodense nodule (0.4cm) at left hepatic lobe.
      • Some tiny nodules in bil. lungs (mild regression).
    • 2022-05-04 Patho - lung transbronchial biopsy
      • Lung, left, CT-guide biopsy —- chronic inflammation with interstitial fibrosis
      • Sections show alveolar tissue with active interstitial fibrosis and chronic inflammation. Foamy cell aggregates and alveolar cell hyperplasia is also present. No definite granuloma, or malignancy is found.
      • The immunohistochemical stains reveal CK(+), TTF-1(+), and CDX2(-). Please correlate with the clinical presentation.
    • 2022-05-04 CT Guide biopsy
      • LLL lung nodule, s/p CT-guided biopsy
      • Due to tree-in-bud appearance in CT scans, an infectious process (tuberculosis?) shoulde be ruled out.
      • Suggest clinical correlation
    • 2022-04-29 Whole body PET scan
      • Glucose hypermetabolism in the right middle lung, highly suspected cancer with lung mets, suggesting biopsy for investigation.
      • Glucose hypermetabolism in the left upper, left lower, and right upper lungs, the nature is to be determined (inflammation/infecion process, lung mets or others ?), suggesting further investigation and close follow-up.
      • Glucose hypermetabolism in bilateral pulmonary hilar lymph nodes, right mediastinal lymph nodes, right cervical lymph nodes and right infraclavicular lymph nodes, the nature is to be determined also (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      • Esophageal and colon cancers with right middle lung metastasis at least, by this F-18 FDG PET scan.
    • 2022-04-10 KUB
      • Degeneration of bony structures.
      • Stool retention in bowl.
    • 2022-04-08 CT - abdomen, pelvis
      • S/P LAR with autosuture retention over the rectosigmoid junction. There is no evidence of tumor recurrence.
      • There are several enlarged nodes in the paratracheal space, right hilum, and subcarina space. Metastatic nodes are suspected.
    • 2021-12-03 Patho - colon segmental resection for tumor
      • pathologic diagnosis
        • Large intestine, colon, rectosigmoid junction, laparoscopic LAR — Adenocarcinoma, moderately differentiated
        • Resection margins, proximal and distal: free
        • Lymph node, mesocolic, dissection— Positive for adenocarcinoma (4/20)
        • Pathology stage: pT3N2a(if cM0); AJCC stage IIIB
      • microscopic examination
        • Histology: Adenocarcinoma
        • Histology Grade: moderately differentiated
        • Depth of invasion: pericolorectal tissue
        • Angiolymphatic invasion: Present.
        • Perineural invasion: Not identified.
        • Discontinuous extramural tumor extension: Not identified
        • Circumferential (radial) margin of rectum: Uninvolved
        • Lymph node metastasis, mesocolic: Positive (4/ 20)
    • 2021-12-01 Sigmoidoscopy
      • advanced colorectal cancer, RS junction (25-28cm from AAV), s/p Tattoo injection
      • mixed hemorrhoid.
    • 2021-11-13 CT - chest
      • s/p esophagectomy with gastric tube reoncstruction.
      • Bilateral lung focal opacity, stationary. Previous inflammation is considered.
      • Intusussception of the sigmoid colon into rectum is found. Compatible with rectal cancer.
    • 2021-11-11 CT - abdomen, pelvis
      • Imaging stage: T3N2M0, stage IIIB
    • 2021-11-11 Patho - colon biopsy
      • RS junction, 25 cm to 28 cm AAV, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction. Mucosal ulcer is present.
      • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-11-09 Sigmoidoscopy
      • Advanced colorectal cancer, RS junction(25cm to 28cm AAV), s/p biopsy
      • Mixed hemorrhoid.
    • 2021-06-08 CT - chest
      • No recurrent esophageal tumor. post treatment related change and inflammatory process RUL and LLL, stationary.
    • 2020-12-22 CT - chest
      • No recurrent esophageal tumor. post treatment related change and inflammatory process (infectious bronchiolitis) RUL and LLL (new lesion).
    • 2020-05-12 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in lungs, stationary.
      • 2-vessels CAD.
    • 2019-11-03 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process (infectious bronchiolitis) in both lungs, slightly in progression.
      • 2-vessels CAD.
    • 2019-06-11 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, slightly in regression.
      • 2-vessels CAD.
    • 2018-11-29 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
    • 2018-06-05 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, stationary.
    • 2017-12-13 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs, in regression.
      • pneumonia in LLL?
    • 2017-06-14 CT - chest
      • No recurrent esophageal tumor; post treatment related change and inflammatory process in lungs.
      • pneumonia in LLL?
  • consultation
    • 2023-01-10 Radiation Oncology
      • Q
        • for R/O port-A obstruction
        • This 70-year-old man, a patient of colon cancer with lung mets S/P C/T. Owing to left port-A obstruction was noted. We need expertise to evaluate his condition thanks!
      • A
        • According to the clinical history and imaging findings, venography is indicated.
    • 2022-05-04 Radiation Oncology
      • A
        • This 69-year-old patient is a case of bilateral lung nodules, suspected pulmonary metastasis. CT-guided biopsy is indicated. Please chek platelet, PT, and aPTT before this procedure. We will inform the risk of insufficient specimen, pneumothorax, hemorrhage, infection, and air embolism to the patient and the family.
  • surgical operation
    • 2021-12-02 Laparoscopic LAR        
      • A large locally advanced tumor at RS-colon with intussusception and partial obstruction. Some turbid (30ml) ascites was found at pelvic floor. Marked edema of the colon wall and dilatation with much soft0liquid stool retention.    
      • The whole procedure was smooth. Blood loss was less than 30ml.    
      • Adhesion of two segment of small bowel with anterior abdomen wall was seen.    
      • Anastomosis was achieved using endo-GIA/black*2 + CDH-33 + TISSEEL. Air test is ok.    
      • A drain in pelvis near anastomosis.    
    • 2018-03-21
      • Diagnosis
        • Paralysis of vocal cords or larynx, unilateral , complete
      • PCS code
        • 66008A
      • Finding
        • Complete paralysis of left vocal cord.
        • Sculptured silicon mass was inserted to left paraglottic space for adduct left vocal cord
  • chemoimmunotherapy
    • 2023-01-10 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-12-19 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 690mg 2hr + fluorouracil 2800mg/m2 4850mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-11-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4800mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-09-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-09-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-08-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 320mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-07-27 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-07-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 310mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-06-24 - bevacizumab 5mg/kg 300mg 90min + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-06-09 - irinotecan 170mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-05-24 - irinotecan 160mg/m2 290mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4300mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + atropine 1mg + granisetron 2mg
    • 2022-04-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-04-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4980mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-03-23 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-03-08 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-02-21 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-02-07 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-01-17 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-01-03 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr

==========

2023-01-10

  • Vital signs are stable without extreme abnormalities in the 2023-01-09 lab results.
  • The suspected obstruction of the port-A is referred to Radiation Oncology for venography.
  • The patient has less yellowish sputum with his cough.

2022-12-20

  • The WBC level was elevated at 14K/uL on 2022-12-19, sputum was coughed up recently, and the scheduled chemotherapy was postponed due to a broncopnemonia event in late October 2022. Ciprofloxacin has been prescribed and the sputum culture is currently being conducted.

2022-12-07

  • The vital signs are stable. Lab data on 2022-12-06 showed no extreme abnormalities. A reduction in body weight of 5kg in the past six months (65.4kg 2022-12-07 <- 70.8kg 2022-06-08) might be caused by a lack of appetite.
  • The underlying condition of carrying HBV is appropriately managed with Vemlidy (tenofovir).

2022-04-25

  • The patient’s stage IIIB R-S colon cancer was treated with FOLFOX since 2022-01-03 following laparoscopic LAR on 2021-12-02.
  • On the CT images obtained on 2022-04-08, there were enlarged nodes in paratracheal space, right hilum, and subcarina space, which are suspected to be metastatic.
  • Lab results on 2022-04-22 showed liver and kidney functions, serum electrolytes, and blood cell counts were generally normal. However, the CRP level of 3.99 mg/dL and body temperature of 38.9 degrees were observed on 2022-04-23, which is currently being treated with tapimycin (piperacillin, tazobactam) 4.5gm IVD Q6H.

700954740

230110

{Recurrent left breast cancer with bilateral lung, right pleura, liver, bone and lymph node metastases, rcTxN2M1, stage IV}

  • lab data
    • CEA
      • 2022-08-02 CEA 24.80 ng/mL
      • 2022-07-12 CEA 35.48 ng/mL
      • 2022-04-19 CEA 224.79 ng/mL
    • CA153
      • 2022-08-02 CA153 643.7 U/mL
      • 2022-07-12 CA153 888.4 U/mL
      • 2022-06-23 CA153 1277.8 U/mL
      • 2022-04-19 CA153 4941.4 U/mL
    • CA199
      • 2022-06-23 4351.42 U/mL
    • Zinc, Zn
      • 2022-06-06 494 ug/L
      • 2021-11-15 432 ug/L
  • exam finding
    • 2023-01-09 SONO - chest
      • Bilateral pleural effusion (Left: moderate and Right: loculated minimal), post left pig-tail insertion.
    • 2023-01-08 CXR
      • Mass like lesion over RLL.
      • Bilateral pleural effusion.
      • Segmental atelectasis of both lower lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2023-01-03 SONO - chest
      • Right thorax: small amount pleural effusion.
      • Left thorax: moderate amount, serosanguinous pleural effusion s/p drainage of 550 cc pleural effusion.
    • 2022-12-27 SONO - chest
      • Bilateral thorax: small amount pleural effusion; thoracocentesis was not performed due to high risk of complications.
    • 2022-12-20 CXR
      • Rt greater than Lt bilateral pleural effusions and Rt lateral loculated effusion still visible
      • Osteoblastic metastasis in spine, Rt humeral head, and ribs
    • 2022-12-20, -12-06, -11-12, -10-25 CXR
      • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
      • Pleura effusion of bilateral costal-phrenic angle
      • S/P Mastectomy, left.
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-12-20 SONO - chest
      • Left thorax: minimal amount pleural effusion
      • Right thorax: small amount pleural effusion s/p drainage of 250 cc, yellowish pleural effusion.
    • 2022-12-15 SONO - chest
      • pleural effusion
      • Chest echography was performed first. The suitable intercostal space was selected and located.
      • Catheter was inserted with negative pressure smoothly.
      • Left side pleural effusion was drawn smoothly.
    • 2022-12-15 SONO - abdomen
      • Diagnosis: Liver metastasis
      • Suggestion: Regular ultrasound follow up
    • 2022-12-06 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 210 ml yellowish
        • Pleural tapping 16 #-needle Left side 440 ml straw-color
    • 2022-10-06 KUB
      • Osteoblastic change of L3 vertebral body and bilateral ilium are noted that are c/w bony metastases.
      • Hepatomegaly is suspected.
    • 2022-10-06 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 390 ml serosanguineous
        • Pleural tapping 16 #-needle Left side 320 ml bloody
    • 2022-10-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (78.1 - 18.7) / 78.1 = 76.06%
        • M-mode (Teichholz) = 76
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Mild MR, TR and PR
      • No regional wall motion abnormalities
      • Sinus tachycardia during echocardiography
    • 2022-09-28 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 350 ml bloody
    • 2022-09-13 SONO - chest
      • Special Procedure:
        • Pleural tapping 16 #-needle Right side 150 ml serosanguineous
        • Pleural tapping 16 #-needle Left side 270 ml bloody
    • 2022-08-23, -08-09, -07-22, -07-12 CXR
      • A nodular opacity projecting in the right lower lung is suspected. Please correlate with CT.
      • S/P port-A implantation.
      • Pleura effusion of bilateral costal-phrenic angle
      • S/P Mastectomy, left.
      • Borderline cardiomegaly
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-08-11 CT - chest
      • Findings
        • Chest:
          • Bilateral loculated effusion more on right hemithorax is found.
          • S/p port-A placement with its tip at Superior vena cava.
          • S/P mastectomy at left side.
        • Visible abdomen:
          • Patch like low density area is found at both lobes of liver. Liver meta is considered. In comparison with CT dated on 2022-03-08, the lesions regressed.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no ascites accumulation at abdominal cavity.
      • Imp
        • S/P mastectomy at left side
        • Liver meta. In regression.
        • Bilateral pleural effusion, suspected pleural meta.
        • Bone meta, please correlate with bone scan study.
    • 2022-08-05 Bladder Sonography
      • PVR 45.6 mL (postvoided residual)
    • 2022-08-05 Uroflowmetry, UFR
      • flow pattern: obstructive
    • 2022-07-29 Bladder Sonography
      • PVR 8.47 mL (postvoided residual)
    • 2022-06-29 SONO - chest
      • symptom: dyspnea
      • indication: suspected pleural effusion
      • clinical diagnosis: left breast cancer post MRM in 2008, with liver, bone and bilateral malignant pleural effusion
      • procedure: The patient was in sitting upright posture while the chest echography was performed using 3.75-mHz convex probe.
      • findings:
        • There was no pleural effusion and it was free and anaechoic. Limited LLL and left hemidiaphragm movement was found.
        • No active lung lesion of left lung field
          • Left-side of thorax
          • Right-side of thorax
            • There was minimal pleural effusion
            • RLL atelectasis
      • echo diagnosis:
          1. Pleural effusion, minimal, right
          1. Consolidation, RLL
    • 2022-06-23 CXR
      • S/P port-A implantation.
      • Pleura effusion of right costal-phrenic angle
      • S/P Mastectomy, left.
      • Borderline cardiomegaly
      • Osteosclerotic change at right humeral head is suspected.
    • 2022-05-31 CXR
      • S/P port-A implantation.
      • Pleura effusion of right and left costal-phrenic angle
      • S/P Mastectomy, left.
    • 2022-05-16 Chest PA erect view
      • regression of massive moderate Rt pleural effusion s/p pigtail drain placement
      • resolution of Lt pleural effusion s/p pigtail drain placement
      • port-A catheter inserted into SVC via Right internal jugular vein
      • osteolytic/osteoblastic metastasis in spine,
      • normal heart size
    • 2022-05-13 Chest Ultrasound
      • Echo diagnosis:
        • Right side massive pleural effusion with lung passive collpase, s/p 14Fr. pig-tail catheter insertion smoothly
        • Left side small to moderate amount pleural effusion, s/p 14Fr. pig-tail catheter insertion smoothly.
    • 2022-04-26 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2021/12/07, some of the previous bone lesions are slightly more evident, suggesting multiple bone metastases in slight progression.
    • 2022-04-25 Cell block
      • Adenocarcinoma, in favor of breast origin
      • Smears and cell block show clusters and single cells of adenocarcinomatous cells with large hyperchromatic nuclei, pleomorphism and high N/C ratio.
      • Immunohistochemical stain reveals Calretinin(-), TTF-1(-) and GATA3(+).
    • 2022-04-25 Chest Ultrasound
      • Echo diagnosis:
        • Bilateral pleural effusion (Left: trivial and Right: moderate), s/p right diagnostic and therapeutic thoracentesis.
    • 2022-04-24 EKG
      • Normal sinus rhythm
      • Nonspecific T wave abnormality
    • 2022-04-08 Cell block
      • Positive for malignancy
      • 50 cc orange turbid right pleural effusion
      • The smears and cell block show many individual or clustering of hyperchromatic atypical epithelial cells, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-03-08 Her-2/neu DNA in Situ Hybridization, DISH
      • Result of Her2 in Situ Hybridization
        • HER-2 (by in situ hybridization) — Negative (NOT amplified)
      • Method and Details
        • Number of observers: 1
        • Number of invasive tumor cells counted: 20
        • Average number of HER2 signals per cell: 2.05
        • Average number of CEP17 signals per cell: 1.9
        • HER2/CEP17 ratio: 1.08
        • Heterogeneous signals: Absent
        • Origin slide and block number: S2022-3847
        • Specimen: Formalin-fixed paraffin embedded tissue
        • Adequacy of sample for evaluation: Yes
        • Method of in situ hybridization: CISH (Ventana INFORM HER2 Dual ISH DNA Probe Cocktail Assay, Roche company)
    • 2022-03-08 Patho - soft tissue/mass/lipoma/debridement
      • Diagnosis
        • Skin, left neck, excision — Consistent with metastatic breast carcinoma — Seborrheic keratosis
      • Microscopic description
        • Section shows one piece of hyperkeratosis, papillomatous skin with keratin cysts and interdigitation of epidermis and papillary dermis. A dermal tumor, measuring 0.5 x 0.4 x 0.3 cm, composed of pleomorphic tumor cells is seen. The immunohistochemical stain reveals GATA3(+). The morphology and immunohistochemical stain are consistent with metastatic breast carcinoma. The tumor is 0.1 cm away from the unspecified closest resection margin.
      • Immunohistochemical Study
        • ER (Ab): Positive (95%, strong)
        • PR (Ab): Negative
        • Her-2/neu (Ab): Equivocal (2+)
        • Ki-67: 30%
    • 2022-03-08 CT - liver, spleen, biliary duct, pancreas
      • S/P left breast operation. Progression of liver metastases. Stable condition of bony metastases.
      • Bil. pleural effusion.
    • 2021-12-07 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2020/09/22, more new bone lesions are noted, suggesting multiple bone metastases in progression.
    • 2021-12-06 SONO - breast
      • S/P left mastectomy.
      • Right breast cysts and fibroadenomas.
      • Left chest wall nodule, suggest follow up.
      • BI-RADS2. benign finding
    • 2021-12-06 CT - liver, spleen, biliary duct, pancreas
      • S/P left breast operation. Progression of liver and bony metastases.
    • 2021-05-19 SONO - breast
      • Status post left mastectomy.
      • Tiny right breast fibroadenomas.
      • Suggest follow up.
      • BI-RADS category 2, Benign finding.
    • 2021-05-10 Gynecologic ultrasonography
      • EM 5.0mm
    • 2021-05-04 CT - abdomen, pelvis
      • S/P left mastectomy. Multiple liver metastasis, progression.
      • Multiple bone metastasis.
      • Right axillary lymph node, metastasis?
    • 2021-04-22 SONO - abdomen
      • Bil. liver metastases (up to 2.1cm).
    • 2021-02-24 SONO
      • Metastases on both hepatic lobes are suspected and the largest one 3.35 cm in S7. Please correlate with contrast enhanced dynamic CT.
      • A hepatic cyst 0.7 cm in S3 is noted.
    • 2021-02-24 CT - lung/mediastinum/pleura
      • Findings
        • Lungs: nondependent subpleural fibrotic change in LUL, related to treatment. several nodular opacities in medial basal segment of RLL and a tiny nodule in S6 of the same lobe. nodularity of interlobar fissures in Rt lung.
        • Mediastinum: no enlarged LN or mass.
        • Hila: no enlarged LN or mass.
        • Vessels: aorta: normal appearance, central pulmonary arteries: normal caliber.
        • Heart: normal in size of cardiac chambers.
        • Pleura: trace pleural effusion.
        • Chest wall: s/p Lt MRM< no LAP
        • Visible abdominal contents:
          • multiple metastatic hepatic tumors up to 3.2 cm (longest axial diamter).
          • normal appearance of gallbladder. gall bladder stones.
          • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, adrenal glands, pancreas, and kidneys. bile ducts: No dilatation.
          • no enlarged lymph node.
        • Extensive Mild atherosclerotic change of the abdominal aorta and bilateral common/external iliac arteries.
        • Visualized bones: lytic and blastic metastatic change in multiple vertebral bodies and left iliac wing..
      • Impression:
        • Lt brest ca s/p MRM with liver, bones, and lung metastases.
    • 2020-11-03 MRI - brain
      • No brain nodule or metastasis.
    • 2020-10-26 Patho - lymphnode biopsy
      • Lymph node, left neck, SONO guided core biopsy — Invasive carcinoma, no special type, NST.
      • IHC stains: ER (+, 95%, strong intensity), PR( +, 2-5%, intermediate intensity), Her2/neu: negative (score=1+), Ki-67(17%0), p53 (10%, weak intensity).
    • 2020-09-29 Whole body PET scan
      • Glucose hypermetabolism involving the left anterior upper chest wall, in multiple focal areas in bilateral lung fields, pleura and right lobe of the liver, in multiple bones and multiple lymph nodes as mentioned above, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
    • 2020-09-22 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2017/08/01, a new lesion in the the lower T-spine. Bone metastasis should be watched out. Please correlate with other imaging modalities for further evaluation.
      • No prominent change is noted in the lesions in the L3-5 spines. Degenerative spine disease may show this picture.
      • A new hot spot in the lateral aspect of left rib cage and increased activity in the right femoral shaft. The nature is to be determined (post-traumatic change? bone metastases? other nature?). Please correlate with other clinical findings and follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and bilateral knees, compatible with benign joint lesions.
    • 2020-09-15 SONO - abdomen
      • Left liver cyst (0.66x0.78cm). Gallbladder polyp (0.18cm).
    • 2020-07-17 Gynecologic ultrasonography
      • EM 5.4mm
    • 2020-03-05 Mammography
      • S/P left mastectomy. A benign calcification in right breast.
      • BI-RADS: Category 2: benign findings.-annual screening.
    • 2020-03-05 SONO - abdomen
      • Left liver cyst (0.64x0.76cm). Gallbladder polyp (0.35cm).
    • 2019-07-06 SONO - abdomen
      • Left liver cyst (0.63x0.68cm). Gallbladder polyp (0.22cm).
    • 2018-07-10 SONO - hepatobiliary
      • Small Gallbladder polyps.
    • 2018-04-17 SONO - hepatobiliary
      • A gallbladder polyp
    • 2017-08-01 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2015/12/15, the faint hot spots in bilateral rib cages are less evident, probably more benign in nature.
      • Mildly increased activity in the L3-5 spines. Degenerative spine disease may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and left knee, compatible with benign joint lesion.
  • consultation
    • 2022-02-21 Metabolism and Endocrinology
      • Q
        • This 58-year-old post-menopausal woman has left breast cancer (pT1cN0M0,stage:I) s/p MRM on 2008/11/14 at CGMH Linkou branch. The pathology showed invasive ductal carcinoma ,size 1.9 cm, Gr2, LN (0/41); ER(+):60%, PR(+):5%, HER2/neu(+++), FISH(-), pT1cN0M0, stage:IA.
        • She has adjuvant chemotherapy of CEF (Fluorouracil + Epirubicin + Endoxan) 6 course since 2008-12 ~ 2009-05 at CGMH Linkou branch. Then she kept Hermone therapy of Tamoxifen 10 mg/tab 1# po BID. Due to progression high level CEA 6.024 ng/ml (2012/09/10) -> 5.891 ng/ml (2012/12/10) -> 7.484 ng/ml (2013/03/4).
        • After physical examination showed no palpable nodule or mass over bil. breast with axilla regions.
        • Whole body PET scan showed
            1. a glucose hypermetabolic lesion in the left axillary region, A metastatic lesion should be considered frist;
            1. Mild glucose hypermetabolism in two right upper neck level II lymph nodes, Inflammatory process is more likely on 2013/03/26.
        • Then we arranged FNA for left axillar LN on 2013/04/05. The pathology showed positive for malignant tumor.
        • She underwent removal of left axillary soft tissue and implantation-Port A (Right) on 2013/04/26 (rTxN1M2, stage IIA).
        • Salvage chemotherapy with Taxotere *4~6 course for every three weeks was prescribed since 2013/05/13 ~ 2013/09/06. AI treatment since 2013/09/23.
        • Multiple bone mets by whole body bone scan and mulpital lung, pleural, right liver and LN mets by PET were noted on 2020/09/29.
        • CDK4/6 inhibit with Kisqali + AI since 2020/12/07. Patient hold CDK4/6 inhibit with Kisqali + AI since 2021/05 due to seeking detox therapy on her own. But tumor marker elevated.
        • After explant to patient. PIK3CA mutation (+). Faslodex + piqray was suggest.
        • Under impression of recurrent left breast cancer with multiple bone, lung, pleural, right liver and LN mets, stage IV. She was admitted for piqray 150mg 2tab QD PO.   
        • Due to hyperglycemia, we change metformin 0.5# BID to GalvusMet 1# BID and add on Tresiba 8U HS since 2022-02-11. But nausea and general weakness after GalvusMet. she hold medicine by herself. Now we need your help for medicine suggestion. Thank you so much!!
      • A
        • O:
          • F/S QDAC around 80-110
          • F/S HS around 300-400 (getting higher)
        • P:
          • Taper Tresiba to 6U HS (If F/S HS < 140, take some snack before sleep)
          • Add repaglinide 1# TIDAC, also add Trajenta 1 tab QD
    • 2022-02-12 Metabolism and Endocrinology
      • S:
        • This 58-year-old female, with past history of left breast CA s/p MRM, was admitted due to recurrent left breast cancer. We were consulted for blood sugar control.
      • O:
        • BH: 151 cm, BW: 52.7 Kg
        • Diet: normal diet
        • Medication in OPD: Metformin 0.5# BID
        • Medication during hospitalization: RI 8U ST on the night of 2022-02-10
        • Na: 137, K: 4.3
        • AST/ALT: 41/49
        • BUN/Cr: 19/0.86 (eGFR: 71.78)
        • F/S: 376/419/321
        • HbA1c: 6.1 -> 8.8
        • Urine ACR: unavailable
        • OPH OPD: no record
      • A:
        • Type 2 DM (Alpelisib and megesterol induced)
      • Suggestions:
        • Switch metformin 0.5# BID to GalvusMet 1# BID
        • Add on Tresiba 8U HS (If F/S HS < 140, take some snack before sleep)
        • Megesterol is recommended to drink a small amount regularly
        • Urine ACR can be collected in OPD later
        • Meta OPD F/U
  • surgical operation
    • 2022-03-08
      • Surgery
        • left neck tumor excision
      • Finding
        • left neck tumor 1cm
      • Procedure
        • IVGA
        • fusiform incision
        • tumor excision
        • wound closure
    • 2019-01-11
      • Malignant female breast neoplasm, NOS
      • PCS code 62009C
        • Excision of muscle or deep tissue tumoror, deep foreign body
  • chemotherapy
    • 2022-09-28 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-09-21 - Halaven (eribulin) 1.4mg/m2 2.22mg 5min
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-08-31 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
      • dexamethasone 4mg + metoclopramide 10mg
    • 2022-08-11 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-07-21 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-06-29 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-06-07 - Nolbaxol (docetaxel) 60mg/m2 90mg 1hr
    • 2022-05-16 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-04-29 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-03-14 ~ 2022-05-09 - Afinitor (everolimus 10mg QD). Everolimus is an inhibitor of a kinase called mammalian target of rapamycin (mTOR)
    • 2022-03-14 ~ 2022-05-09 - Aromasin (exemestane 25mg QD)
    • 2021-03-08 ~ 2022-04-11 - Zometa (zoledronic acid, bisphosphonate) 11 cycles.
    • 2021-03-08 ~ 2022-03-07 - Faslodex (fulvestrant) 11 cycles.
    • 2020-12-07 ~ 2021-05-24 - Kisqali (ribociclib 400mg QD). There were 3 CDK4/6 inhibitors - palbociclib, ribociclib, and abemaciclib - that have been approved for HER2 metastatic breast cancers, usually in combination with hormone therapy.
    • 2017-02-20 ~ 2021-04-05 - Femera (letrozole 2.5mg QD)
    • 2013-09-23 - aromatase inhibitor
    • 2013-05-13 ~ 2013-09-06 - Taxotere (docetaxel) 4~6 course for every three weeks
    • ~ 2012? - Tamoxifen 10mg BID
    • 2008-12 ~ 2009-05 - CEF (Fluorouracil + Epirubicin + Endoxan)

[note]

  • Systemic Therapy for ER- and/or PR+ Recurrent Unresectable or Stage IV (M1) Disease - HER2-Negative and Postmenopausal or Premenopausal Receiving Ovarian Ablation or Suppression (Breast Cancer - NCCN Evidence Blocks - Version 2.2022 - December 20, 2021, p74)
    • Preferred Regimens
      • First-Line Therapy
        • Aromatase inhibitor + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
        • Selective ER down-regulator (fulvestrant, category 1) + non-steroidal aromatase inhibitor (anastrozole, letrozole) (category 1)
        • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) (category 1)
      • Second- and Subsequent-Line Therapy
        • Fulvestrant + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) if CKD4/6 inhibitor not previously used (category 1)
        • For PIK3CA-mutated tumors, see additional targeted therapy options
        • Everolimus + endocrine therapy (exemestane, fulvestrant, tamoxifen)
    • Other Recommended Regimens
      • First- and Subsequent-Line Therapy
        • Selective ER down-regulator
          • Fulvestrant
        • Non-steroidal aromatase inhibitor
          • Anastrozole -Letrozole
        • Selective estrogen receptors modulator -Tamoxifen
        • Steroidal aromatase inactivator -Exemestane
    • Useful in Certain Circumstancesf
      • Subsequent-Line Therapy
        • Megestrol acetate
        • Estradiol
        • Abemaciclib

==========

2023-01-10

  • The patient refused chemotherapy and began receiving Maruyama vaccine treatment (one shot by the end of 2022), an alternative therapy with few English publications (ref: PubMed, Maruyama vaccine official web site: https://www.nms.ac.jp/sh/vaccine/).
  • In most patients with persistent or recurrent symptomatic pleural effusions, repeat therapeutic thoracentesis under ultrasound guidance is generally the first-line option. Multiple sonography-guided pleural effusion tappings have been performed since 2022 with an increase in frequency over time.
  • Albumin has been prescribed appropriately to keep fluid from leaking out of blood vessels. For the purpose of removing fluid, furosemide and spironolactone have also been prescribed. Slight hyponatremia (133 mmol/L 2023-01-09) represents a relative excess of water in relation to sodium in this patient.

2022-10-13

  • Despite the use of Radi-K (potassium gluconate, since 2022-10-04) in conjunction with spironolactone (since 2022-10-10), lab data on 2022-10-13 show serum potassium at 2.7mmol/L still below normal (3.5~5.1). It is recommended to shift oral Radi-K from TID to QID or add a potassium supplement injection to prevent low K from becoming symptomatic.

2022-09-01

  • It is anticipated lower heart rate after taking Concor (bisoprolol). The patient’s heart rate increased to 107 (2022-09-01 08:48) from 86 (2022-08-31 16:38), which should be monitored.
  • The current blood pressure is normal (117/73). Concor should be held temperately if hypotension is observed.
  • Recent CXRs showed borderline cardiomegaly. It is possible to replace Concor with Coralan (ivabradine 5mg) 1# BID if the diagnosis of heart failure is confirmed (to lower the heart rate).

2022-07-22

  • The patient’s blood pressure decreased to 101/57 at 13:20 2022-07-22. If the patient’s blood pressure continues to drop and he becomes symptomatic, please DC Concor temporarily.

2022-06-30

  • The patient has recurrent breast cancer with lung and bone mets characterized by HR(+, ER+, PR-, IHC 2022-03-08) and HER2(-, DISH 2022-03-08) and is receiving docetaxel treatment since early May 2022. Prior to current regimen, mTOR kinase inhibitor everolimus and endocrine therapy exemestane have been employed during mid March to early May of 2022.
  • The chest sonography and X-ray performed in June 2022 indicated lung consolidation as well as osteosclerosis of the bones which should be kept on track in order to prevent them from becoming more symptomatic.
  • CA153 is decreasing, which is a relatively positive sign (2022-06-23 1277.8 U/mL <- 2022-04-19 4941.4 U/mL).
  • Lab data reported on 2022-06-23 indicated that liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. During this hospitalization, both TPR and BP were stable.

2022-06-08

  • CBC, WBC DC, liver and kidney function, blood electrolytes were gross normal according to lab results on 2022-05-31.
  • Low zinc level (494 ug/L, normal 700~1200ug/L, 2022-06-06) is treated with zinc gluconate currently.

700715492

230109

{colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB}

  • diagnosis
      1. Malignant neoplasm of ascending colon
      1. A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB
      1. Type 2 diabetes mellitus without complications
      1. Gout, unspecified
      1. Hyperuricemia without signs of inflammatory arthritis and tophaceous disease
      1. Bipolar disorder, in partial remission, most recent episode manic
      1. Unspecified dementia without behavioral disturbance
      1. Chronic viral hepatitis B without delta-agent
      1. Essential (primary) hypertension
  • lab data
    • 2022-07-08
      • Anti-HBc Reactive
      • Anti-HBc-Value 6.99 S/CO
      • Anti-HBs 473.10 mIU/mL
      • HBsAg Nonreactive
      • HBsAg Value 0.00 IU/mL
      • Anti-HCV Nonreactive
      • Anti-HCV Value 0.10 S/CO
  • exam findings
    • 2023-01-06 Tc-99m MDP whole body bone scan
      • Increased activity in some middle and lower T-spines. Compression fractures and/or degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • A hot spot in the sternum, multiple hot spots in bilateral rib cages and increased activity in the right humeral head. The nature is to be determined (post-traumatic change? other nature?). Please correlate with the clinical history and follow up bone scan for further evaluation.
      • Mildly increased activity in the right wrist, compatible with benign joint lesion.
    • 2023-01-01 KUB plain film and L-spine lateral view
      • Compression fracture of T12.
    • 2023-01-01 CXR
      • Ground glass opacities in bil. lungs.
      • Compression fracture of T12.
    • 2022-12-26 CT - abdomen
      • Abdominal CT with and without enhancement revealed:
        • Hepatic low density lesions are found at right lobe liver up to 4.9cm in largest dimension. Liver meta is considered. In comparison with CT dated on 2022-09-29, the lesions enlarged.
        • Laminated gallstone is found.
        • Visible chest
          • Nodular lesions at both lower lobes is found. Lung meta is considered. In progression.
          • S/p port-A placement with its tip at Superior vena cava
          • Borderline heart size is found.
      • Imp:
        • Ascending colon cancer, stationary in size and extension.
        • Bilateral lung and right lobe liver meta, in progression.
    • 2022-12-24 Nasal bone
      • Fracture of the nasal bone is found.
      • Regional soft tissue swelling is identified.
    • 2022-12-24 Nasopharyngoscopy
      • Scope: bil nasal cavity blood clot s/p L/T
      • smooth NPx, oropharynx, larynx
      • suspect erosion over ant. nasal cavity due to trauma
    • 2022-12-23 Bladder Sonography
      • PVR 52 mL
    • 2022-09-29 CT - abdomen
      • With and without-contrast CT of abdomen-pelvis revealed: Protocol: 4mm slice thickness, axial scan and coronal reconstruction
        • Mild regression fo A-colon cancer and liver/lung metastases.
        • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
        • Gallbladder stones (1.5cm, 3.7cm).
      • IMP:
        • Mild regression fo A-colon cancer and liver/lung metastases.
    • 2022-06-29 CXR
      • Multiple nodules at bil. lungs.
    • 2022-06-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (75 - 18) / 75 = 76.00%
        • M-mode (Teichholz) = 76
      • Indeterminated LV filling pressure and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis and mild aortic root calcification.
      • Prominent epicardial and pericardial fat.
    • 2022-06-20 CT - abdomen
      • Findings
        • Wall thickening of cecum and proximal A-colon with adjacent fat stranding and reginal LAP. Multiple liver and lung metastases.
        • Right renal angiomyolipoma (1.7cm). Bil. renal cysts (up to 1.0cm).
        • Gallbladder stones (1.5cm, 3.7cm).
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2b(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2022-06-20 KUB
      • Presence of radiopaque gallbladder stones.
      • Degeneration and spondylosis of L-S spine.
    • 2022-06-17 Patho - colon biopsy
      • Intestine, large, ascending colon, biopsy — adenocarcinoma
      • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands lined by high-grade dysplastic cells and focal stromal invasion with desmoplasia. The tumor cells display hyperchromatic nuclei, pleomorphism, high N/C ratio and mitotic figures.
      • IHC stain — EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+)
    • 2022-06-16 ECG
      • Left axis deviation
      • Nonspecific T wave abnormality
    • 2022-06-16 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 3.5mm
    • 2022-06-16 Colonoscopy
      • Diagnosis
        • Highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization
        • Mixed hemorrhoids
      • Suggestion
        • OPD F/U
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2022-06-16 Pulmonary bronchodilator test
      • Moderate restrictive ventilatory impairment with significant bronchodilator response suspected poor effort related
      • please correlated with clinical condition
    • 2021-12-23 KUB + L-spine Lat
      • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
      • Presence of spondylolisthesis at L4/5, grade I.
    • 2021-09-22 CT - brain
      • IMP: General brain atrophy. Hydrocephalus.
    • 2021-09-07 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Inferior infarct , age undetermined
      • Possible Anterior infarct , age undetermined
      • Abnormal ECG
    • 2018-05-05 SONO - abdomen
      • Diagnosis
        • fatty liver, moderate
        • incomplete exam of liver gallstone
      • Suggestion
        • suboptimal exam of liver because of subcutaneous fat and liver fatty change
        • suggest F/U
    • 2018-02-24 KUB
      • Degenerative change of the thoracic and lumbar spine with spurs formation/scoliosis and narrowed intervertebral disc spaces.
      • Presenc of radiopaque oval or round density in right upper abdomen, c/w gallbladder stone(s).
    • 2018-01-22 KUB
      • Presence of radiopaque gallbladder stones.
    • 2017-02-15 T-spine AP + Lat.
      • s/p VP in the T7 vertebral body with bone cement extravasation.
    • 2017-01-05 T-spine AP + Lat.
      • mild scoliosis of the T-spine.
      • s/p VP in the T7 vertebral body
  • consultation
    • 2023-01-06 Psychosomatic Medicine
      • Q
        • This 70-year-old woman patient suffered from Stool OB (LIA) = Positive and Occultblood (LIA) > 999 ng/mL on 2022/05/31. No abdominal pain, tarry stool passage and body weight loss was noted. Colonoscopy on 2022/06/16 showed highly suspected colon cancer, A-colon, s/p biopsy, s/p tattoo and clipping for localization and mixed hemorrhoids. Pathology showed adenocarcinoma, IHC stain - EGFR(+), PMS2(+), MLH-1(+), MSH-2(+), MSH-6(+). Abdominal CT on 2022/06/20 showed A-colon cancer with lung and liver metastases, T4aN2bM1b, stage IVB. Tumor mark on 2022/06/21 with CA-199 showed 15056.5 U/ml, CEA showed 995.6 ng/ml. 2D echo on 2022/06/23 showed 1.Indeterminated LV filling pressure and impaired RV relaxation. 2.Normal LV and RV systolic function. 3.Mild aortic valve sclerosis and mild aortic root calcification. 4.Prominent epicardial and pericardial fat. Port-A catheter insertion on 2022/06/29.
        • Palliative chemotherapy with FOLFIRI (Campto 150mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) on 2022/07/12(C1D1), 2022/07/22(C1D15), 2022/08/05(C2D1), 2022/08/17(C2D15), 2022/08/30(C3D1).2022/9/29(C4D1).2022/10/12(C4D15).2022/10/26(C5D1).2022/11/9(C5D15).2022/11/23(C6D1).2022/12/7(C6D15).2022/12/21(C7D1).
        • Target therapy with Avastin(5mg/kg) was given on 2022/08/30(C1), 2022/09/13(C2), 2022/9/29(C3), 2022/10/12(C4), 2022/10/26(C5), 2022/11/9(C6), 2022/11/23(C7), 2022/12/7(C8), 2022/12/21(C9).
        • Followed up CT was performed on 2022/12/26 revealed Ascending colon cancer, stationary in size and extension. Bilateral lung and right lobe liver meta, in progression.
        • The patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to mentioned symptoms, she came to our hospital for help.
        • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management.
        • We had explained the current condition to family and patient still had depressed mood, we need your expertise for further management, thanks 
      • A
        • Acute depressive state
          • suspected adjustment reaction with depressive features
          • suspected bipolar disorder, current episode depressed
        • Symptoms and course:
          • This is a 70 y/o female patient admitted under the impression of urinary tract infection, colon cancer with lung and liver metastasis. We were consulted for fer depressed mood.
          • According to the patient and her family, she recently was informed of the progression of her own disease; therefore, she showed more prominent depressed mood and also transient suicide ideation without plan.
          • She claimed that she would got occasional negative ideation, preoccupied over the condition of her cancer, with hopeless andhelpless feelings; while she also said that she could try to cope with the feelings by sharing them with her family.
          • She denied current suicide ideation or plan.
        • Suggestion:
          • Give depakine 200mg/tab 1# QD + 500mg/tab 1# HS, add zyprexa(5mg) 1# HS
          • Suicide risk assessment: low to moderate, transient idea, family support (+), no organised plan
          • Provide emotional catharsis, and psychoeducation for suicide risk prevention
          • Monitor her mood condition during admission, prevent suicide
          • Arrange PSY OPD f/u
    • 2023-01-04 Hemato-Oncology
      • Q
        • A case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy, the last biochemotherapy with Avastin plus FOLFIRI was administered on 2022/12/21
        • This time, the patient present urinary frequency with interval of 1-2 hour since about one week ago. Urgency urinary incontinence was noted, but no stress urinary incontinence. She also had nocturia every 0.5-1 hour at night with small amount urine. Bilateral flank pain developed for days. Otherwise, she denied cough, rhinorrhea, short of breath, diarrhea, abdominal pain, or chest tightness. Due to entioned symptoms, she came to our hospital for help.
        • At ER, her vital signs revealed BP:151/83mmHg; HR:100bpm; BT:36.2 degrees Celsius; RR:16/min; GCS:E4V5M6. Lab data revealed leukocytosis, normocytic anemia, elevated CRP and lactic acid. Urine analysis showed pyuria and bacteuria. CXR revealed ground glass opacities in bil. lungs and compression fracture of T12. Under the impression of urinary tract infection, the patient was admitted for further evaluation and management. Owing to patient requested, we need your expertise for further management, thanks
      • A
        • This 69 year old woman is a case of Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis s/p palliative chemotherapy. She was admited due to UTI. We may take over if you agree. Thanks for your consultation.
    • 2023-01-03 Family Medicine
      • Q
        • Her family prefered palliative care and decided DNR.
        • We need your expertise to evaluate for palliative caer, sincerely thanks.
      • A
        • 69-year-old female, Ascending colon cancer, T4aN2bM1b, stage IVB, with progressing bilateral lung and right lobe liver metastasis
        • Consciousness clear, ECOG 3
        • We will arrange hospice combine care and follow her condition
        • Indication: Ascending colon cancer
        • Plan: Combined Hospice Care
    • 2022-12-24 ENT
      • A
        • Epistaxis after falling down, mild NO,
          • the patient claimed that she fainted before falling
        • O:
          • Scope: bil nasal cavity blood clot s/p L/T
          • smooth NPx, oropharynx, larynx
          • suspect erosion over ant. nasal cavity due to trauma
        • A:
          • Bil epistaxis, anterior
        • Plan:
          • s/p local treatment
          • Allegra, transamin if no contraindication
          • Education done, if bleeding again, compression ant. nose for at least 20 mins with head downward and mouth open, if still bleeding, back to hosspital soon
          • ENT OPD f/u
  • chemoimmunotherapy
    • 2022-12-21 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-12-07 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-23 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-09 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-12 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 48 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-09-29 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-09-13 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 240mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
    • 2022-08-30 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 230mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-2
    • 2022-08-17 - irinotecan 120mg/m2 200mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-08-05 - irinotecan 90mg/m2 150mg 90min + LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1
    • 2022-07-22 - LV 400 mg/m2 650mg 2hr + 5-FU 400 mg/m2 650mg 10min + 5-FU 2400 mg/m2 4000mg 46 hr (standard)
      • dexamethasone 4mg + metoclopramide 10mg
    • 2022-07-12 - LV 300 mg/m2 500mg 2hr + 5-FU 300 mg/m2 500mg 10min + 5-FU 2000 mg/m2 3300mg 46 hr (75% dose)
      • dexamethasone 4mg + metoclopramide 10mg

==========

2023-01-09

  • The results of the culture have not yet been released.
  • UTI is currently managed with empirical Cefepime 2g Q8H (not for ESBL risk; ESBL = extended spectrum beta-Lactamase).
  • If VRE or MRSA are suspected (eg, based on prior isolates), vancomycin (for MRSA) or daptomycin or linezolid (for VRE) might be added.

[tube feeding]

  • The patient-carried Depakine Tablet (valproic acid 500mg) package insert instructs “not to crush or chew the tablet.”
  • To replace Depakine Tablet 500mg HS, it is recommended to use Depakine Solution (sodium valproic 200mg/mL, 40mL/bt, available currently in stock) 2.5mL HS.
  • As the liver and kidney function of the patient have not declined (2023-01-05 and 2023-01-09 lab data), there is no need to adjust the dose.

2022-09-30

  • After adding irinotecan to the regimen in early Aug 2022, the levels of CEA and CA199 have been cut in half since the last month indicated that the treatment was working.
    • 2022-09-16 CEA 1085.5 ng/ml
    • 2022-08-19 CEA 1873.6 ng/ml
    • 2022-07-26 CEA 1895.2 ng/ml
    • 2022-09-16 CA-199 6337.5 U/ml
    • 2022-08-19 CA-199 15268.5 U/ml
    • 2022-07-26 CA-199 15964.6 U/ml
  • The patient with type 2 diabetes is currently on Galvus Met (vildagliptin (DPP4i) + metformin (biguanide)) with blood sugar levels over 180 mg/dL as recorded on 2022-09-29 and 2022-09-30.
  • The initialization of SGLT2i Canaglu (canagliflozin 100mg) QDAC, Forxiga (10mg) QD, or Jardiance (empagliflozin 25mg) QD might be an option in the event of consecutive 2 or 3 data points over 200 mg/dL.

2022-08-31

  • 2022-08-19 CEA 1873 ng/mL and CA199 15268 U/mL remained high. 2022-08-30 lab data indicated grossly normal liver and kidney function, serum electrolytes, and CBC.
  • The patient has been diagnosed with hypertenstion. The blood pressure records during this hospitalization were 113~138 / 59~75, not excessive for the time being. This is the first time the patient receiving bevacizumab, which is associated with a high incidence of hypertension (24% to 42%), so close monitoring is recommended.

2022-07-25

  • 2022-06-23 2D transthoracic echocardiography showed: 1. Indeterminated LV filling pressure and impaired RV relaxation; 2. Normal LV and RV systolic function; 3. Mild aortic valve sclerosis and mild aortic root calcification. The initial dose of LV + 5-FU was set at 75% of the standard dose.
  • The patient has been prescribed Depakine (valproate) 700mg daily by our psychosomatic medicine OPD for her bipolar disorder since Jan 2017. Well-tolerated.
  • The patient has been prescribed Euricon (benzbromarone) 50mg daily by our cardiology OPD for her hyperuricemia since Mar 2017. In accordance with the every helf-year laboratory data, her uric acid levels were all within normal ranges from 2020-11 to 2022-04.
  • Blood sugar levels were slightly elevated during this hospitalization, ranging from 110 to 253 mg/dL. In spite of this, there were no two consecutive days with glucose levels over 200 mg/dL, so it might not be necessary to adjust the hypoglycemic medication.

2022-07-13

  • The patient’s HbA1c were 7 +- 0.4%, serum glucose AC were 160 +- 30 mg/dL in the last three years, slightly above normal, a more intensive intervention might not be necessary if there is no urgency.
  • TPR, BP remain stable during this hospitalization.
  • In patients with moderate dementia (CDR = 2), Witgen (memantine 10 mg/tab) might be considered as an optional add-on.

700089206

230106

  • diagnosis - 20230105 admission note
    • Malignant neoplasm of colon, unspecified
    • Fever, unspecified
    • Malignant neoplasm of sigmoid colon
    • Secondary malignant neoplasm of liver and intrahepatic bile duct
    • Gastrointestinal hemorrhage, unspecified
  • family history
    • The patient has very strong family history of colon caner, from the father’s side.
  • exam findings
    • 2023-01-05, 2022-12-23 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Possible Inferior infarct, age undetermined
      • Anterolateral infarct, age undetermined
      • Abnormal ECG
    • 2022-12-23 CXR
      • Hypoinflation of both lung is noted.
    • 2022-12-21 CT - brain
      • No evidence of intracranial lesion.
    • 2022-12-21 Nerve Conduction Velocity (NCV) and Electromyography (EMG)
      • normal motor DLs, CMAP amplitudes and NCVs of bil. median, ulnar, peroneal and tibial n.
      • normal sensory DLs, SNAP amplitudes and NCVs of bil. median, ulnar, and sural n.
      • the F-wave latencies of bil. median, ulnar, peroneal and tibial n. were normal.
      • the H-reflex study of bil. tibial n. were normal
    • 2022-12-14 CT - abdomen
      • History: 20220914 CT: sigmoid colon cancer, cT4aN2aM1b (liver and non-regional LNs metastases)
      • Findings: Comparison: prior CT dated 2022/09/14.
        • Prior CT identified segmental asymmetrical wall thickening at the sigmoid colon with irregular contour is noted again, stable in wall thickness except poor enhancement that that is c/w adenocarcinoma of the sigmoid colon S/P C/T with partial response.
        • Prior CT identified metastatic nodes in the adjacent mesocolon are noted again. Most of them show decreasing in size. However, the largest one 4 cm in size shows increasing in size to 5.5 cm that is c/w progressive disease.
        • Prior CT identified multiple metastases on both hepatic lobes are noted again, increasing in size and number that are c/w progressive disease.
        • Prior CT identified several metastatic nodes in the celiac trunk and hepatoduodenal ligament are noted again, mild increasing in size that are c/w progressive disease.
        • There are soft tissue lesions in the liver hilum and ligamentum teres that may be metastatic nodes or lymphedema?
        • The gallbladder shows marked edematous wall thickening that may be hypoalbuminemia.
        • There is ascites in the abdomen and pelvis and suggestive small soft tissue nodules in the omentum and mesentery.
          • Please correlate with ascites cytology to evaluate if there is carcinomatosis?
          • In addition, There is splenomegaly (the greatest anterior-posterior dimention 15 cm).
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • Others
          • There is no focal abnormality in the biliary system and pancreas.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Adenocarcinoma of the sigmoid colon with LNs and liver metastases S/P C/T show progressive disease.
    • 2022-09-22 Patho - stomach biospy
      • Stomach, body, AW, biopsy — Fundic gland polyp
    • 2022-09-22 Panendoscopy
      • Reflux esophagitis, lower esophagus, LA classification, grade A
      • Superfical gastritis, antrum
      • Gastric polyp, body, AW, s/p biopsy
    • 2022-09-21 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • There was no variant detected in the KRAS/NRAS gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation may not benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-09-20 KUB
      • There is vas deferens calcification. Please correlate with serum glucose to R/O DM.
      • Fecal material store in the colon.
    • 2022-09-17 CT - chest
      • Indication: This is a 39-year-old male who was newly diagnosed colon cancer stage IV (with liver metastasis), we would like to arrange him a lung CT, in order to rule out lung metastasis.
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Subpleural nodule at right upper lobe up to 0.2cm in largest dimension is found. Benign process is favored.
          • No evidence of bilateral pleural effusion.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
        • Visible abdomen:
          • Low density lesions at both lobes of liver are found. Liver meta is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • Suggest clinical correlation
      • Imp:
        • Diffuse liver meta.
        • No evidence of pulmonary meta in the study.
    • 2022-09-14 CT - abdomen
      • History:
        • Passing bloody stool since last week asssociated with left upper quadrant pain.
        • 20220912 sigmoidoscopy: An ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon.
      • Indication:
        • sigmoid colon cancer for staging
      • Findings:
        • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
          • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
        • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
          • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
        • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
        • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2022-09-13 Patho - colon biopsy
      • Intestine, large, sigmoid colon, biopsy — adenocarcinoma
      • Immunohistochemical stain — EGFR(+), MLH1(+), PMS2(-), MSH2(+), MSH6(+)
      • Microscopically, it shows adenocarcinoma composed of a proliferation of irregular neoplastic glands with areas of cribriform architecture, and infiltrative growth pattern. The tumor cells display hyperchromatic nuclei with pleomorphism, prominent nucleoli, high N/C ratio and mitotic figures.
    • 2022-09-12 Sigmoidoscopy
      • Diagnosis
        • Probable sigmoid colon cancer, s/p biopsy
        • Hemorrhoid
        • Incomplete study of colon
      • Suggestion
        • Total colonoscopy is impossible due to the luminal stenosis caused by the tumor.
        • Pursue pathology result
        • Consider CT scan for further investigation
      • Complication
        • No immediate complication
    • 2020-10-30 SONO - abdomen
      • Diagnosis
        • Fatty liver, moderate
        • GB polyp
        • suspicious, Renal stone, right
        • Renal cyst, left
        • pancreatic body and tail masked by gas.
      • Suggestion
        • encourage exercise and diet adjustment.
        • Visit Urology if symptoms revealed.
    • 2020-10-16 SONO - nephrology
      • Left renal cysts
      • Left renal stone
  • consultation
    • 2022-12-20 Neurology
      • Q
        • This is a 40-year-old male underlying colon cancer with multiple liver metastasis, cT4N2aM1b. This time, he came to our emergency room due to fever with chills off and on for three days. He was admitted for infection control and further chemotherapy. During admission, he complaint about dizziness, general weakness, and unstable gait. We need your help for further evaluation. Thank you very much.
      • A
        • dizziness, unsteadiness esp. while standing up and walk for steps, tilting at times, but the symptoms progressed for longer times after each chemotherapy
        • NE: aware, fluent speech, normal cranial nerves, no obvious focal weakness, diffuse hypo-reflexia, bil. thigh and girdle muscle atrophy, no obvious tenderness
        • Impression:
          • suspect cancer related myopathy and neuropathy, also dysautonomia
        • Suggest:
          • brain CT and nerve conduction study (motor and sensory NCV, H-reflex, F-wave) might be arranged
          • I would like to follow up this patient. Thank you for your consultation.
    • 2022-09-15 Hemato-Oncology
      • Q
        • The patient had strong family history of colon cancer from the father’s side.
        • Ealier of the day, CT report shows as follow:
          • There is segmental asymmetrical wall thickening at the sigmoid colon with irregular contour and lumen stenosis, measuring 9 x 3.8 cm in size that is c/w adenocarcinoma of the sigmoid colon (T4a).
            • In addition, There are six enlarged nodes in the adjacent mesocolon and the largest one measuring 4 cm in size (N2a).
          • There are multiple poor-enhancing masses on both hepatic lobes, the largest one measuring 5.6 cm in S7, that are c/w liver metastases.
            • In addition, There are several enlarged nodes in the celiac trunk and hepatoduodenal ligament that may be non-regional lymph nodes metaseses? (M1b)
          • There are several renal cysts on both kidney and the largest one measuring 1 cm in size at left upper pole.
          • There is mild ascites in the pelvis. Please correlate with ascites cytology to evaluate if there is carcinomatosis?
          • Impression (Imaging stage): T:T4a(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value).
        • Consider the patient and his family are eager to engage into further treatment, we’d like to cousult with oncologists, with your expertise, we will have better insight of the future treatment for the patient (Whether the patient should go under what kind of chemotherapy)
        • We know Dr. Wan is very occupied today, please evaluate the patient at your free time, appreciate.
      • A
        • This 39 year old man is a case of sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Initially presentation is bloody stool. Besides, he has family history of colon cancer from the father’s side. Signoid colonscopy show an ulcerative mass with annular growth causing luminal stenosis was noted at distal sigmoid colon. Further insertion failed due to luminal stenosis. We are consulted for further evaluation.
        • Impression:
          • Favor sigmoid colon cancer with liver and celiac trunk and hepatoduodenal ligament lymph nodes metastases. Wait pathology. CEA pending.
        • Suggestion:
          • Consult CRS for operation or stenting evaluation due to impending luminal stenosis.
          • Systemic chemotherapy is indicated for metastasis colon cancer (for palliative or down stage). Arrange port A insertion, if patient agree further treatment. In addition, may consider clinical trial if avialable. Please check All-RAS + BRAF assays.
          • Check HbsAg, Anti-Hbc, Anti-HCV before chemotherapy. Arrange chest CT (+/-contrast) for complete work up r/o lung meta
          • We wound like to folluw up this case. If there is any problem, please feel free to let us known.
    • 2022-09-13 Colorectal Surgery
      • Q
        • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry, stool routine and image were performed. Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy; Hemorrhoid. Under the tentative diagnosis of Propable colon tumor, S colon, the patient was admitted for further evaluation and treatment. So we need your expert for colon tumor, S colon further Tx. Thanks!
      • A
        • The patient denied any systemic disease before.He presented with passage of blood in stool with dizziness for one week.Hence the patient was brought to our ER for evaluation and management. A series of examinations including blood routine, blood biochemistry,stool routine and image were performed.Sigmoid colon scope showed Probable sigmoid colon cancer, s/p biopsy ;Hemorrhoid.Under the tentative diagnosis of Propable colon tumor,S colon,the patient was admitted for further evaluation and treatment.So we need your expert for colon tumor,S colon..
        • A: Tumor of S-colon with lumen narrowing
        • P:
          • Waiting CT result
          • Surgical intervention with laparoscopic colectomy is indicated
          • We will visit this patient soon
  • chemotherapy
    • 2022-12-07 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 160mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5100mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
    • 2022-11-16 - cetuximab 500mg/m2 1000mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + metoclopramide 10mg
    • 2022-11-02 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5600mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-10-19 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-10-05 - cetuximab 250mg/m2 500mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5700mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug
    • 2022-09-19 - cetuximab 400mg/m2 800mg 90min + oxaliplatin 85mg/m2 170mg 4hr + leucovorin 430mg/m2 800mg 2hr + fluorouracil 2400mg/m2 5800mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug

==========

2023-01-06

  • According to the updated lab data (2023-01-06 05:55), the serum potassium level has returned to normal (3.8 mmol/L), and the potassium supplement might be slowed down or held temperarily if there is no continuous leakage suspected.

2022-12-15

  • 2022-12-13 WBC 15.23 *10^3/uL, CRP 8.15 mg/dL, the infection signs are treated with Brosym (cefoperazone + sulbactam) without an issue.

700962042

230106

  • exam finding
    • 2022-11-20 CT - abdomen
      • Clinical history: 53 y/o female patient with ovary cancer with peritonal seeding
      • With and without contrast enhancement CT of abdomen–whole:
        • S/P hysterectomy.
        • Outpouching lesion in ascending colon, suggesting ascending colon diverticulum.
      • Impression:
        • S/P hysterectomy. Suggest follow up.
        • Ascending colon diverticulum.
    • 2022-08-10 CT - abdomen
      • History: ovarain cancer, s/p neoadjuvant bidirectional chemotherapy (IP with Taxotere/Cisplatin x 3 cycles, IV with Taxol/Carboplatin x 4 cycles).
      • Indication: ovary cancer with peritonal seeding S/P HIPEC for FU
      • Impression:
        • S/P hysterectomy. There is no evidence of tumor recurrence.
    • 2022-08-10 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
    • 2022-06-27 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (163 - 50) / 163 = 69.33%
        • M-mode (Teichholz) = 69
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA
      • Trivial MR, trivial AR, mild to moderate TR
      • Preserved RV systolic function
    • 2022-06-20 CT - chest
      • Comparison was made with previous CT dated on 2021 2022
        • Lungs:
          • Platelike lung atelectasis over Rt middle lobe
          • subtle mosaic pulmonary attenuation in both lungs
        • Mediastinum and hila: no enlarged LN or mass.
        • Vessels: mild coronary arterial calcification.
          • Aorta: normal caliber, mild atherosclerotic change of aortic arch and descending thoracic aorta.
          • Central pulmonary arteries: normal caliber.
      • Impression:
        • suspect small airways disease involving both lungs d/d drug treatment related change.
    • 2022-02-09 CT - abdomen, pelvis
      • S/P hysterectomy. There is no evidence of tumor recurrence.
    • 2021-10-08 Patho - peritoneum biopsy
      • diagnosis
        • Peritoneum, left lower, cytoreductive surgery - Serous carcinoma, seeding
        • Appendix, cytoreductive surgery - Serous carcinoma, seeding
        • Peritoneum, right flank, cytoreductive surgery - Serous carcinoma, seeding
        • Omenum, cytoreductive surgery - Serous carcinoma, seeding
        • Peritoneum, right upper, cytoreductive surgery - Serous carcinoma, seeding
        • Gallbladder, cytoreductive surgery - Serous carcinoma, seeding
      • IHC: WT-1(+), CK7(+), CK20(-), PAX-8(+)
    • 2021-10-08 Patho - uterus neoplastic
      • diagnosis
        • Ovary, bilateral, salpingo-oophorectomy (s/p chemotherapy) - Serous carcinoma, high-grade
        • Fallopian tube, bilateral, salpingo-oophorectomy - Serous carcinoma, seeding
        • Uterus, serosa, abdominal total hysterectomy - Serous carcinoma, seeding
  • consultation
    • 2022-06-25 Chest Medicine
      • Q
        • for dyspnea & pneumonia over both lungs
        • for intermittent fever for one more ago
        • This 52 y/o female, a pt of ovarian CA wt peritoneal seeding Dx in April 2021, s/p pre-Op neoadjuvant IV C/T wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 3 (Bidirectional C/T, intraperitoneal-systemic C/T) from May 2021 to July 2021 & #4 IV Taxol / Carboplatin on 20210901 & Bil, salpingo-oophorectomy & cytoreductive surgery & HIPEC on 20211007. She was admitted due to high fever and dyspnea and cough for 2 days. CXR showed pneumonia over both lungs. We need expertise to evaluate her condition thanks!
      • A
        • CxR
          • Lung markings: increased density in the bilateral lower lung fields, in progression
        • CT
          • Platelike lung atelectasis over Rt middle lobe
          • subtle mosaic pulmonary attenuation in both lungs
            • suspect small airways disease involving both lungs d/d drug treatment related change.
          • Imp
            • Bilateral pneumonia, r/o pneumonitis, pathogen?
        • Suggestion
          • Check PJP (done), CMV (done), atypical pathogens (done), TB*3, Cryptococcus, Aspergillus
          • May add IV medason 0.5amp Q12H and taper when condition inproved
          • Keep tapimycin + Targocid, may add Cravit if CxR progression
          • F/U CxR on 20220625 and closely (CXR, BT improved on 20220625)
          • Keep I/O balance, electrolyte balance. correct anemia
          • Arrange 2D for heart function survey
          • Check Alb next time
          • follow up lab and CXR days later
          • If condition still progression with unstable O2 saturation, intubation with ICU admission and bronchoscope with full work-up survey might be needed
    • 2021-10-08 Chest Medicine
      • Q
        • She was admitted and received 3 combined surgery
          • right upper, right flank and left lower peritonectomy, appendectomy, cholecystectomy
          • abdominal total hysterectomy + bilateral salpingooophorectomy
          • bilateral URS-exam and ureteral catheterization on 20211007.
        • Post-op he was transferred to SICU for intensive care.
        • Cruuent problem:
          • right lung pleural effusion
        • We need your epertise for evaluation. Thanks a lot.
      • A
        • Right side pleural effusion abruptly expressed due to
          • elevated hydrastatic pressure
          • Major abdominal operation
        • Suggestion
          • we will arrange chest echo for pig-tail insertion
          • reduce hydrastatif fluid infusion
          • Lasix to keep I/O negative
          • High risk of kidney injury due to multiple nephrotoxic agents use
          • delay extubation till right pleural effusio drained out.
          • Enteral feeding as soon.
          • Thanks and f/u prn.
    • 2021-04-17 Hemato-Oncology
      • Q
        • The 55 y/o female, a pt wt suspected ovarian CA or gastric CA wt peritoneal mets Dx in April 2021.
        • PH:
          • Hypertension under medical control for years.
          • Tachycardia treated with propanolol.
          • HBV.
        • She suffered from left upper abdominal pain since 20210403
        • Her abdominal pain aggravated when she is eating, drinking and lying on the left side. She also had abdomen fullness and nausea for one month, denied of body weight loss. At ER, abdomen echo showed massive ascites, then tapping was done.
        • Abd CT showed ascites and peritoneal soft tissue density, suspected peritoneal carcinomatosis, suspect wall thickening of gastric antrum.
        • Under the impression of spontaneous bacteria peritonitis with hollow organ perforation, she was admitted to GI ward for management on 2021/04/08.
        • GS was consulted for suspected hollow organ perforation, and suggested exploratory laparascopy. She underwent operation of laparoscopic peritoneal tumor excision and PD tube implantation (Ascites amount: 8000ml) on 20210412.
        • CA-125: 496.8, normal CEA, CA-199.
        • Ascites cytology: malignancy. Pathology revealed Metastatic serous carcinoma,
          • IHC the tumor cells shows: CK7(+), CK20(-), CK5/6(-), WT1(+), and PAX8 (+).
        • Bidirectional C/T. We need your expertise for suspect ovarian cancer with peritoneal metastatic evaluation and thanks for your times.
      • A
        • Lab:
          • Peritoneum, laparoscopic peritoneal biopsy (20210413): Met serous carcinoma.
        • Abd CT (20210407):
          • Extraluminal air; DDx: hollow organ performation, previous peritoneocentesis
          • Ascites and peritoneal soft tissue density, r/o peritoneal carcinomatosis
          • Suspect wall thickening of gastric antrum
        • EGD & colonscopy will be done.
        • Medical advice:
          • It is most likely that the pt suffered from ovarian CA wt peritoneal seeding if EGD & colonoscopy shows negative.
          • If the pt accepts aggressive Tx for peritoneal mets, may consider bidirectional systemic IV C/T plus intra-peritoneal (IP) C/T.
        • No standard treatment for peritoneal carcinomatosis (PC) from colon or gastric cer. Peritoneal cavity acts as a sanctuary against systemic C/T probably because of the existence of a blood peritoneal barrier consisting of stromal tissue between mesothelial cells and submesothelial blood capillaries.
          • Only a small amount of systemic drugs are capable of penetrating this barrier and passing into the peritoneal cavity (eg: 5-FU, paclitaxel, docetacel, gemcitabine, doxorubicin).
          • IP chemotherapy offers potential therapeutic advantages over systemic chemotherapy by generating high local concentrations of chemotherapeutic drugs in the peritoneal cavity. This concentration difference enables the exposure of small nodules of PC before cytoreductive surgery ( CRS ) and lowers the systemic toxicity.
        • Bidirectional IV / IP C/T first then do Op. Tx schedule as following:
          • multidisciplinary treatment combining Bidirectional C/T:
            • Neoadjuvant intraperitoneal-systemic C/T protocol (NIPS),
          • Peritonectomy & Gyn Op.
          • Hyperthermic intraperitoneal chemoperfusion (HIPEC)
          • Early postoperative intraperitoneal C/T (EPIC).
        • Aims of NIPS are stage reduction, the eradication of peritoneal free cancer cells, and an increased incidence of complete cytoreduction (CC-0) for PC.
        • Early postoperative intraperitoneal chemotherapy (EPIC) can eradicate residual intraperitoneal cancer cells before fibrin can accumulate around residual cancer cells on the peritoneal surface.
        • The current state-of-the-art treatment for colorectal peritoneal dissemination CRS (cytoreductive surgery) & HIPEC.
        • Pt wt low tumor volume, well/mod. differentiated tumors and complete cytoreduction may potentially benefit from CRS & HIPEC.
        • CRS wt peritonectomy plus HIPEC confers a prolonged survival. Complete cytoreduction is an essential factor for a good outcome.
        • NIPS plus peritonectomy may improve the incidence of complete cytoreduction.
          • ref: J Clin Oncol 2004; 22: 3284-3292 & J Surg Oncol 2009; 100: 311-316 )
        • Peritoneal wash cytological examination was performed before and after NIPS & other intraperitoneal chemotherapy.
        • Systemic IV chemotherpay wt Taxol / Carboplatin concurrently wt IP C/T wt Taxotere / Cisplatin Q3W x 4 (Bidirectional C/T, intraperitoneal-systemic C/T). Then will do abd CT for response evaluation.
  • surgical operation
    • 2021-10-07 total hysterectomy + bilateral salpingo-oophorectomy
  • chemotherapy
    • 2023-01-06 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-12-12 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-11-21 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2023-10-31 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-10-14 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-09-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2023-08-09 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-07-19 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-06-07 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2023-05-16 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg
    • 2022-04-18 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-03-23 - bevacizumab 7.5mg/kg 600mg 1.5hr
      • dexamethasone 4mg + diphenhydramine 50mg
    • 2022-03-01 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 450mg 2hr
      • dexamethasone 4mg + diphenhydramine 30mg + famotidine 20mg + granisetron 2mg
    • 2022-02-07 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2022-01-17 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-12-27 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-12-06 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-11-12 - bevacizumab 7.5mg/kg 600mg 1.5hr + paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 400mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-10-07 - [cisplatin 75mg/m2 142mg + docetaxel 60mg/m2 114mg + gentamicin 40mg + sodium bicarbonate 4200mg] ST IP 90min (the surgical operation day)
    • 2021-09-02 - paclitaxel 175mg/m2 300mg 3hr + carboplatin AUC 5 440mg 2hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-07-06 - paclitaxel 100mg/m2 185mg 3hr + carboplatin AUC 5 540mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 55mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-06-02 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 600mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg
    • 2021-05-04 - paclitaxel 100mg/m2 190mg 3hr + carboplatin AUC 5 435mg 2hr + [docetaxel 40mg/m2 74mg + cisplatin 30mg/m2 56mg + gentamicin 40mg + sodium bicarbonate 2800mg] IP 1hr
      • dexamethasone 4mg + diphenhydramine 50mg + famotidine 20mg + granisetron 2mg

==========

2023-01-06

  • As a result of anemia, the patient received blood transfusion of LPRBC and was discharged on 2023-01-06 under stable conditions.

2022-03-02

  • platin-based regimen has been introduced since May 2021, bevacizumab added since Nov 2021 s/p total hysterectomy + bilateral salpingo-oophorectomy, most recent CT on 2022-02-09 showed no evidence of tumor recurrence. no issue with current medication.

701432080

230106

[OxyNorm tube feeding]

  • The package insert of OxyNorm (oxycodone 5mg) instructs “Do not chew or crush them.”
  • For NG feedings or gastrostomies, add some water to the tube, open the capsule and pour the contents directly into the tube, then rinse the tube with 15mL of water, then another 10mL of water, several times. In addition to water, milk or liquid nutrition can also be used.

[no sodium version of piperacillin + tazobactam]

  • Cefim (cefepime) and Pipe&Tazo (piperacillin + tazobactam) cover overlapping spectrum of micromials. However, the former is a hydrochloride salt, which should not increase the sodium levels in the body, while the latter is sodium-based.
  • As this patient is 77 years of age, weighs 50kg, and has a creatinine level of 1.97 mg/dL, the estimated CrCl is 22mL/min, it is recommended that cefepime should not exceed 2g once daily.
  • When possible, bacterial culture should still be performed to confirm the pathogen and limit the scope of antibacterial treatment.

701465162

230106

  • diagnosis
    • Adult T-cell lymphoma/leukemia (HTLV-1-associated) not having achieved remission
  • present illness - 20221228 admission note
    • This is a 61-year-old male with the past history of DM under diet control, hypertension without medication control, monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25. He lived in America and received surgical and medication treatment there, he came back to Taiwan on 2022/12/25. This time, he came to our hematology and oncology outpatient department for further evaluation and treatment. According to the patient, he sufferred from abdominal discomfort for almost four months, especially after meal. Accompanied with poor appetite, nausea, vomiting, and dizziness. Intermittent chest tightness and mild dyspnea without radiation pain nor cold sweating was also mentioned. He lost about 10 kilograms in the recent three months. There was no fever, no chills, no dysuria, no tarry stool. Under the impress
  • past history
    • DM under diet control
    • HTN without medication control
    • Monomorphic epitheliotropic intestinal T-cell lymphoma s/p ileocecectomy, small bowel resection, end ileostomy on 2022/11/25
  • family history
    • His father has peritoneal cancer.
    • His mother has cervical cancer and hypertension.
    • His sister has lung cancer.
    • His brother has thyroid cancer.
  • lab data
    • 2022-12-28 Anti-HBc Reactive
    • 2022-12-28 Anti-HBc-Value 6.64 S/CO
    • 2022-12-28 Anti-HCV Nonreactive
    • 2022-12-28 Anti-HCV Value 0.20 S/CO
    • 2022-12-28 HBsAg Nonreactive
    • 2022-12-28 HBsAg (Value) 0.45 S/CO

2023-01-06

[tube feeding]

It is possible to peel the Concor (bisoprolol 1.25mg) tablet in half or grind it for tube feeding.

2022-12-29

  • High bilirubin (total and direct), AST, ALT; slightly high Glucose (AC), HbA1c; slightly low serum Na, K have been seen in lab data on 2022-12-28/29.
  • There is no past history of hypercholesterolemia or available laboratory data to support this condition, Tulip (atorvastatin) might not be indicated.

700976532

230104

  • past history - 20221229 admisstion note
    • Hypertension
    • Hepatocellular carcinoma (stage unknown) status post partial hepatectomy 8 years ago in RenAi Hospital.
  • exam findings
    • 2023-01-04 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (145 - 27) / 145 = 81.38%
        • M-mode (Teichholz) = 81
      • Mild biventricular hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation; mildly dilated LA.
      • Dilated LV with normal LV and RV systolic function.
      • Mild aortic valve sclerosis; trivial MR; mild TR.
      • Possible mild to moderate pulmonary hypertension (the estimated systolic PA pressure 53 mmHg).
      • Moderate amount pericardial effusion (100-200 ml) without signs of tamponade
    • 2022-12-31 MRI - L-spine
      • Findings
        • Diffuse bone marrow fat replacing disease was seen, seen as abnormal low signal intensity on T1WI.
        • Multiple nodular bone destructing masses also were noted, up to 23 mm in size at posterior body of L1.
        • A right body mass was found at T2.
        • After IV contrast administration shows well or heterogenous enhancement of the masses or tumors.
        • However, no obvious dural sac or spinal cord compression was found.
      • IMP:
        • Diffuse bone marrow fat replacing disease at bil. pelvic bones, thoraco-lumbar spine, with sloid masses or nodules (myelomas) as described above.
    • 2022-12-29 CT - abdomen
      • Findings
        • Multiple osteolytic lesions in ribs, spine and pelvic bones.
        • Hyperplasia of left adrenal gland.
        • Wall thickening of rectum.
        • Tiny gallbladder stones.
        • Pericardial effusion.
        • Atherosclerosis of aorta, iliac, coronary arteries.
        • Right pleural effusion.
      • IMP:
        • Multiple osteolytic lesions in ribs, spine and pelvic bones. DDX: metastases, multiple myeloma.
        • Wall thickening of rectum.
    • 2022-12-29 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • Left anterior fascicular block
      • Bifascicular block
      • Abnormal ECG
    • 2022-12-29 Pelvis-THR and Lt. Hip Lat
      • Destruction at left iliac bone, r/o bone metastasis.
    • 2022-12-29 L-spine AP + Lat. (including sacrum)
      • Lumbar spondylosis.
      • Maintained bony alignment.
      • Atherosclerosis of abdominal aorta.
    • 2022-10-07 ECG
      • Normal sinus rhythm
      • Left axis deviation
      • Right bundle branch block
      • Abnormal ECG
    • 2022-06-27 KUB
      • suspected osteolytic lesions at left iliac and sacral bone
      • No abnormal calcification
      • Unremarkable psoas shadows
      • Suggest clinical correlation and follow up evaluation

[assessment]

  • A higher overshoot of bilirubin total than bilirubin direct might hint a sign that the patient’s red blood cells are breaking down at an unusual high rate.

    • 2023-01-04 Bilirubin total 1.57 mg/dL
    • 2023-01-02 Bilirubin total 1.18 mg/dL
    • 2022-12-30 Bilirubin total 1.06 mg/dL
    • 2022-12-29 Bilirubin total 0.54 mg/dL
    • 2023-01-04 Bilirubin direct 0.31 mg/dL
    • 2022-12-30 Bilirubin direct 0.24 mg/dL
  • During the first half hour of 14 o’clock 2023-01-04, there was a brief tachycardia moment with SBP exceeding 200mmHg. The vital signs are relatively stable now.

  • According to the Concor (bisoprolol 5mg/tab) package insert, the drug shold be swallowed with some liquid and not to be chewed. We are in the process of consulting the distributor for a response.

  • Atenolol can be used as an alternative antihypertensive agent (atenolol 50mg ~ bisoprolol 5mg) available under the brand name Urosin in the stock.

701449858

230104

  • diagnosis - 20230103 admission note
    • Enteropathy-type (intestinal) T-cell lymphoma
    • Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure
    • Infection following a procedure, initial encounter
    • Non-Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
    • Pleural effusion, not elsewhere classified
  • past history
    • Deny to have history of cancer, hypertension, mental diseases, asthma or diabetes. 
    • Allergy: NKDA
  • family history
    • Mother: breast cancer.
  • exam findings
    • 2022-12-05 CT - abdomen
      • Indication: Enteropathy-type (intestinal) T-cell lymphoma
      • Abdominal CT with and without enhancement revealed:
        • Abdomen
          • Dilated small intestines at RLQ is found about 6.05cm in largest dimension. Suggest follow up.
          • The urinary bladder is well distended without soft tissue lesion.
          • There is no evidence of destructive bone lesion.
          • Increased intestinal gas is found.
          • The GB is well distended without soft tissue lesion
          • There is no evidence of paraarotic LAPs.
          • Loculated effusion at right anterior abdominal wall is found.
        • Visible chest
          • S/p port-A placement with its tip at Superior vena cava.
          • Small lymph nodes at right sternum, right paracaval and hilar region is found.
      • Imp:
        • Post op. change of the abdomen with loculated effusion at RLQ. Abscess?
        • Mediastinal and sternal lymph nodes, please correlate with PET.
    • 2022-12-02 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy
        • No evidence of T cell prloliferation
        • Hypercellularity (80~90%), in favor of reactive hyperplasia of myeloid linegae
      • Correlation with peripheral blood test, blood smear, flow cytometry and clinical findings is recommended.
      • Microscopically, it shows hypercellularity (80~90%), presence of trilineage marrowe component with increased myeloid lineage. Occasional megakaryocytes are seen. T-cells are highlighted by CD3 and there is no evidence of T cell prloliferation. CD34 and CD117 are negative for blasts.
      • Immunohistochemical stain reveals MPO (diffuse +), CD71(focal+), CD56(-), CD20(focal+), CD138(-), CD10(-) and TdT(-).
    • 2022-11-29 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (115 - 33) / 115 = 71.30%
        • LVEF (%) = 71
        • M-mode (Teichholz) = 71
      • Normal LV systolic function with normal wall motion.
      • Concentric LVH, dilated LA; impaired LV relaxation.
      • Normal RV systolic function.
      • Mild MR; mild TR; mild PR.
    • 2022-11-14 CXR
      • Solitary pulmonary nodule at RLL.
      • Interstitial pattern at bil. lower lungs.
    • 2022-10-24 Whole body PET scan
      • Increased FDG uptake in the abdomen and pelvis, right mediastinal lymph nodes, and right infraclavicular fossa lymph nodes, highly suspected T-cell lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      • Glucose hypermetabolic lesions in the right lobe of the liver, highly suspected lymphoma with liver involvement.
      • Increased FDG uptake in bilateral pulmonry hilar regions, probably reactive nodes.
      • Increased FDG uptake in bilateral femoral shaft, the nature is to be determined (lymphoma, severe anemia or other nature ?), suggesting biopsy for further investigation.
      • T-cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2022-10-14 Patho - small intestine resection for tumor
      • Diagnosis:
        • Small intestine, resection — Monomorphic epitheliotropic intestinal T-cell lymphoma (type II enteropathy-associated T-cell lymphoma)
        • Peritoneum, peritonectomy — Monomorphic epitheliotropic intestinal T-cell lymphoma, by direct invasion
      • Gross description
        • Specimen submitted in fresh consists of a segment of small intestine, measuring 54 cm in length, with a piece of peritoneum, measuring 7.8 x 6.5 cm. An invasive tumor measuring 15.0 x 9.5 x 8.0 cm is seen in the central portion and measuring 15.0 and 10.0 cm away from the bilateral resection margins. On cutting, the tumor is gray, solid, elastic. Transmural invasion to mesentery and peritoneum, adhesion, and fistula formation are noted. Several enlraged lymph nodes are found and dissected. Representative sections are taken and labeled as: FsA1-2, for frozen examnation. After formalin fixation, additional sections are taken and labeled as: A1-2: bilateral resection margins; A3-4: with peritoneum; A5-8: tumor (A7: fistula); A9-10: lymph nodes.
      • Microscopic description
        • Sections show small intestine with diffuse, transmural invasion of medium-sized lymphoid cells.
        • Lymph node is involved. The tumor has invaded to the peritoneum and very close (< 0.1 cm) to the resection margin of peritoneum. The bilateral resection margins are free of tumor.
        • The immunohistochemical stains reveal CK(-), CD3(+), CD20(-), CD5(-), CD56(+), CD8(+), CD4(-), and Granzyme B(-).
        • NOTE: The tissue is the same as F2022-477.
    • 2022-10-13 Frozen resection
      • Preliminary diagnosis:
        • Small intestine, biopsy — small round blue cell tumor
    • 2022-10-12 Pulmonary Flow Volume Loop
      • mild restrictive impairment
    • 2022-09-05 Patho - lung transbronchial biopsy
      • Lung, RML, CT-guide biopsy — a tiny cluster of atypical cell present (please see microdescription)
      • Sections show alveolar lung tisssue with a tiny cluster of atypical cells.
      • The atypical cells are not found in deeper section. Please correlate with the clinical presentation.
      • The immunohistochemical stains reveal CK(+), TTF-1(-), p40(-), CD56(-), CDX2(-) and CD117(-).
    • 2022-09-02 CT - chest
      • Indication: Suspected of small bowel malignancy
      • Multidetector CT (256-detectors, iCT Philips, was performed with 0.625 mm collimation & 2.5 mm slice thickness)
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • Subpleural round nodular lesion at right middle lobe up to 0.5cm is found.
          • Patent airway is found.
          • There is no evidence of mediastinal LAP
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Swelling of intestinal wall at RLQ is found. suspected small bowel cancer.
          • Low density change at left liver tip up to 2.8cm is found. Hemangioma is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Imp:
          • Small bowel cancer with right middle lobe meta.
          • Hepatic hemangioma.
    • 2022-09-01 CT - abdomen
      • History and indication: abdominal pain
      • Protocol: 4mm slice thickness, axial scan and coronal reconstruction
      • With and without-contrast CT of abdomen-pelvis revealed:
        • Wall thickening of small bowel with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion and LNs metastases.
        • Minimal ascites.
        • Left liver hemangioma (3.3cm).
        • Bil. renal cysts (up to 2.1cm).
        • A nodule (1.3cm) at left adrenal gland.
        • A nodule (6mm) at RML.
        • Normal appearance of spleen, pancreas.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • Intact bony structures.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • Atherosclerosis of aorta, iliac arteries.
        • Some calcifications in prostate.
      • IMP:
        • In favor of small bowel cancer with adjacent fat stranding, adjacent bowel loop/ right abdominal wall invasion, LNs and lung metastases.
  • consultation
    • 2022-09-01 General and Gastrointestinal Surgery
      • A
        • S
          • periumbilical pain for one week
          • firm but ill-defined mass over central abdominal area
          • poor appetite for several weeks
          • but no significant BW loss
          • no N/V
          • no tarry/bloody stool
        • PE
          • fair looking
          • pale conjunctive
          • smooth respiration
          • RHB
          • abdomen: soft and distended, but firm mass at central abdomen, no peritoneal sign
        • Lab
          • no leukocytosis, no left shift
          • Hb: 10
          • high CRP
        • CT
          • focal bowel wall thickening wtih fat stranding and peritoneal invasion, favor malignancy, less likely inflammation related
        • suggest
          • admit for preop survey
          • BT with PRBC 2u
          • check tumor markers, HBV and HCV
          • arrange lung CT after admission
  • surgical operation
    • 2022-10-13
      • Surgery
        • small bowel tumor resection
        • peritonectomy
        • partial T-colon colectomy
      • Finding
        • huge tumor over proximal ileum, about 110cm proximal to the ileocacal valve
        • tumor invasion to the abdomianl wall and T-colon
        • multiple enlarged LNs over mesentary
        • no other palpable seeding tumor
        • no ascites
        • frozen section of small intestine: favor lymphoma, less likely adenocarcinoma
  • chemoimmunotherapy
    • 2023-01-03 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
      • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + granisetron 2mg D1-5
    • 2022-11-29 - methylprednisolone 500mg/m2 900mg D1-4 + etoposide 40mg/m2 70mg 1hr D1-4 + cisplatin 20mg/m2 35mg 18hr D1-4 + cytarabine 1500mg/m2 2700mg 2hr D5 (ESHAP)
      • dexamethasone 4mg D1-5 + diphenhydramine 30mg D1-5 + palonosetron 250ug D1-5
  • Diffuse large B cell lymphoma (DLBCL): Suspected first relapse or refractory disease in medically-fit patients (2023-01-04 https://www.uptodate.com/contents/diffuse-large-b-cell-lymphoma-dlbcl-suspected-first-relapse-or-refractory-disease-in-medically-fit-patients)
    • R-ESHAP (Rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) ref: Martín A, Conde E, Arnan M, et al. R-ESHAP as salvage therapy for patients with relapsed or refractory diffuse large B-cell lymphoma: the influence of prior exposure to rituximab on outcome. A GEL/TAMO study. Haematologica 2008; 93:1829.
      • Administration - R-ESHAP includes rituximab (375 mg/m2 on day 1), etoposide (40 mg/m2/day as a one-hour infusion on days 1 to 4), methylprednisolone (250 to 500 mg/day as a 15-minute infusion on days 1 to 5), cisplatin (25 mg/m2/day as a continuous infusion from day 1 to 4), and cytarabine (2 g/m2 as a two-hour infusion on day 5), every three or four weeks.
      • Adverse effects - Hematologic toxicity is universal, with significant rates of neutropenic fever (30 percent) if growth factors are not used. Other adverse effects (eg, nausea, vomiting, diarrhea, nephrotoxicity, electrolyte disturbances) are generally mild.
      • Outcomes - A retrospective study of 163 patients reported that ESHAP for relapsed DLBCL was associated with 75 to 86 percent ORR and 41 to 50 percent CR, while for primary refractory DLBCL, ORR was 33 percent and CR was 8 percent.

700552812

230102

  • exam findings
    • 2022-12-30 SONO - abdomen
      • Few small gallstone are noted.
    • 2022-12-09 Nasopharyngoscopy
      • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb post of operation on 2022/02. recurrence malignancy
      • tumor over right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall, cT4aN3bM0 under palliative chemotherapy
    • 2022-11-12 Nasopharyngoscopy
      • Scope: smooth NPx
      • NG in serted smoothly
    • 2022-10-31 Patho - soft tissue biopsy / simple excision (non lipoma)
      • Labeled as “midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus”, CT guided biopsy — bland spindle cell lesion.
      • IHC stains: desmin (+), CD34(+), Ki-67 <1%. CK(-), CD117(-), Dog-1(-), S-100(-), GFAP(-).
      • The possibility of bland smooth muscle tumor or glomus tumor cannot be excluded. Further work up, including excisional biopsy, might be considered.
    • 2022-10-26 CT - abdomen
      • History and Indication: biliary hepatitis and GI bleeding,
      • MD CT (iCT 256 slices) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
        • Few enlarged nodes in ppara-aortic space are suspected.
        • There is mild ascites in the pelvis.
        • The gallbladder shows few small stones and borderline distension but no wall thickening or surrounding fatty stranding. please correlate with clinical condition.
        • There is a tiny renal stone in right lower pole.
        • S/P nasogastric tube insertion
        • Others
          • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery.
      • Impression:
        • There is a poor enhancing lesion measuring 3.4 x 2.2 x 8 cm (width x depth x cranial-caudal length) at the midline omentum of the pelvis with suspicious connected with the urinary bladder dome and the uterine fundus. Please correlate with MRI.
          • The differential diagnosis include urachal cyst with infection, urachal tumor, and uterine tumor?
        • Few enlarged nodes in ppara-aortic space are suspected.
        • There is mild ascites in the pelvis.
    • 2022-10-25 SONO - abdomen
      • GB stone, multiple
      • GB sludge
    • 2022-10-24 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcers with stigma of recent hemorrhage, Forrest classification type IIa or IIc, bulb and 2nd portion s/p
        • hemostasis with APC
        • Gastric ulcer scar, prepyloric antrum, LC site
        • Hypopharynx mass lesion
        • Reflux esophagitis LA grade A
        • Superficial gastritis, s/p CLO tes
        • Gastric erosions, middle body, GC site
      • Suggestion
        • Keep on IV PPI therapy
        • F/U CLO test
    • 2022-10-23 ECG
      • sinus rhythm
      • Left axis deviation
      • Low voltage QRS
    • 2022-10-23 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • S/P port-A catheter insertion.
      • S/P N-G tube insertion.
    • 2022-10-23 Supine KUB
      • Presence of pneumatosis intestinalis over right-side of the abdomen.
      • S/P N-G tube insertion.
    • 2022-10-09, -09-27 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased infiltration over LLL. May be active infection.
      • Degenerative joint disease of T-spine with marginal osteophytes.
      • S/P port-A catheter insertion.
    • 2022-09-08 MRI - nasopharynx
      • Post-OP follow up. Pain of right neck and face. Recent fever was noted.
        • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
        • Complete CCRT
        • Scar contraction of right neck
        • Painful swelling of left neck
        • A fixed palpable mass was noted of right submandibular region with skin involved; Highly suspected tumor recurrence
      • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1WI with FS (thickness=5 mm, gap=1mm) and sagittal T1WI with FS(thickness= 4 mm, gap=1 mm) and show:
        • Extensive soft tissue mass with heterogeneous enhancement involving right part of mouth floor, submandibular space and overlying skin, buccogingival mucosa, medial pterygoid muscle, soft palate, tongue base and oropharyngeal wall (with necrotic change). Abnormal intensity also noted in right mandible, masseter muscl, along sternocleidomastoid muscle and surrounding right proximal ECA.
        • S/P flap reconstrution of right part of the oral tongue and lymph node dissection at right neck.
        • No enlarged lymph node.
        • No abnormality at nasopharynx, hypopharynx and larynx.
      • IMP:
        • Right tongue border cancer s/p treatment with advanced recurrence is first considered.
    • 2022-08-19 CT - abdomen
      • History:
        • Persistent cholestatic hepatitis of unexplained cause.
        • Recent echo showed no biliary lesion
      • MD CT (Revolution) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Impression:
        • Few gallstones are noted and the size < 5 mm.
        • A small renal stone 3 mm in right lower pole is noted.
    • 2022-08-15 SONO - nephrology
      • Parenchymal renal disease
      • Incomplete voiding, mild
    • 2022-08-10 SONO - abdomen
      • Parenchymal liver disease
      • GB stones (non-fasting GB)
    • 2022-07-07 Stomach, antrum, biopsy— ulcer with Helicobacter infection
    • 2022-07-06 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcer, Forrest classification type IIa, bulb s/p hemostasis with APC
        • Reflux esophagitis LA grade A
        • Superficial gastritis
        • Gastric ulcer, Forrest classification type III, antrum
        • Duodenal ulcer, Forrest classification type III, D1 to D2
      • Suggestion
        • High dose PPI *3 day
        • F/U patho
    • 2022-06-08 MRI - nasopharynx
      • Post-OP follow up
        • Squamous cell carcinoma of right tongue border, pT4aN3bM0, pstage IVb s/p wide excision; neck dissection and free flap reconstruction
        • Complete CCRT
      • Pre- and post-contrast multiplanar MRI studies of the head and neck region from skull base to lower neck were performed using the protocol: pre-contrast coronal T1WI and T2WI (thickness=3 mm, gap=1 mm), sagittal T1WI (thickness=4 mm, gap=1 mm), axial T1WI and T2WI with FS (thickness=5 mm, gap=1 mm), and post-contrast coronal T1WI with FS (thickness= 3 mm, gap=1 mm), axial T1-WI (thickness=5 mm, gap=1mm) and sagittal T1WI (thickness= 4 mm, gap=1 mm) and showed:
        • post-OP change at the right tongue with neck dissection and free flap reconstruction.
        • heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
      • IMP:
        • suspected tumor recurrence in the heterogeneous enhancing lesions in the right oropharynx, right buccogingival mucosa and right tongue base.
    • 2022-02-07 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Duodenal ulcer with suspicious SRH, Forrest class IIa, SDA, s/p APC
        • Duodenal ulcers with oozing bleeding, Forrest Ib, second portion, s/p APC
        • Gastric ulcers
        • Reflux esophagitis LA grade A
        • Superficial gastritis, s/p CLO test
        • Incomplete study due to retention of food residue
      • Suggestion
        • High dose PPI use
        • Pursue CLO test result
        • Suggest second-look endoscopy in 2-3 days.
    • 2022-02-07 Sigmoidoscopy
      • Diagnosis
        • Tarry-bloody colon content, suggestive of bleeding proximal to the distal colon
        • Internal hemorrhoids
        • Incomplete study of colon
      • Suggestion
        • This finding is compatible with the clinical diagnosis of UGI bleeding
        • Correlate with other clinical information
        • Repeat colonoscopy after full bowel preparation if clinically indicated
    • 2022-02-07 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • GB stones
        • CHD dilatation, mild; CBD masked
        • Parenchymal renal disease
        • Minimal amount of right pleural effusion with subpleural consolidation of right lower lung
        • suboptimal echo window
      • Suggestion
        • OPD follow-up
    • 2022-02-05 CT - abdomen
      • Gallbladder stones
      • Right renal stone
      • Intravenous contrast leakage in this study
    • 2022-01-25 Pathology - oral cancer (wide excision + lymph node)
      • Diagnosis
        • Tongue, right, frozen section for base margin (F2022-30) followed by wide excision S2022-1491) — Squamous cell carcinoma, well differemtiated
        • Frozen section for base margin (F2022-30) — Free.
        • Lymph node, right neck, dissection — Metastatic carcinoma
          • pT4a pN3b (if cM0) and if p16 is negative; pStage: IVB, at least.
        • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated.”, “Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • Macroscopic examination
        • Surgical Procedure(s): wide excision and radical neck lymph node dissection
        • Specimen Type:
          • Main location: right tongue
          • Other part(s) included: right mandibular gland
          • Lymph node dissection: yes right radical neck dissection
        • Specimen Integrity: intact
        • Specimen Size: Greatest dimensions: Tissue labeled as “01. Main tumor, right”: 7 x 5.5 x 3.5 cm.
          • Additional dimensions (if more than one part): Tissue labeled as “02. right mandibular gland”: 5 x 3.6 x 2.5 cm. And Frozen section tissue (F2022-30) labeled as “base, right”: 1 piee: 0.6 x 0.4 x 0.3 cm.
        • Depth of invasion: 17 mm
        • Tumor Site: right tongue border
          • Laterality: right
        • Tumor Focality: single focus
        • Tumor Size: Greatest dimension: 4.7 cm
          • Additional dimensions (if available): 2.2 x 1.7 cm
        • Mucosal Surface: ulcerated
        • Gross Tumor Extension: muscle
        • Tissue for frozen section: F2022-30: right base margin.
        • Tissue for formalin fixation: S2022-1491A: right main tumor= A1: vertical section of tumor with superior or ventral side margin; A2: vertical section of inferior or mouth floor side margin A3: vertical section of tumor with anterior margin; A4: vertical section of posterior margin; A5: gingiva; A6-9: tumor; A10: sublingual gland; B1: level 1 lymph node; B2-3: level 2 lymph nodes (with the largest one bi-sected, submitted in B2); B4-6: level 3 lymph nodes ( the larger two lymph nodes bi-seted and submitted in B4 and B5); B7: level4 lymph nodes; B8-9: level 5 lymph nodes (with the larger one bi-sected, submitted in B8); B10-11: parotid tail lymph nodes; B12-16: submandibular gland; B17: submandibular gland lymph nodes.
      • Microscopic examination
        • Histologic Type: Squamous cell carcinoma, (classical variant)
        • Histologic Grade: G2: Moderately differentiated
        • Microscopic Tumor Extension: (specify) muscle
        • Margins- Margins uninvolved / involved by invasive carcinoma
          • Distance from closest margin: 7 mm from base margin of the main tissue. This distance does not included the size of the frozen section specimen.
        • Margins uninvolved / involved by moderate and/or severe dysplasia: no dysplasia
          • Distance from closest margin: Not applicable
        • Lymph-Vascular Invasion: present
        • Perineural Invasion: present
        • Neck Lymph Nodes:=B1: level 1 lymph node (0/2); B2-3: level 2 lymph nodes (1/7, 2 mm in size, with extranodal extension); B4-6: level 3 lymph nodes ( 3/12, largest focus 21 mm, with ENE); B7: level4 lymph nodes (0/3); B8-9: level 5 lymph nodes (0/8); B10-11: parotid tail lymph nodes(0/14); B12-16: submandibular gland (0/3); B17: submandibular gland lymph nodes (0/3).
          • Ipsilateral: Number examined: 52; Number involved: 4
          • Contralateral (if available): N/A
        • Size (greatest dimension) of largest metastatic deposit: 2.1 cm
        • Extranodal extension: present
        • IHC stain: p16 (-).
    • 2022-01-21 Tc-00m MDP whole body bone scan
      • Increased activity in the lower C-spine and L3-4 spines. Degenerative change may show this picture.
      • Increased activity in the maxilla. Dental problem and/or sinusitis may show this picture.
      • Some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2022-01-20 MRI - Nasopharynx
      • Indication: SCC of right tongue border
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
      • Findings
        • Right lateral tongue tumor, up to 43 mm in length and 18 mm in depth.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor.
        • Multiple enlarged right level I-II LNs, some with central necrosis.
      • IMP:
        • Right tongue CA, with neck LAPs. T3N2bMx Stage IVA
    • 2022-01-05 Patho - tongue biopsy
      • Labeled as “right tongue border”, incision biopsy — squamous cell carcinoma.
      • IHC stains: p40 (+), p16 (-).
    • 2020-11-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (156 - 64) / 156 = 58.97%
        • M-mode (Teichholz) = 59
      • Gr II LV diastolic dysfunction; severely dilated LA and dilated RA.
      • Dilated LV with normal LV and RV systolic function.
      • Prominent posterior mitral annulus calcification with trivial MR; trivial TR; mild aortic valve sclerosis.
      • Prominent aortic root calcification with multiple large protruding atheromas (1.2-1.7 cm of thickness).
      • Dilated proximal ascending aorta (34mm).
  • chemotherapy
    • 2022-12-27 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-12-13 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-11-29 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-11-15 - cetuximab 250mg/m2 300mg 2hr + cisplatin 30mg/m2 40mg 1hr + fluorouracil 1600mg/m2 2000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-09-30 - docetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr
      •                 diphenhydramine 30mg + granisetron 1mg
    • 2022-09-29 - cetuximab 400mg/m2 500mg 2hr
      •                 diphenhydramine 30mg
    • 2022-09-13 - decetaxel 40mg/m2 50mg 2hr + carboplatin AUC 2 150mg 3hr + (leucovorin 100mg/m2 130mg + fluorouracil 1000mg/m2 1300mg) 22hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-04-25 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg
    • 2022-04-15 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-04-06 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-03-23 - carboplatin AUC 2 150mg 3hr
      • dexamethasone 4mg + diphenhydramine 30mg + granisetron 1mg
    • 2022-03-15 - carboplatin AUC 2 150mg 3hr
      •                 diphenhydramine 30mg + granisetron 1mg

[assessment]

  • 2023-01-01 lab results indicated serum K, Na, Mg and albumin were below normal ranges, and an adequate corresponding supplement may be beneficial.

701454820

230102

  • diagnosis - 2022-11-19 discharge note
    • Pancreatic tail cancer with liver metastasis, stage IV s/p chemotherapy with FOLFIRINOX from 2022/10/21
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
  • past history
    • Hypertension in 2021/10 with Norvasc 1# po QD and Carvedilol 6.25mg 1# po QD control
    • Hyperlipidemia in 2021/10 with Crestor 10mg 1# po QD control          
  • family history
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.   
  • lab data
    • 2022-10-07 Anti-HBc Nonreactive
    • 2022-10-07 Anti-HBc-Value 0.15 S/CO
    • 2022-10-07 Anti-HBs 163.89 mIU/mL
    • 2022-10-07 HBsAg (quantitative) Nonreactive
    • 2022-10-07 HBsAg Value (quantitative) 0.00 IU/mL
    • 2022-10-07 Anti-HCV Nonreactive
    • 2022-10-07 Anti-HCV Value 0.07 S/CO
    • 2022-09-26 CA-199 22806 U/mL (Taipei Mackey Hospital)
  • exam findings
    • 2022-11-05 ECG
      • Normal sinus rhythm
      • Incomplete right bundle branch block
      • ST elevation, consider early repolarization, pericarditis, or injury
      • Abnormal ECG
    • 2022-10-11 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Adenocarcinoma, well differentiated, compatible with metastatic pancreatic ductal adenocarcinoma
      • The sections show a picture of adenocarcinoma, well differentiated, composed of nests of columnar neoplastic cells with slightly pleomorphic nuclei, abundant cytoplasm, mucin secretion, and form duct-like glandular structures, mainly in portal areas. Vascular invasion is present.
      • IHC shows: CK7(+), CK20(+), and CA19-9(+). The finding is compatible with metastatic pancreatic ductal adenocarcinoma.
    • 2022-09-19 MRI (TaiAn Hospital)
      • Suspected pancreatic tumor (4 cm) with adhesion to spleen hilum, tail and suspected liver metastasis.
  • chemoimmunotherapy (FOLFIRINOX)
    • 2022-12-30 - oxaliplatin 85mg/m2 150mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg 4200mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-12-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-29 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-16 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 180mg/m2 300mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-11-02 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 400mg/m2 650mg 10min + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3
    • 2022-10-21 - oxaliplatin 85mg/m2 140mg 2hr + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 650mg 2hr + fluorouracil 2400mg 4000mg 46hr
      • dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + atropine 0.5mg SC + aprepitant 125mg D1-3

==========

2022-11-30

  • With an initiating of dose-reduced irinotecan and skipped fluorouracil bolus, FOLFIRINOX has been administered to this patient with pancreatic tail cancer with liver metastases since 2022-10-21, and no serious adverse reactions have been reported.
  • In recent lab tests, CEA (2022-11-15 20.18ng/mL) and CA199 (2022-11-15 >19090U/mL) levels remained high.
  • The underlying conditions of hypertension and hyperlipidemia are managed with patient-carried medication with no extreme abnormal results on examinations.

701012983

221229

  • diagnosis
    • Malignant neoplasm of duodenum
  • past history]
    • Past medical history:
      • Cardiovascular disease - CAD, DM
      • Hepatitis B or C carrier - denied
      • Current medications – DAPT
    • Past surgical history:
      • no gastrectomy/colectomy/splenectomy   
  • family history]
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.     
  • exam findings
    • 2022-11-08 CT - abdomen
      • Clinical history: 56 y/o male patient with duodenal adenocarcinoam pT3bN2 cM0; stage IIIB, s/p Op in May 2022.
      • With and without contrast enhancement CT of abdomen whole:
        • S/P whipple operation.
        • Right renal cyst, 1.2cm.
        • Unremarkable change of the liver, spleen and left kidney.
        • There are multiple enlarged lymph nodes in the paraaortic, aortocaval and peripancreatic regions.
        • Presence of ascites.
      • Impression:
        • S/P whipple operation.
        • Multiple metastatic lymph nodes and ascites, progression.
        • R/O right renal cyst.
    • 2022-11-08 CXR
      • Spondylosis of the T-spine
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-11-01 SONO - abdomen
      • Diagnosis
        • Dilated CBD
        • Dilated left intrahepatic duct
        • Splenomegaly, mild
        • Ascites
        • Pancreas masked
      • Suggestion
        • No more fever
        • elevated CEA/CA 19-9
        • highly suspected tumor reucrrent
        • Suggest medical ONC follow up and treat, but patient refuse (due to no money). suggest him seeking help from social worker but also refuse.
    • 2022-06-13 CXR
      • Ground glass opacity in bilateral lower lungs.
    • 2022-06-08 CXR
      • Ground glass opacity in RLL.
    • 2022-05-31 Patho - pancreas total/subtotal resection
      • Pathologic diagnosis
        • Duodenum, 2nd and 3rd portion, whpple operation — Periampullary adenocarcinoma, poorly differentiated
        • Pancreas, head, whpple operation — Involved by adenocarcinoma
        • Lymph node, peripancreatic, dissection — Metastatic adenocarcinoma (2/2)
        • Lymph node, group 7,8,9, dissection — Metastatic adenocarcinoma (2/3)
        • Gallbladder, whpple operation — Negative for malignancy
        • Omentum, whpple operation — Negative for malignancy
        • AJCC 8th edition Pathology stage: pT3bN2(if cM0); AJCC stage IIIB
    • 2022-05-24 CT - chest
      • History: Duodenal cancer
      • Impression
        • no abnormality in both lungs. 2nd portion duodenal tumor with pancreatic head involvement and complete obstruction.
        • suspect old subendocardial infarct in LAD territory.
    • 2022-05-19 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 33) / 109 = 69.72%
        • M-mode (Teichholz) = 68
      • Adequate LV systolic function with normal resting wall motion
      • Dilated aortic root
      • Septal hypertrophy; LV diastolic dysfunction, Gr 1
      • Trivial MR and trivial TR
      • Preserved RV systolic function
    • 2022-05-18 Pulmonary Flow Volume Loop
      • Mild restrictive lung defect
    • 2022-05-17 MRI - pancreas
      • History and indication: Duodenal stricture
      • Findings
        • Marked motion artifact.
        • Wall thickening of duodenum, 2nd portion, with pancreas invasion. Some LNs at retroperitoneum.
        • Distention of stomach.
        • Tiny renal cysts.
        • Normal appearance of liver, spleen, adrenals.
        • Normal appearance of gallbladder.
        • Patency of portal vein.
        • No ascites.
        • No abnormal intensity in bilateral basal lungs.
      • IMP:
        • In favor of duodenal tumor with pancreas invasion and obstruction.
    • 2022-05-17 Patho - stomach
      • Labeled as “Some white and plaque-like lesions were noted at lower esophagus”, biopsy (B) — ulcer. PAS stain shows no fungal species.
    • 2022-05-17 Patho - stomach
      • Duodenum, SDA, s/p biopsy (A) — adenocarcinoma.
      • IHC stain: Her2/neu: negative (score =0)
      • Section shows duodenal mucosal tissue with irregular aborted glands and isolated signet ring-like neoplastic cells.
    • 2022-05-16 Upper GI and Small Intestine
      • UGI and small bowel series revealed:
        • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
        • Normal contour and mucosal pattern of the esophagus.
        • Distention of stomach.
        • Normal appearance of duodenal bulb.
        • Partial obstruction of duodenum (2nd portion).
        • No abnormal bowel loop displacement.
        • The passage time is about 120 minutes.
    • 2022-05-16 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis LA Classification grade D
        • Suspected esophageal candidiasis, lower esophagus, s/p biopsy (B)
        • Superficial gastritis
        • Duodenal obstruction, SDA, r/o peptic stricture according to the recent endoscopic diagnosis of duodenal ulcers in other hospital, s/p biopsy (A)
        • Incomplete study due to residual food retention
      • Suggestion
        • Consult GS for surgical evaluation
        • Arrange upper GI series
    • 2022-05-13 CT - abdomen
      • History: vomit with coffee ground for days accompanied with tarry stool for once since this morning. Abdominal distended
      • Indication: GI bleeding.
      • MD CT (Aquilion Prime SP) of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is asymmetrical wall thickening at the duodenal 2nd portion, causing marked distension of the stomach S/P nasogastric tube insertion.
          • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
        • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
          • Please correlate with CA199 and MRI.
        • A renal cyst measuring 1.5 cm in right upper pole is noted.
        • There is no focal abnormality in the liver, gallbladder, biliary system, spleen & left kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • There is asymmetrical wall thickening at the duodenal 2nd portion, causing obstruction.
          • Please correlate with gastroscopy to R/O ulcer with deformity or cancer?
        • There is a poor enhancing lesion in the pancreatic uncinate process, measuring 1.5 cm in size.
          • Please correlate with CA199 and MRI.
    • 2022-05-13 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Suboptimal study due to much residual food retention
        • Reflux esophagitis LA Classification grade C
        • Superficial gastritis
        • Suspicious of duodenal ileus
      • Suggestion
        • Suggest NG tube decompression use
        • Arrange KUB

[assessment]

  • The patient has been diagnosed with duodenal cancer for several months. There may be a reason why he does not actively participate in treatment because he is financially underprivileged (according to social service team’s note 2022-12-28). The availability of treatment options may be limited as a result.
  • With adequate hydration and flomoxef treatment, the decreased blood pressure has returned to normal (95/55 to 127/70) on 2022-12-29.

700022077

221228

  • exam findings
    • 2022-12-03 CT - abdomen
      • Findings:
        • Wall thickening of cecum and proximal A-colon with adjacent mesentery and peritoneal invasions.
        • Multiple enlarged regional lymph nodes, more than 10.
        • Multiple mass lesions with peripheral enhancement in liver.
        • No ascites or extraluminal free air.
        • Enlarged lymph nodes in para-aortic region.
        • No bony destructive lesion on these images.
        • Multiple nodular lesions in both lung fields.
      • Impression
        • suspected Acending colon CA with peritoneal invaion, lymph node metastasis, and liver & lung metastasis

==========

2022-12-28

  • A nasogastric tube can be used to administer all of the oral medications listed in the active prescription.
  • There may be an enhanced CNS depressant effect when tramadol, chlorzoxazone, and oxazolam are administered together.
  • Amlodipine and tramadol’s serum concentrations may be increased by fluconazole, a moderate CYP3A4 inhibitor.
  • The ingredients in Acetal, Sketa, and Tramacet all include acetaminophen. The maximum daily dose of acetaminophen is not recommended to exceed 3000mg.
  • Please continue to monitor any potential adverse reactions caused by drug interactions.

2022-12-05

  • The CT image taken on 2022-12-03 indicated that cancer of the colon or cecum may be present. A work-up is currently being conducted on the patient. As far as the active prescription is concerned, there is no problem.

700132375

221226

{drug identification}

The drug imprinted “CTP A23” on the red-white capsule has not been found in available databases and remains unidentified.

700555339

221226

  • exam findings
    • 2022-11-25 KUB
      • Disc space narrowing with marginal osteophyte formation and vacuum phenomenon of L5-S1.
      • There are few calcified nodular shadows projecting over the both side buttock area, which may be due to old injection granuloma or bone island of the ilium. please correlate with clinical history.
    • 2022-11-25 Chest supine view
      • Widening of the right upper mediastinum is noted, which may be due to torturous innomiate vessel or tumor. Please correlate with standing p-a view or CT.
      • Borderline cardiomegaly
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion?
    • 2022-11-25 Chest plain film
      • Unremarkable change in the visible trachea
      • cardiomegaly; mediastinal widening.
      • Lung markings: unremarkable.
      • Normal bilateral hemidiaphrams
      • Clear bilateral costophrenic angles
      • Unremarkable change in bilateral clavicles
    • 2022-06-05 CT - abdomen (at Shin Kong Hospital)
      • Tumor location: U-M/3 rectum
      • Tumor size: Measurable: around 3.5-cm (largest diameter)
      • Tumor invasion: T4b, transmural, right adnexal to right uteirne border.
      • Regional nodal metastasis: N2, five nodes along IMA.
      • Distant metastasis (In this study): No Other findings: small nodes around IMA orifice level of aorta/IVC.
      • Impression :
        • Locally invasive U-M/3 rectal cancer, T4bN2M0 stage with segmental obstructive colitis.
        • Questionable small nodes around IMA orifice level of aorta/IVC.
        • CBD dilatation with sludge.
        • A-colon diverticulae.
        • Uneven fatty liver with S5 cyst.
        • L3-5 spinal stenosis with left L4-5

==========

2022-12-26

[ABX use evaluation]

For most adults, the initial recommended antifungal treatment is an echinocandin (caspofungin, micafungin, or anidulafungin) given through the vein. Fluconazole, amphotericin B, and other antifungal medications may also be appropriate in certain situations.

2022-11-28

  • Based on the recent diagnosis and prescription in the PharmaCloud, the patient should have underlying conditions such as CKD stage 3 (N18.3), lumbar region spondylosis with radiculopathy (M4726), cardiovascular promblem (nicorandil, bisoprolol, spironolactone), and diabetes (vildagliptin, gliclazide).
  • Nicorandil and bisoprolol have been added to the active prescription as patient-carried items and regular insulin 2 units BID is being used, both the blood pressure and blood sugar levels are within acceptable ranges.
  • As of 2022-11-28, the eGFR is 72.1, so there is no need to adjust the dosage.
  • The elevated CRP level is decreasing (4.63mg/dL 2022-11-28 <- 13.09ng/dL 2022-11-25), which might suggest a mitigation in the condition.
  • The active prescription does not pose an issue.

700864309

221222

  • exam findings
    • 2022-12-09 SONO - urology
      • Right renal stone
      • Right renal cyst
    • 2022-12-09 Bladder Sonography
      • PVR: 22.8ml (PVR = postvoided residual)
    • 2022-12-09 TRUS-P, Transrectal Ultrasound of Prostate
      • Benign prostatic hyperplasia
    • 2022-11-23 Patho - stomach biopsy
      • Labeled as “30cm below the incisors”, Biopsy (B) — benign hyperplastic squamous mucosa.
      • Stomach, antrum. Biopsy (A) — Chronic gastritis, H pylori present
    • 2022-11-23 Whole body PET scan
      • Glucose hypermetabolic lesions in the left soft palate, compatible with the primary malignant neoplasm of soft palate.
      • Glucose hypermetabolic lesions in bilateral cervical lymph nodes, highly suspected cancer with regional lymph nodes metastases.
      • Glucose hypermetabolic lesions in bilateral pulmonary hilar regions, probably reactive nodes.
      • Malignant neoplasm of soft palate, no evidence of distant metastasis, by this F-18-FDG PET/CT scan.
    • 2022-11-22 MRI - nasopharynx
      • Indication: soft palate cancer
      • MRI of the head and neck in multiplanar projections, multisequence imaging acquisition without and with IV Gd-DTPA administration shows:
        • A left soft palate tumor, extending to right, up to 3 cm.
        • Enlarged bil. neck LNs.
        • After IV contrast administration shows well or heterogenous enhancement of the mass or tumor and LNs.
      • IMP:
        • Left soft palate tumor, T2N2M0 stage II (P16+), IVA (P16-).
      • Imaging Report Form for Oropharynx Carcinoma
        • Impression (Imaging stage): T:T2(T_value) N:N2(N_value) M:M0(M_value) STAGE:II (P16+), IVA(P16-)(Stage_value)
    • 2022-11-22 Esophagogastroduodenoscopy, EGD
      • Reflux esophagitis LA Classification grade A
      • Hiatal hernia.
      • Esophageal ulcer, M/3, s/p biopsy (B)
      • Superficial gastritis, s/p CLO test
      • Gastric shallow ulcers, antrum, s/p biopsy (A)
      • CLO test: Positive
    • 2022-11-22 Pulmonary flow volume loop
      • Mild to moderate obstructive ventilatory impairment
    • 2022-11-22 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99 - 24) / 99 = 75.76%
        • M-mode (Teichholz) = 76
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated both atria and RV, grade 1 LV diastolic dysfunction
      • Mild AR, MR, and PR, moderate to severe TR
      • Pulmonary hypertension
    • 2022-11-21 ECG
      • Sinus rhythm with 1st degree A-V block
      • Voltage criteria for left ventricular hypertrophy
      • ST & T wave abnormality, consider anterolateral ischemia
    • 2022-11-21 CXR
      • No cardiomegaly
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased lung markings over both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-11-16 Patho - nasopharyngeal/oropharyngeal biopsy
      • Tumor, soft palate, biopsy — Compatible with squamous cell carcinoma and candidiasis
      • The specimen submitted consisted of three small pieces of tumor tissue measuring up to 0.5 x 0.3 x 0.2 cm in size, fixed in formalin. Grossly, they were gray in color and soft in consistence. All embedded for sections in one cassette.
      • Microscopically, the sections show a picture of ulcer with fungal hyphae and spores, morphology consistent with candidiasis and high grade (severe) dysplasia with pleomorphic and hyperchromatic nuclei and dyskeratosis. However, no convincing stromal tissue included in the limited specimen. According to histopathologic finding and clinical information (Show Chwan Memorail Hospital: pathlology revealed malignancy. Uvula, biopsy — Squamous cell carcinoma, moderately differentiated), it is compatible with squamous cell carcinoma, moderately differentiated. Closely follow up
      • Immunohistochemistry of P16(-)
    • 2022-11-15 Nasopharyngoscopy
      • soft palate cancer
  • consultation
    • 2022-11-24 Radiation Oncology
      • Q
        • After admitted, MRI showed : left soft palate tumor, T2N2M0. Abd echo showed some parts of pancreas blocked by bowel gas, especially head and tail. PES showed reflux esophagitis LA Classification grade A. Superficial gastritis, and gastric shallow ulcers. Under the impression of soft palate cancer, cT2N2M0, HPV pending, we suggest him to recevied surgery or CCRT. His daughter need opinion for radiotherpy. We need your help for further evaluation. Thank you very much!!
      • A
        • He has no genuine teeth now. CT-simulation will be arranged on 20221130. Plan to deliver 50 Gy/ 25 fx to the bil. neck lymphatic drainage area and orophayrnx. Then boost the soft palate tumor and LAPs to 70 Gy/ 35 fx. RT will start around 20221202 or 20221205. Thank you very much.
    • 2022-11-24 Cardiology
      • Q
        • This is a 91-year-old man with underlying hypertension and coronary artery disease under medication control for many years. No operation history. He had odynophagia for 3 months. Soft palate cancer was told at Show Chwan Hospital. He admitted to our ENT OPD for cancer work up. After work up, soft palate cancer stage IV was diagnosed.
        • We also arrange 2D echo which revealed Dilated both atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, pulmonary hypertension. PFT showed: Mild to moderate obstructive ventilatory impairment.
        • We request your consultation for further evaluation.
      • A
        • S
          • This patient suffered from soft palate cancer and was admitted to our hospital for evaluation about the treatment, including surgical, chemotherapy or radiotherapy. After admission, noted to have mild to modeate pulmonary hypertension while pre-OP heart function survey and CV had been consulted. However, they changed mind about surgical tratment and preferred CCRT at the meantime.
        • O
          • Lung function test: Mild to moderate obstructive ventilatory impairment
          • EChocardiography: M-mode(Teichholz) = 76; TR: moderate to severe; Max pressure gradient = 38 mmHg
            • Preserved LV and RV systolic function with normal wall motion
            • Dilated both atria and RV, grade 1 LV diastolic dysfunction
            • Mild AR, MR, and PR, moderate to severe TR
            • Pulmonary hypertension
        • Diagnosis:
          • mild to moderate pulmonary hypertension
        • Suggestion:
          • This patient currently had no signs of dyspnea, acute heart failure sign or chest pain. Since preserved LV systolic dysfunction noted, there was no acute contra-indication for surgical intervention.
            • If surgical treatment was arranged, may try pre-operative statin to prevent CAD attack, e.g. Short-term Atorvastatin 1/2# ~1# QD (20mg)
          • Since the pulmonary hypertension was only mild to moderate, and patient had no active symptom, conservative management and search for underlying cause are recommended.
            • The most obvious cause of pulmonary hypertension might be lung disease, since patient’s tricuspid valve showed no thickening at the meantime
            • Suspected Group 3: Pulmonary Hypertension Due to Lung Disease
              • may arrange chest CT to evaluate the lung parenchymal (group 3) and with contrast for pulmonary artery (artery intimal narrow, group 1 or thrombus group 4)
  • chemoimmunotherapy
    • 2022-12-14 - Erbitux (cetuximab) 250mg/m2 400mg 2hr (CCRT) dose 400 <- 600
      • premed - betamethasone 4mg + diphenhydramine 30mg
    • 2022-12-14 - Erbitux (cetuximab) 400mg/m2 600mg 2hr (CCRT)
      • premed - betamethasone 4mg + diphenhydramine 30mg

[note]

  • Cetuximab-Containing Combinations in Locally Advanced and Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma (Front. Oncol., 20 May 2019 https://doi.org/10.3389/fonc.2019.00383)
    • Cetuximab remains to date the only targeted therapy approved for the treatment of head and neck squamous cell carcinoma (HNSCC). The EGFR pathway plays a key role in the tumorigenesis and progression of this disease as well as in the resistance to radiotherapy (RT). While several anti-EGFR agents have been tested in HNSCC, cetuximab, an IgG1 subclass monoclonal antibody against EGFR, is the only drug with proven efficacy for the treatment of both locoregionally-advanced (LA) and recurrent/metastatic (R/M) disease. The addition of cetuximab to radiotherapy is a validated treatment option in LA-HNSCC. However, its use has been limited to patients who are considered unfit for standard of care chemoradiotherapy (CRT) with single agent cisplatin given the lack of direct comparison of these two regimens in randomized phase III trials and the inferiority suggested by metanalysis and phase II studies. The current use of cetuximab in HNSCC is about to change given the recent results from randomized prospective clinical trials in both the LA and R/M setting. Two phase III studies evaluating RT-cetuximab vs. CRT in Human Papillomavirus (HPV)-positive LA oropharyngeal squamous cell carcinoma (De-ESCALaTE and RTOG 1016) showed inferior overall survival and progression-free survival for RT-cetuximab combination, and therefore CRT with cisplatin remains the standard of care in this disease. In the R/M HNSCC, the EXTREME regimen has been the standard of care as first-line treatment for the past 10 years. However, the results from the KEYNOTE-048 study will likely position the anti-PD-1 agent pembrolizumab as the new first line treatment either alone or in combination with chemotherapy in this setting based on PD-L1 status. Interestingly, cetuximab-mediated immunogenicity through antibody dependent cell cytotoxicity (ADCC) has encouraged the evaluation of combined approaches with immune-checkpoint inhibitors in both LA and R/M-HNSCC settings. This article reviews the accumulated evidence on the role of cetuximab in HNSCC in the past decade, offering an overview of its current impact in the treatment of LA and R/M-HNSCC disease and its potential use in the era of immunotherapy.

[assessment]

  • During the past month, the patient’s liver and kidney functions have declined.

    • Creatinine
      • 2022-12-21 Creatinine 2.06 mg/dL
      • 2022-12-14 Creatinine 1.58 mg/dL
      • 2022-11-21 Creatinine 1.29 mg/dL
    • BUN
      • 2022-12-21 BUN 67 mg/dL
      • 2022-12-14 BUN 51 mg/dL
      • 2022-11-21 BUN 34 mg/dL
    • S-GPT/ALT
      • 2022-12-21 S-GPT/ALT 89 U/L
      • 2022-12-14 S-GPT/ALT 54 U/L
      • 2022-11-21 S-GPT/ALT 10 U/L
    • S-GOT/AST
      • 2022-12-21 S-GOT/AST 51 U/L
      • 2022-12-14 S-GOT/AST 36 U/L
      • 2022-11-21 S-GOT/AST 19 U/L
  • As the patient’s CrCl level is 17 mL/min according to the Cockcroft-Gault formula, it is recommended that the dosage of clarithromycin and amoxicillin be halved.

  • For patients with severely impaired kidney function, neither cisplatin nor carboplatin is recommended. Cetuximab is being administered as part of the patient’s treatment with CCRT.

  • In this patient, transthoracic echocardiography (2022-11-22) revealed dilated atria and RV, grade 1 LV diastolic dysfunction, mild AR, MR, and PR, moderate to severe TR, and pulmonary hypertension. Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving cetuximab with radiation therapy or a cetuximab product with platinum-based therapy and fluorouracil. It is recommended to closely monitor serum electrolytes, including magnesium, potassium, and calcium, during and after cetuximab administration.

701448280

221222

{not completed}

  • exam findings
    • 2022-11-23 PD-L1 IHC
      • Tumor cell (TC) staining assessment: TC >= 10% and < 50%
      • Percentage of 28-8 expressing tumor cells (%TC): 30%
    • 2022-11-23 PD-L1 22C3
      • Tumor Proportion Score(TPS) assessment: <1%
        • Tumor Proportion Score(TPS): <1%
      • Combined Positive Score(CPS) assessment: <1
        • Combined Positive Score(CPS): <1
    • 2022-11-23 PD-L1 SP142
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana)
        • Tumor cell (TC) staining assessment: TC < 1%
        • Percentage of PD-L1 expressing tumor cells (%TC): < 1 %
        • Tumor-infiltrating immune cell (IC) staining assessment: IC < 1%
        • Proportion of tumor area occupied by PD-L1 expressing tumor-infiltrating immune cells (% IC): < 1 %
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-11-15 CT - abdomen
      • Regression of prior seen liver dome marginal enhanced tumor as compare with CT study on 2022-09-03.
      • Liver cirrhosis.
      • Paraaortic and mesentery lymph nodes.
      • Left lower lung nodule, suspected lung metastasis.
    • 2022-11-14 Nasopharyngoscopy
      • no obvious tumor mass noticed over hupopharynx
    • 2022-10-04 Patho - stomach biopsy
      • Stomach, upper body, biopsy — Chronic gastritis, H pylori NOT present
    • 2022-10-03 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Hypopharyngeal cancer, post CCRT, with esophageal inlet involvement
        • Esophageal varices, F1CbLi, RCS(-)
        • Superficial gastritis, s/p CLO test and biopsy at LC of upper body
        • Suspected Portal hypertensive gastropathy
        • Shallow duodenal ulcer, bulb
        • R/O Papillitis or periampullary lesion
        • Failure of endoscopy-guided NG insertion
      • Suggestion
        • Suggest surgical gastrostomy
        • Correlate with other clinical data for the endoscopic finding of enlargement of papilla
    • 2022-09-08 CT - abdomen
      • In favor of liver, lung and LNs metastases.
    • 2022-09-02 Whole body PET scan
      • Glucose hypermetabolism involving the right and posterior aspects of the hypopharynx with invasion to the the right thyroid cartilage and proximal portion of the esophagus, compatible with advanced hypopharyngeal malignancy. Please correlate with other clinical findings for further evaluation.
      • Glucose hypermetabolism in multiple bilateral neck lymph nodes, compatible with metastatic lymph nodes.
      • Glucose hypermetabolism in a a focal area in the dome of liver. Either liver metastasis or primary liver malignancy may show this picture.
      • Mild glucose hypermetabolism in the soft palate. The nature is to be determined. Please correlate with other clinical findings for further evaluation.
      • Mild to moderate glucose hypermetabolism in the distal portion of the esophagus and mild glucose hypermetabolism in a focal area in the anterior aspect of right lower lung field. The nature is also to be determined (inflammatory process? other nature?). Please also correlate with other clinical findings for further evaluation.
    • 2022-09-01 MRI - larynx
      • Imaging Report Form for Hypopharynx Carcinoma
        • Impression (Imaging stage) : T:T4(T_value) N:N3(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-09-01 SONO - abdomen
      • Diagnosis
        • Propable Cirrhosis
        • Suspected regenerative nodules,bil
        • Right pleural effusion ,mild
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP,HBV,HCV
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
        • Because of cirrhosis ,infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months
    • 2022-09-01 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Hypopharygeal lesion extended to upper esophagus
        • Esophageal varices, F2CbLm
        • Duodenal ulcer scar, bulb
        • Portal hypertensive gastropathy
      • Suggestion
        • Suspected liver cirrhosis
    • 2022-08-22 Patho - nasopharyngeal/oropharyngeal biopsy
      • DIAGNOSIS
        • Soft palate, right, biopsy— squamous cell carcinoma, moderately differentiated (p16: -)
        • Posterior pharyngeal wall tumor, right, biopsy— high-grade dysplasia (p16: -)
      • Microscopically, section A shows moderately differentiated squamous cell carcinoma consisting of proliferation of atypical squamous cells with focal stromal invasion and areas of dyskeratosis. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and some mitiotic activity. Section B show a small piece of high-grade dysplastic squamous cells.
      • Immunohistochemical stain reverals p16(-).
    • 2022-08-22 Nasopharyngoscopy
      • Findings
        • smooth nasopharynx, bulging of right lateral pharyngeal wall with obliteration of right pyriform sinus; posterior wall mass with partial necrotic tissue; suspect R vocal cord palsy; poor visualization of glottis.
      • Diagnosis/Conclusion
        • suspect R hypopharyngeal cancer
  • consultation
    • 2022-09-05 Hemato-Oncology
      • Q
        • We request your consultation for further management.
      • A
        • Impression:
          • advanced hypopharyngeal malignancy with invasion to the the right thyroid cartilage and proximal portion of the esophagus, cT:T4N3M0, stage IVB, soft palate biopsy SCC
          • Propable Cirrhosis, Suspected regenerative nodules, bil, Right pleural effusion, mild
        • Suggestion:
          • Since a case of iver cirrhosis, the primary tumor of liver is needed to be considered. Triple phase liver CT and AFP would be helpful.
          • CCRT is indicated. Then, consult RT for further evaluation.
          • May arrange my OPD if discharge.
    • 2022-09-02 Oral and Maxillofacial Surgery
      • Q
        • This 50 y/o man is a case of hypopharyngeal cancer. The patient suffered from lumping throat on and off and hoarseness for 2 weeks. Body weight loss was noted too. He had smoking habit 1 pack/day, beer about 3 bottle/day, and betel nuts about 2pack/day.
        • He was admission due to right vocal palsy and soft palate tumor biopsy revealed: soft palate squamous cell carcinoma, moderately differentiated (p16: -); posterior pharyngeal wall high-grade dysplasia (p16: -).
        • After admission, cancer work up was arranged. The neck MRI on 9/1 which revealed the tumor invasion to hypopharynx, thyroid cartilage, cricoid cartilage and extended to esophagus, cT4bN3M0, stage IVB. The abdominal sono revealed suspect liver cirrhosis, and right pleural effusion.
        • We request your consultation for pre-chemotherapy dental evaluaion.
      • A
        • For pre-chemotherapy dental evaluaion.
        • O:
          • Hopeless tooth of 11, 21, 28, 43, 44, 45 were noted.
          • Panoramic film revealed severe periodontitis of full mouth.
          • Severe poor oral hygiene.
        • P:
          • Take panoramic X-ray film to check up.
          • Explain findings and treatment plan to the patient and his brother.
          • Suggest extraction of tooth 11, 21, 28, 43, 44, 45 before chemotherapy and radiotherapy.
        • The risk of osteomyelitis after tooth extraction or implantation after radiotherapy has been informed, the patient said that he did not want to have the tooth extracted, and he had to think again

700365018

221221

{not completed}

  • lab data
    • 2022-10-19 HBsAg (NMed) Negative
    • 2022-10-19 HBsAg Value (NMed) 0.396
    • 2022-10-19 Anti-HBc (NMed) Positive
    • 2022-10-19 Anti-HBc Value (NMed) 0.00702
    • 2022-10-19 Anti-HCV (NMed) Negative
    • 2022-10-19 Anti-HCV Value (NMed) 0.0379
  • exam findings
    • 2022-10-26 All-RAS + BRAF mutations assay
      • All-RAS: Detected (KRAS codon 12 GGT>GTT, p.G12V
      • BRAF: There was no variant detected in the BRAF gene.
    • 2022-10-25 Tc-99m MDP whole body bone scan
      • Increased activity in the middle T-spines and some L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2022-10-24 Whole body PET scan
      • Increased FDG uptake in the rectal region and peripheral lymph nodes, compatible with rectal cancer with regional lymph nodes metastases.
      • Glucose hypermetabolic lesions in bilateral retromolar and submandibular lymph nodes, the nature is to be determined (reactive nodes, distant lymph nodes metastases, lymphoma, or others ?), suggesting biopsy for investigation.
      • Increased FDG uptake in bilateral palatine tonsils, probably a chronic inflammation/infection process.
      • Increased FDG uptake in bilateral pulmonary hilar and mediastinal lymph nodes, probably reactive nodes.
      • Malignant neoplasm of rectum with regional lymph nodes metastases, cTxN2M0, by this F-18-FDG PET/CT scan.
    • 2022-10-18 CT - abdomen
      • Clinical history: 59 y/o male patient with rectal cancer.
      • With and without contrast enhancement CT of whole abdomen:
        • Thickening wall at the rectum, suspected rectal malignancy.
        • Presence of perirectal lymph nodes.
        • Unremarkable change of the liver, spleen, pancreas and both kidneys.
        • No enlarged lymph node in the paraaortic region.
        • No ascites.
        • Fibrotic infiltrates in bilateral lung apex.
        • Suspicious right upper lung nodule, suggest follow up.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N2(N_value) M:M0(M_value) STAGE: IIIC__(Stage_value)
    • 2022-09-20 Patho - colon biopsy
      • Large intestine, rectum, 5cm to 10cm from anal verge, biopsy — Adenocarcinoma, moderately differentiated
      • Specimen submitted in formalin consists of several pieces of tan, irregular tissue measuring up to 0.3 x 0.2 x 0.1 cm.
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
      • The immunohistochemical stains reveal EGFR(+), PMS2(+), MLH1(+), MSH2(+), and MSH6(+).
    • 2020-09-20 Colonoscopy
      • Findings
        • The scope reach the cecum under fair colon preparation. Many liquid fece with seeds were noted, which blocked almost half of the colon.
        • One semi-annular rectal tumor was noted from 5cm AAV to 10cm AAV. Biopsy was done.
      • Diagnosis
        • Highly suspected rectal cancer, s/p biopsy
        • Suboptimal study
      • Suggestion
        • F/U pathology report
        • CRS OPD follow up
        • Small lesions may be missed due to suboptimal bowel preparation.
      • Complication
        • No immediate complication
  • consultation
    • 2022-10-20 Hemato-Oncology
      • Q
        • After fully explained of the condition, pre-op CCRT first followed by surgical treatment was suggested. We needs your expert experience for evaluation of pre-op CCRT. Thanks a lot !!
      • A
        • I would like to take over this case for neoadjuvant CCRT for his rectal cancer with perirectal lymph nodes, cstage T3N2bM0.
    • 2022-10-19 Radiation Oncology
      • Q
        • This 59 y/o male patient sufferre from loose stool and blood in stool for 1 year. Tumor maker with CEA showed 7.18 ng/mL. Colonscopy was performed on 2022/09/20 and revealed highly suspected rectal cancer, 5~10 cm from anal verge, s/p biopsy. Biopsy pathology showed adenocarcinoma, moderately differentiated. Lab data showed anemia (6.6 g/dL) and blood transfusion was done. Abdominal CT revealed rectal cancer with perirectal lymph nodes, cstage T3N2bM0, stage IIIC.
      • A
        • Pre-op CCRT is indicated. CT-simulation will be arranged on 20221024. Plan to deliver 45 Gy/ 25 fx to the pelvis. Then boost the rectal tumor and LAPs to 50.4 Gy/ 28 fx. RT will start around 20221026 or 27.
  • chemotherapy
    • 2022-12-20 - oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 620mg 2hr + fluorouracil 400mg/m2 620mg 2hr + fluorouracil 2400mg/m2 3700mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 3mg
    • 2022-12-06
    • 2022-11-21
    • 2022-11-07

[assessment]

  • According to the available lab data, the levels of MCV, MCH, and MCHC have been frequently low since July 2022.
  • Low MCV, MCH, and MCHC can be caused by anemia which could include iron-deficiency anemia and anemia due to chronic disease.
  • Thalassemia can also affect the production of hemoglobin, leading to low MCV, MCH, and MCHC.
  • Foliromin (ferrous sodium citrate) has been prescribed since mid-Nov 2022, but the readings of the MCV, MCH, and MCHC have only shown a minimal improvement.
  • As far as FOLFOX treatment is concerned, there are no issues.

701446872

221221

  • exam findings
    • 2022-11-29, -11-03, -11-01 Body fluid cytology - ascites
      • negative
    • 2022-10-21 CT - abdomen
      • History: Gastric adenocarcinoma of proximal middle body great curvature, metastasis to adjacent omentum pT4aN1M1 stage IV post total gastrectomy with lymphadenectomy of station 1 to 12A and 14V, Retrocolic Roux-en-Y anastomosis reconstruction with Endo GIA on 2022-09-07.
      • Findings:
        • S/P total gastrectomy.
        • S/P Jackson-Pratt drainage tube insertion from right and left abdominal wall.
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of ascites or lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P total gastrectomy.
        • There is no evidence of tumor recurrence.
    • 2022-09-08 Patho - stomach subtotal/total (tumor)
      • PATHOLOGIC DIAGNOSIS
        • Tumor, stomach, total gastrectomy — Poorly cohesive carcinoma
        • Margins, bilateral cutting ends, ditto — Free of tumor invasion
        • Lymph nodes, LN 1, ditto — Free of tumor metastasis (0/7)
        • Lymph nodes, LN 2, ditto — Free of tumor metastasis (0/7)
        • Lymph nodes, LN 3, ditto — Tumor metastasis (1/19) with isolated tumor cells and tumor deposits
        • Lymph nodes, LN 4, ditto — Free of tumor metastasis (0/20)
        • Lymph nodes, LN 5, ditto — Free of tumor metastasis (0/1)
        • Lymph nodes, LN 6, ditto — Free of tumor metastasis (0/4)
        • Lymph nodes, LN 7,8,9,11,12, ditto — Free of tumor metastasis (0/8)
        • Lymph nodes, LN 10, ditto — Free of tumor metastasis (0/5)
        • Lymph nodes, LN 14v, ditto — Fat only
        • Omentum, omentectomy — Free of tumor invasion
        • AJCC Pathologic staging — pT4aN1M1, stage IV
      • MACROSCOPIC EXAMINATION
        • Specimen type: Stomach, lymph node and omentum
        • Specimen size: 19.3 x 10.2 x 1.3 cm in size, 189 gm in weight
        • Number of lesions: Solitary
        • Tumor site: middle body, greater curvature
        • Tumor size: 1.2 x 0.8 cm
        • Tumor configuration: ulcerative tumor
        • Omentum: 38 x 16 x 1.2 cm, no significant change
      • MICROSCOPIC EXAMINATION
        • Histologic type: Poorly cohesive carcinoma
        • Histologic grade: Grade 3, poorly differentiated
        • Depth of tumor invasion: serosa layer
        • Lymph nodes: tumor metastasis (1/71) in total number without extracapsular extension
        • Omentum: free of tumor invasion
        • AJCC Pathologic Staging: pT4aN1M1
        • Bilateral resection margins: Free of tumor invasion
        • Additional pathologic findings: ulcer with mild intestinal metaplasia
        • Perineural invasion: Present
        • Lymphovascular space invasion: Present
        • Immunohistochemical stains:
          • CAM5.2(+) for serosal invasion
          • CK(+) for isolate tumor cells within lymph node and tumor deposits in LN3
          • HER2(-, Dako score 0 ) for tumor
    • 2022-08-22 CT - abdomen
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T:T1a(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
    • 2022-08-16 Patho - stomach biopsy
      • Stomach, antrum to lower body, biopsy— chronic gastritis with intestinal metaplasia. No H.pylori present
        • Microscopically, it shows chronic gastritis with lymphoplasmacytic infiltrate and intestinal metaplasia. No Helicobacter-like bacillus is seen.
      • Stomach, middle body, biopsy— poorly differentiated adenocarcinoma
        • Microscopically, it shows poorly differentiated adenocarcinoma composed of proliferation of atypical tumor cells arranged in solid architecture. The tumor shows pabundant cytoplasm and pushing nuclei with signet ring cell-like picture. No H.pylori is seen.
        • Immunohistochemical stain reveals CK(+) at tumor cells.
    • 2022-08-15 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Esophageal phleboectasia, lower and middle esophagus
        • Chronic superficial gastritis, s/p CLO
        • Gastric ulcer, A2-H1, middle body, suspected dysplastic or malignant lesion, s/p biopsy (A)
        • Probable intestinal metaplasia, antrum to lower body, s/p biopsy (B)
        • Gastric xanthoma
        • Bile reflux in stomach
      • Suggestion
        • PPI therapy
        • Pursue CLO test and pathology result
        • EGD follow-up is indicated
  • chemoimmunotherapy
    • 2022-12-12 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3700mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-11-29 - oxaliplatin 50mg/m2 75mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2500mg/m2 3760mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-31 - oxaliplatin 50mg/m2 70mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 3800mg 46hr + [docetaxel 40mg/m2 60mg + cisplatin 30mg/m2 40mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 2mg
    • 2022-10-21 - oxaliplatin 70mg/m2 100mg 2hr + leucovorin 400mg/m2 625mg 2hr + fluorouracil 2500mg/m2 4000mg 46hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg
    • 2022-09-14 - mitomycin-c 16mg/m2 25mg 2hr D2 + [fluorouracil 500mg/m2 780mg + gentamicin 40mg + NaHCO3 2800mg] IP 1hr D1-5
      • premed - betamethasone 4mg

==========

2022-12-21

  • The bowl movement in this patient reached 3 times on 2022-12-20. It is recommended to hold the Through (sennoside) temperately and monitor the changes in the bowl movement these days.

701464956

221221

{drug identification}

A request has been made for us to identify drugs for 10 items.

In total, 9 items have been identified as follows, with 1 item remaining unidentified.

  • Meptin-mini (procaterol 25mcg)
  • Nexium (esomeprazole 40mg)
  • Tareg (valsartan 80mg)
  • Norvasc (amlodipine 5mg)
  • Solaxin (chlorzoxazone 200mg)
  • Rovo (repaglinide 1mg)
  • Aricept (donepezil 10mg)
  • Gaslan (dimethicone 40mg)
  • Medicon-A (dextromethorphan 20mg)

These drugs will be sent back to ward by the in-hospital porter.

701006949

221219

{not completed}

  • exam findings
    • 2022-12-12 Chest PA + Lat LT
      • Diffuse osteoblastic change of the T-and L-spine are suspected. Please correlate with bone scan.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-10-24 - Tc-99m MDP whole body bone scan with SPECT
      • The Tc-99m MDP bone scan with SPECT at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
      • IMPRESSION: Some of the previous bone lesions including the left rib cage, some T- and L-spine, right S-I joint, and left femoral trochanters come to slightly more evident compared with the previus study on 2022-03-31, suggesting metastatic bone disease in progression.
    • 2022-10-13 CXR
      • Cardiomegaly is noted.
      • Tortous aorta with calcification is noted.
      • Increased pulmonary vasculature is found.
    • 2022-10-12 CT - abdomen
      • Findings:
        • There is a newly-developed hypodense lesion 1 cm in S4/8 dome of the liver at non-enhanced CT and that may be metastasis? Please correlate with MRI.
        • Presence of gallbladder stone.
        • There are few hyperdense lesions in the distal CBD that are c/w distal CBD stones.
        • Bilateral renal cysts (up to 1.1 cm).
        • Diffuse osteoblastic bony metastases with L2 compression fracture.
        • S/P colostomy at the sigmoid colon.
        • s/p Abdominal-perineal resection.
      • Impression:
        • Metastasis 1 cm in S4/8 of the liver is highly suspected. Please correlate with MRI.
        • Few gallstones and distal CBD stones.
    • 2022-03-31 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed inhomogenously increased activity in the skull, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, clavicles, sacrum, bilateral multiple pelvic bones, bilateral S-I joints, humeri and femurs.
      • IMPRESSION: The scintigraphic findings are compatible with diffuse bone metastases.
    • 2022-03-01 KUB
      • Presence of ileus.
      • Heterogeneous density of bony structures.
      • Compression fracture of L2.
      • A calcified spot at RUQ.
    • 2022-02-24 Patho - colon segmental resection for tumors
      • PATHOLOGIC DIAGNOSIS
        • Lower rectum, laparoscopic abdominal perineal resection —- Metastatic adenocarcinoma, compatible with prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9, with rectum invasion
        • Bilateral resection margins — Free
        • Lymph node, mesocolic, dissection —- Tumor present (2/7) without extracapsular extension (0/2)
        • AJCC 8th edition Pathology stage (prostatic cancer) — pT4N1(cM1b: by CT finding), stage IVB
      • MACROSCOPIC EXAMINATION
        • Operation procedure: laparoscopic abdominal perineal resection
        • Specimen site: lower rectum, 1.5 cm above dentate line
        • Specimen size: 16.5 cm in length including a portion of skin measuring 1.2 cm in length
        • Tumor size: annularly ulcerated, 4.5 x 2.5 cm
        • Tumor location: 8.5 cm and 4.0 cm away from the two resection margins, respectively
        • Depth of invasion grossly: perirectal fat tissue
        • Mucosa elsewhere: congestion, ulcer
        • Another segment of unremarkable colon measuring 6.5 cm in length is reveived
        • Representative sections are taken and labeled as: A1-2: bilateral resection margin; A3: colon, non-tumor; A4-9: tumor; A10-13 and X1-30: lymph node, mesocolic.
      • MICROSCOPIC EXAMINATION
        • Histology: prostatic acinar adenocarcinoma, Gleason score 4 + 5 = 9
        • Depth of invasion: rectal wall to mucosa
        • Angiolymphatic invasion: Present
        • Perineural invasion: Present.
        • Lymph node metastasis, mesocolic: tumor present (2/7)
        • Extranodal involvement: Not identified
        • Pathologic Stage Classification (prostatic cancer): pT4N1 (cM1b: by CT finding), stage IVB
        • Type of polyp in which invasive carcinoma arose: N/A
        • Immunohistochemistry: EGFR(+), CK7(-), CK20(-), PSA(+, focal), CDX-2(+), CD56(-)
    • 2022-01-25 CT - abdomen
      • S/P colostomy. Suggest follow up.
      • Lymph nodes in the mediastinum and right hilar region, suspected lymph node metastasis. Stationary.
      • Gallbladder stone.
      • Intralumal hyperdense lesions in the CBD, suspected CBD stones.
      • Bilateral renal cysts.
      • Ascending colon diverticula.
      • Bone metastasis. L2 compression fracture.
    • 2022-01-25 CXR
      • Ground glass opacity in LLL.
      • Interstitial pattern at right lung.
      • Presence of ileus.
      • Heterogeneous density of bony structures.
    • 2022-01-07 Bronchodilator Test
      • Mild obstructive ventilatory impairment with significant bronchodilator response
    • 2022-01-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 29) / 105 = 72.38%
        • M-mode (Teichholz) = 73
      • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with trivial AR; mild TR.
      • Dilated aortic root and proximal ascending aorta (38mm) with mild calcification.
    • 2021-11-22, -11-03 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
    • 2021-10-12 Patho - colon biopsy
      • Colon tumor, 1 cm above dentate line, biopsy — Adenocarcinoma, pooylr differentiated
      • Microscopically, the sections show a picture of poorly-differentiated adenocarcinoma characterized by nest or individual tumor cells infiltration.
      • Immunohistochemistry shows CK(+); MLH1(+), MSH2(+), MSH6(+) and PMS2(+) for tumor cells.
    • 2021-10-12 Colonoscopy
      • Rectal tumor, 1cm above dentate line, with luminal narrowing, s/p biopsy
      • Mixed hemorrhoid
    • 2021-10-07 CT - abdomen
      • History and indication: suspected colon cancer survey
      • Findings
        • Enlargement of prostate.
        • Wall thickening of rectum with adjacent fat stranding.
        • Multiple bony metastases.
        • Some LNs at pelvic cavity and paraaortic region.
        • A calcified spot (1.2cm) at gallbladder fossa.
        • Small renal cysts.
        • Left minimal pleural effusion. Some ground glass opacities at bil. lungs. A nodule at LLL.
        • Gallbladder stone (0.8cm).
        • Atherosclerosis of aorta, iliac, coronary arteries.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3(T_value) N:N2a(N_value) M:M1b(M_value) STAGE:IVB(Stage_value)
    • 2021-09-29 MRI - L-spine
      • Bony metastasis in T12-S4 vertebral bodies and bilateral iliac wings.
      • Multiple para-aortic metastatic LAPs.
      • Lumbar spondylosis.
    • 2021-09-28 CT - chest
      • no evidence lung infection. moderate centrilobular emphysema in both upper lobes of lungs. no lung tumor.
      • extensive bony lesion, metastasis or hematogical disorder.
      • extensive LAD CAD.
    • 2021-09-23 CXR
      • Tortousity of thoracic aorta and calcified atherosclerotic change at aortic arch and D-aorta. dilated ascending aorta?
      • mild enlarged cardiac silhoutte
      • Platelike lung atelectasis over Rt midlung zone hazy areas of increased opacity (ground-glass opacitie) over Lt lower lung zone
  • chemoimmunotherapy
    • 2022-11-14 - Abraxane (nab-paclitaxel) 75mg/m2 100mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 4mg + granisetron 1mg (palliative, for prostate cancer)
    • 2021-12-06 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-29 - fluorouracil 200mg/m2 340mg 24hr (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-22 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-08 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg
    • 2021-11-01 - fluorouracil 200mg/m2 340mg 24hr D1-D2 (CCRT for colorectal cancer)
      • premed - diphenhydramine 30mg + dexamethasone 4mg + metoclopramide 10mg

701070156

221219

  • diagnosis - 2022-11-09 discharge note
    • Malignant neoplasm of cervix uteri, unspecified
    • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB s/p CCRT with recurrence and paraaortic lymph node metastasis with bone invasion
    • hepatitis B of anti-Hbc : positive
    • Hyperkalemia
    • Hyponatremia
  • family history
    • Mother died of cervical cancer when 53 y/o.
    • There is no family history of, hypertension, mental diseases or asthma.
    • First older sister diagnosed of diabetes.
  • exam findings
    • 2022-11-08, -10-31, -10-28, -09-22 KUB
      • Wedge deformity and total collapse at right lateral aspect of L4 vertebral body and suggestive osteolytic lesion at right lateral aspect of L3 vertebral body are noted that are c/w bony metastase after correlate with CT.
      • scoliosis of L-spine with convex to left side
      • Fecal material store in the colon.
    • 2022-11-07, -10-21, -09-26, -08-30 CXR
      • Enlargement of cardiac silhouette.
    • 2022-10-11 Tc-99m MDP whole body bone scan
      • Increased activity in the lower L-spines. Bone metastases should be watched out.
      • Increased activity in the sacrum and right S-I joint. Either degenerative change or bone metastases may show this picture. Please correlate with other imaging modalities for further evaluation.
      • A faint hot spot in the anterior aspect of right 6th rib. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips and knees, compatible with benign joint lesions.
    • 2022-09-21 CT - abdomen
      • Findings
        • osteolytic lesions in right lateral aspect of L3 and L4 vertebral bodies with right lateral extension and invasion to right psoas muscle, about 122.8mm.
        • Tumor encasement of the right internal and external iliac arteries was noted. Right hydornephrosis and right hydroureter were also noted.
      • IMP:
        • tumors in the right paraspinal region.
        • rihgt hydronephrosis and right hydroureter
    • 2022-09-21 ECG
      • Normal sinus rhythm
      • Right bundle branch block
      • Abnormal ECG
    • 2022-08-26 ECG
      • Normal sinus rhythm
      • Incomplete right bundle branch block
      • Cannot rule out Inferior infarct, age undetermined
      • ST & T wave abnormality, consider anterior ischemia
      • Abnormal ECG
    • 2022-08-19 CT - abdomen
      • History:
        • 2022/08/18 right hip pain radiated to foot for a peroid of time
        • 2021/11 visited our gyn OPD:
          • Carcinoma of the uterine cervix, stage T1N1M0, stage IIIB
          • Completion of radiotherapy on 2015-04-21. Suspicious paraaortic lymph node metastasis.
        • 2021/11 MRI here showed suspect recurrence
        • She said she has received C/T at Tailand this year, result?
      • Indication: Suspected recurrent tumor in right paraspinal region and L3-4 invasion
      • MD CT of the abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. CT images were obtained during non-enhanced and portal venous phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • There is osteolytic lesion in right lateral aspect of L3 and L4 vertebral body with right lateral extension and invaded into right psoas muscle, causing a heterogeneous poor enhancing soft tissue mass lesion (the cranial-caudal diemsnion:12.5 cm) that is c/w bony metastasis.
          • In addition, right external iliac artery shows small size that is c/w encasement by the metastatic mass in right psoas muscle.
        • There is right side hydroureteronephrosis and the etiology is due to passive comprssion of right M/3 ureter by the upper described metastatic mass in right psoas muscle .
        • There is no focal abnormality in the liver, gallbladder, biliary system, pancreas, spleen & both kidney.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • Bony metastases in L3 and L4 vertebral body with metastatic mass in right psoas muscle.
    • 2022-08-15 Gynecologic ultrasonography
      • Bilateral adnexae free
      • EM 2.5mm
    • 2021-11-29 MRI - pelvis
      • Clinical history: 56 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB.
      • Cervical cancer s/p RT.
      • Infiltrative soft tissue tumor, 4.6x9.8cm in right paraspinal region with L3-4 invasion, suspected metastasis.
    • 2021-11-25 Gynecologic ultrasonography
      • Bilateral adnexae free
      • EM 1.6mm
    • 2017-12-25 CT - pelvis
      • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy/LC for ectopic pregnancy.
      • Findings
        • Lymph node in left paraaortic region, up to 1.25cm, r/o metastatic lymph node. Progression.
      • Impression:
        • Cervical cancer s/p RT, progression of paraaortic lymph node (1.25cm).
    • 2017-07-20 CT - pelvis
      • Clinical history: 52 y/o female patient with carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, hx of appendectomy∕LC for ectopic pregnancy.
      • Findings
        • Lymph node in left paraaortic region, up to 1.03cm, r/o metastatic lymph node.
      • Impression:
        • Cervical cancer s/p RT, regression of pelvic lymph nodes. But presence of paraaortic lymph node, 1.03cm, suggest follow up study.
    • 2017-06-26 Mammography
      • Impression: No mammographic evidence of malignancy, suggest clinical correlation and regular follow up.
      • BI-RADS: Category 1: negative. - annual screening.
  • consultation
    • 2022-08-29 Radiation Oncology
      • Q
        • Patient could not understand our language very well. She said she has received C/T and has MST from Tailand on 2022 ?? This time ,she wa admitted for further management.
      • A
        • S: For radiotherapy due to L3, L4, and right psoas muscle metastases with pain.
          • The patient only received ICRT x 4 fractions at TSGH due to severe left abdomen pain during the 5th ICRT procedure.
          • Chemotherapy: 2015-2-2; 2015-3-2; 2015-4-9
          • PI: This is a case of squamous cell carcinoma of the uterine cervix, initial stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases. The patient suffered from pain of right flank area. She said ever received radiotherapy at Bangkok in 2022.
          • Hx of appendectomy/LC for ectopic pregnancy.
          • Family Hx: mother (died of cervical cancer)
        • O:
          • ECOG: 2
          • PE: neck and bil SCF: neg; bil low limbs: no edema; pain of right flank area.
        • A:
          • Squamous cell carcinoma of the uterine cervix, stage T1N1M0, stage IIIB, s/p CCRT, with L3, L4, and right psoas muscle metastases.
        • P:
          • The patient said she ever received radiotherapy of the right flank area at Bangkok in 2022. We need to understand the details of radiotherapy at Bangkok. She is applying these information. RTC: 2022-08-31.
  • chemoimmunotherapy
    • 2022-11-21 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-10-25 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-09-29 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr
    • 2022-09-07 - bevacizumab 15mg/kg 500mg 1.5hr + paclitaxel 175mg/m2 200mg 3hr + cisplatin 50mg/m2 58mg 2hr

[assessment]

  • In the lab data collected on 2022-12-18, there were no extreme abnormalities that warranted postponing the chemotherapy schedule.
  • It was noted that the blood pressure dropped to 90/50 at dusk on 2022-12-18. Prior to the administration of the chemotherapy, the vital signs should be within a fairly stable range.

701236803

221219

  • diagnosis - 20221216 admission note
    • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
    • Pleural effusion, not elsewhere classified
    • Pneumonia, unspecified organism
    • Localized enlarged lymph nodes
    • Essential (primary) hypertension
  • exam findings
    • 2022-12-18 CXR
      • approriately positioned endotracheal tube in place
      • Lt internal jugular central venous catheter in place with tip projecting over Rt paratracheal space
      • regression of Lt pleural effusion s/p chest tubes placement
      • Port-A catheter inserted into SVC junction via left subclavian vein.
      • extensive hazy increased opacity in the right mid to lower lung zone with obscuration of silhouttes of the right left heart border
    • 2022-12-16 ECG
      • Sinus tachycardia
      • Low voltage QRS
      • Borderline ECG
    • 2022-12-06 Cell Block Cytology
      • 50 cc brown turbid pleural effusion - Atypia
      • The smears and cell block show small lymphocytes and reactive mesothelial cells.
      • Immunocytochemistry shows CD20(+) > CD3(+) lymphocytes, Bcl-6(+/-, equivocal) and CD10(+, focal) for lymphocytes, follicular lymphoma can not be excluded entirely. Follow up
    • 2022-12-06 SONO - chest
      • Right thorax: minimal amount pleural effusion.
      • Left thorax: moderate amount, serosanguinous pleural effusion s/p insertion of 14 Fr. pig-tail catheter and fixed at 15cm.
    • 2022-12-05 CXR
      • S/P port-A implantation.
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
      • Left pleura effusion is noted.
      • Prominence of left hilar shadow is noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and close follow-up.
    • 2022-11-22 Patho - peritoneum biopsy
      • Abdomen, CT-guide biopsy— Follicular lymphoma
      • Histology type: B-cell neoplasms - Follicular lymphoma
      • Immunohistochemical stain profiles: CD20(+), CD3(-), CD10(+), Bcl-2(+), Bcl-6(+), CD5(+), CD23(-), cyclin D1(-).
    • 2022-11-21 CXR
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
    • 2022-10-26 Whole body PET scan
      • Glucose hypermetabolic lesions in the left NP region and left axillary lymph nodes come to less evident, and glucose hypermetabolic lesions in bilateral cervical lymph nodes, left iliac bone, right pubic bone and right femur disappear compared with the previous study on 2020-09-17, indicating response to current therapy.
      • However, glucose hypermetabolic lesions in bilateral supraclavicular and left infraclavicular lymph nodes, bilateral mediastinal lymph nodes, abdominal and pelvic lymph nodes, and spleen become markedly more prominent, suggesting lymphoma in progression.
      • B-cell lymphoma s/p treatment with residual/recurrent tumor involving lymph node regions on both sides of the diaphragm and spleen, c-stage IIIS (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-10-25 Neurosonology
      • Mild atherosclerosis in Rt ECA.
      • Normal pulsatility index (PI) in detected intracranial artery system.
      • Inadequate total blood flow volume of bilateral Vertebral artery (85 ml/min), indicating Vertebrobasilar insufficiency (VBI).
    • 2022-10-25 Brainstem Auditory Evoked Potentials, BAEP
      • This abnormal BAEP study suggests a peripheral sensori-neural hearing disorder on both sides.
    • 2022-10-01 CT - chest
      • Indication:
        • Small cell B-cell lymphoma, lymph nodes of head, face, and neck
        • Localized enlarged lymph nodes
        • Essential (primary) hypertension
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • S/p port-A placement with its tip at SUPERIOR VENA CAVA.
          • Lymphadenopathy at bilateral thoracic inlet and superior mediastinum. In comparison with CT dated on 2022-03-19, the lesion enlarged.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Lymphadenopathy at paraaortic and pelvic floor is found.
          • The urinary bladder is well distended without soft tissue lesion.
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • IMp:
        • Lymphadenopathy at bilateral thoracic inlet and mediastinum and abdominal paraaortic and pelvic floor, in enlargement.
    • 2022-09-15 Nasopharyngoscopy
      • Findings
        • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx; mucus coating on left nasopharynx, local treatment done
      • Conclusion
        • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
    • 2022-06-23, -03-03, -01-06, 2021-10-14, -08-12, -06-10, -05-18 Nasopharyngoscopy
      • Findings
        • bi nasal cavity clear; smooth nasopharynx, tongue base and hypopharynx mucosa; normal vocal function; no tumor found at bi pharynx
      • Conclusion
        • Head neck lymphoma (nasopharynx and neck) s/p chemotherapy, No evidence of tumor recurrence
    • 2022-03-19 CT - chest
      • S/p port-A placement with its tip at Superior vena cava
      • No evidence of recurrent/residual lymphadenopathy in the study.
    • 2021-09-09 CT - chest
      • NO evidence of lymphadenopathy in the current study.
      • Minimal right lower lobe and left lower lobe lung collpase.
    • 2021-04-12 CT - neck
      • a small nodular lesion in the right parotid gland
      • suspicious a nodular lesion in the right thyroid gland.
    • 2020-11-30 CT - neck
      • a nodular lesion in the right parotid gland.
      • regression of the left nasopharyngeal tumor
    • 2020-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (100 - 17) / 100 = 83%
        • M-mode (Teichholz) = 83
      • Normal LV filling pressure; mild RV hypertrophy with impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild aortic valve sclerosis.
      • Mildly dilated proximal ascending aorta (35mm).
    • 2020-09-17 Whole body PET scan
      • The FDG PET findings are compatible with lymphoma involving the left aspect of the nasopharynx, multiple lymph nodes on both sides of the diaphragm and multiple bones as mentioned above. Please correlate with other clinical findings for further evaluation.
    • 2020-09-16 CXR
      • Hypoinflation of both lung is noted.
      • Spondylosis with scoliosis of the T-spine with convex to right side
      • Enlargement of cardiac silhouette.
    • 2020-09-16 Patho - bone marrow biopsy
      • Bone marrow, biopsy — lymphoid aggregation
      • Microscopically, it shows 40% of cellularity with 2:2 or M:E ratio, trilineage cellular component, mature megakaryocyts and presence of lymphoid aggregations.
      • Immunohistochemical stain reveals CD20(+), Bcl-2(+ at aggregation), CD10(focal+), CD138(1~2%), CD117(-), Bcl-6(-), CD34(-), CYCLIN D1(-), MPO (+), CD71(+).
      • NOTE: Clinical correlation is essential.
    • 2020-09-04 Patho - nasopharyngeal/oropharyngeal biopsy
      • Nasopharynx, left, biopsy— B cell type lymphoma, low grade
      • Microscopically, it shows B cell type lymphoma characterized by proliferation of low-grade B cell type lymphoid cells. The follicular architecture is not significant. Mitoses are not common.
      • Immunohistochemical stain reveals CD20(+), CK(-), CD10(+), Bcl-2(+), cyclin D1(-), CD3 (+ at background T cell), MUM1(-), C-myc(-), CD23(-), CD5(+), Ki67 index: < or = 10%.
      • NOTE: The result of IHC stain is in favor of follicular lymphoma.
    • 2020-09-03 Nasopharyngoscopy
      • Findings: left nasopharynx mild swelling, biopsy done
      • Diagnosis: left nasopharyngeal lesion
    • 2020-08-28 CT - neck
      • Findings
        • a heterogeneous enhancing lesion, about 22mm in the longest axis, in the left nasopharynx.
        • enlarged lymph nodes in the bilateral posterior cervical spaces, and left supraclavicular fossa.
      • IMP: suspected left NPC with bilateral neck enlarged lymph nodes
    • 2020-05-12 Patho - lymph node region resection
      • Lymph node, level IV, V, excision — reactive follicular hyperplasia
      • Microscopically, sections of regional lymph nodes show reactive follicular hyperplasia characterized by prominent uniformly spaced but enlarged germinal centers.They vary considerably in size and shape,and display dumbbell, hourglass,round or bizarre configurations. The mantle zone and germinal centers are sharply demarcated in a reactive follicle. The germinal centers are prominent and hyperplastic and comprise a mixture of small and large lymphoid cells,centrocytes, and centroblasts.Mitotic activity and tingible body macrophages are noted within the germinal centers. The nodal capsule is intact and extranodal extension is not present.
      • Immunohistochemical study revelas Bcl-2: focal negative in germinalcenter, cycline-D1: negative, CD10: neagtive in perigerminal
    • 2020-05-11 Nasopharyngoscopy
      • left neck mass
  • consultation
    • 2022-12-17 Thoracic Surgery
      • Q
        • For insertion chest tube.
        • Under sono- and CT-guiding, drainage of left pleural effusion was performed smoothly (8 Fr. pig-tail catheter) and some yellowish fluid was obtained on 20221216.
        • Now obstruction, so we need help insertion chest tube.
      • A
        • I have visited the patient and reviewed the images. Complicated effusion pending empyema was impressed. VATS (Video-assisted Thoracoscopic Surgery) decortication will be indicated. I have explained the current condition with her family. I will arrange operation as soon as possible. Thanks for your consultation!! (Decortication is a type of surgical procedure performed to remove a fibrous tissue that has abnormally formed on the surface of the lung, chest wall or diaphragm.)
    • 2020-09-23 Dermatology
      • Q
        • However vesicles on left waist for one week and pain sensation was noted. we need your expertise for further management, thanks
      • A
        • Skin finding: some erythematous papules and macules and patches with excoriations on face, trunk and 4 limbs
        • Imp: eczema, r/o chichenpox (low probability)
        • Plan:
          • xyzal 1# HS
          • mycomb cream BID topical used for face, trunk and 4 limbs
    • 2020-05-08 ENT
      • Q
        • This 61 year old female is a case of H/T for 6 years regular medication control.
        • She complained left lower neck mass for one month and went to TaoYuan Land Seed Hospital for help. CT showed left neck mass, suspected lymphoma (3.53.5cm fixed to spine r/o neuroma and one lymph node above it around 11cm). Sono guide biopsy done on 2020/04/28 which revealed atypical lymphoid hyperplasia. Owing to personal reason, she came to our hospital for second opinion and was admitted for further management on 2020/05/07.
        • Deaf and mutism
        • we need your expertise for biopsy of left lower neck, thanks
      • A
        • We will arrange tumor excision next week

700541887

221216

  • diagnosis - 20221215 admission note
    • Malignant neoplasm of transverse colon
    • T-colon CA, pT3N1a cM0, stage IIIB, s/p Op
  • past history
    • The patient had no systemic diseases, including CNS,、CV, and infection
    • history of operation:
      • Uterine myoma s/p myomectomy (2014)
      • Left adrenal tumor s/p op (2017),
      • Thyroid benign nodule s/p bil. thyroidectomy (2020), taking thyroid and hypertension drugs
      • Internal hemorrhoid s/p Ligation (2021/12/21, 2022/01/18)
  • family history
    • Her elder sister was diagnosed of endometrial cancer
    • No members of the family with diabetes.
  • exam finding
    • 2022-09-30 CT - chest
      • Indication: colon cancer S/P op A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
      • Chest CT with and without IV contrast ehnancement shows:
        • Chest:
          • One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. The lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
          • S/p port-A placement with its tip at Superior vena cava.
          • Small lymph nodes are found at left axillary region.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Low density lesion at S2 about 1.71cm in largest dimension is found. Simple cyst is considered.
          • The spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • The liver, pancreas, both kidneys and adrenals are intact.
      • Imp: One ground glass nodule at right lower lobe up to 1.69cm in largest dimension is found. A daughter nodule up to 0.63cm is also found. the lesions are more solid as compared with previous CT on 2022-09-08, infectious process is considered.
    • 2022-09-08 CT - abdomen
      • History and indication:
        • Adenocarcinoma of esophagogastric junction status post laparotomy partial gastrectomy, thoracostomy partial esophacectomy with gastric tube reconstruction and feeding jejunostomy on 2022/07/18, pT3N2M0 stage IIIB
      • With and without-contrast CT of abdomen-pelvis revealed:
        • S/P left adrenectomy.
        • Wall thickening of colon at splenic flexure of colon.
        • Wall thickening of EG junction.
        • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
        • Liver and renal cysts (up to 1.6cm).
        • A calcified spot (5.7mm) at pancreatic body.
        • Normal appearance of spleen, pancreas.
        • Normal appearance of gallbladder. Bile sludge in CBD.
        • Intact bony structures.
        • No ascites, nor enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • Atherosclerosis of the aorta, coronary and iliac arteries.
      • IMP:
        • S/P left adrenectomy.
        • Wall thickening of colon at splenic flexure of colon.
        • Wall thickening of EG junction.
        • A nodule (4.6mm) at RLL. A ground glass opacity (1.6cm) at RLL.
    • 2022-07-19 CXR
      • Atherosclerotic change of aortic arch
    • 2022-07-01 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Liver cyst, S3
        • Renal cyst, right
        • suspicious, angiomyolipoma of right kidney
      • Suggestion
        • semi-annual ultrasound follow up.
    • 2022-04-15 Patho - colon segmental resection for tumor
      • Diagnosis
        • Large intestine, transverse, laparoscopic left segmental colectomy — Adenocarcinoma, moderately differentiated
        • Omentum, partial omentectomy — Negative for malignancy
        • Resection margins: free
        • Lymph node, mesocolic, dissection —- Adenocarcinoma, metastatic (1/14)
        • Lymph node, IMA / SMA, dissection —- Not received
        • AJCC 8th edition Pathology stage: pStage IIIB, pT3N1a(if cM0)
      • Microscopic Description
        • Histologic Type: Adenocarcinoma
        • Histologic Grade: G2: Moderately differentiated
        • Tumor Extension: Tumor invades through the muscularis propria into pericolorectal tissue
        • Margins
          • Proximal margin: Uninvolved
          • Distal margin: Uninvolved
          • Radial or Mesenteric Margin: very close, impending perforation, Distance of tumor from margin: < 0.1 mm
        • Lymphovascular Invasion: Present
        • Perineural Invasion: Present
        • Tumor Budding: Low score (0-4)
        • Type of Polyp in Which Invasive Carcinoma Arose: Not identified
        • Tumor Deposits: Not identified
        • Regional Lymph Nodes:
          • Number of Lymph Nodes Involved/Examined: 1/14; Extranodal involvement: Not identified
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): absent
          • Primary Tumor (pT): pT3: Tumor invades through the muscularis propria into pericolorectal tissues
          • Regional Lymph Nodes (pN): pN1: One to three regional lymph nodes are positive (tumor in lymph nodes measuring >=0.2 mm), or any number of tumor deposits are present and all identifiable lymph nodes are negative
          • Distant Metastasis (pM): if cM0
        • Additional Pathologic Findings (select all that apply): None identified
    • 2022-03-25 CT - abdomen, pelvis
      • Findings:
        • There is asymmetrical wall thickening of the distal transverse colon that is c/w adenocarcinoma.
          • In addition, there are five enlarged nodes in the adjacent mesocolon that may be metastatic nodes.
        • There are two poor enhancing lesion 4 mm in S6 and 6 mm in S4 of the liver that may be cyst. Please correlate with sonography. A hepatic cyst measuring 1.5 cm in S3 is noted.
        • There is no focal lesion in both lung and mediastinum.
        • There are several renal cysts on both kidney and the largest one measuring 1.9 cm in size at right middle pole.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T3 (T_value) N:N2a (N_value) M:M0 (M_value) STAGE:IIIB (Stage_value)
    • 2022-03-21 Patho - colon biopsy
      • Colon, 40 cm from anal verge, biopsy (B) — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
    • 2022-03-21 Colonoscopy
      • Diagnosis
        • Suspect colon cancer, probable distal transverse colon, s/p biopsy, tatto and clipping for localization
        • Colon polyps s/p biopsy removal
        • Internal hemorrhoid
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-12-27 Gynecologic ultrasonography
      • suspected uterine myoma
  • surgical operation
    • 2022-04-14 Laparoscopic left segmental colectomy
      • A 1.5cm depressed tumor lesion is located at distal T-colon
      • After mobilization of splenic and hepatic frexure of colon, segmental resection of T-colon was carried out smoothly. Blood loss was about 30ml.
    • 2022-01-18 Occlusion of Hemorrhoidal Plexus, Open Approach
    • 2021-12-21 Occlusion of Hemorrhoidal Plexus, Open Approach
    • 2020-09-15 Bil. thyroidectomy + neck lymph node resection
      • Hard, ill-defined tumor mass over L’T thyroid gland without extrathyroid extension noted ( frozen section: follicular neoplasm)
      • Several enlarged pre-trachea LNs also noted
    • 2017-11-24 Adrenalectomy
  • chemoimmunotherapy
    • 2022-12-15 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-18 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5160mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-11-04 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5180mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5150mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-10-19 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 730mg 2hr + fluorouracil 2800mg/m2 5140mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-09-07 - oxaliplatin 85mg/m2 155mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5110mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-24 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + granisetron 2mg
    • 2022-08-09 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5090mg 46hr
    • 2022-07-19 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5060mg 46hr
    • 2022-07-04 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-06-20 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2022-06-01 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr

700946496

221214

{Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2(-), stage IIA s/p MRM on 2022-05-13}

  • diagnosis - 2022-11-22 discharge note
    • Malignant neoplasm of unspecified site of left female breast
    • Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles, (Taxotere 60mg/m2) on 2022/09/07~
    • Essential (primary) hypertension
    • Hyperlipidemia, unspecified
    • Gout, unspecified
  • past history
    • Hypertension for >10 years, under medical control in Cathay General Hospital
    • Dyslipidemia for about 3 years under medical control    
  • exam finding
    • 2022-12-06 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 22) / 116 = 81.03%
        • LVEF (%) = 81
        • M-mode (Teichholz) 65
      • Normal LV systolic function with normal wall motion.
      • LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2
      • Normal RV systolic function.
      • Mild to moderate MR; mild TR; aortic valve sclerosis with no AS and AR.
    • 2022-12-05 24Hr Holter ECG
      • Baseline was sinus rhythm
      • Rare isolated VPCs
      • Rare isolated APCs
      • 1 episode of short-run AT, 4 beats
      • No long pause
    • 2022-11-14 Patho - gallbladder (benign lesion)
      • Gallbladder,laparoscopic cholecystectomy — acute cholecystitis
      • The specimen submitted is a gallbladder, in fixed state. The gallbladder measures 6x 3.4x 1.1 cm in size. The serosa is congested and smooth. On opening, the mucosa is eroded. No ulceration is seen. The wall is elastic measuring up to 0.4 cm in thickness. The cystic duct measures 0.3 cm in length and is not remarkable. No gallstone is submitted. Representative sections are taken.
      • Microscopically, it shows chronic cholecystitis with congestion, submucosal fibrosis,and mixed inflammatory infiltrate with Rokitansky-Aschoff sinus formation.
    • 2022-10-28 Patho - stomach biopsy
      • Stomach, PW site of antrum, biopsy — erosion with Helicobacter infection
      • The specimen submitted consists of 3 tissue fragments measuring up to 0.1x 0.1x 0.1 cm in size, fixed in formalin. Grossly, they are brownish and elastic. All for section.
      • Microscopically, it shows erosion with loss of superficial mucosal epithelium. Mild Helicobacter-like bacilli are seen.
    • 2022-10-27 Panendoscopy
      • Diagnosis
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis, s/p CLO test
        • Gastric shallow ulcers and erosions, antrum
        • Gastric ulcer scar, PW site of antrum, s/p biopsy
      • Suggestion
        • Pursue CLO test and biopsy result; EGD F/U if clinincally needed
        • oral PPI use
    • 2022-10-24 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2022-10-21 CT - abdomen
      • History: Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T (Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles
        • MD CT (Revolution) of the chest, abdomen and pelvis was performed with 0.625 mm collimation & 5 mm slice thickness reconstruction. Oral and rectal contrast was not given for bowel opacification. Tri-phasic dynamic CT images were obtained during non-enhanced, arterial phase, portal venous phase, and delayed phase scan following IV contrast injection through autoinjector. Coronal reformated isotropic images were obtained in portal venous phase scan.
      • Findings:
        • S/P Mastectomy, left.
          • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
        • There is no focal lesion in both lung.
          • There are few enlarged nodes in paratracheal space.
          • Follow up is indicated.
        • Left lobe thyroid shows enlarged in size and a lobulated poor enhancing lesion that may be nodular goiter.
          • Please correlate with sonography.
        • The gallbladder shows mild wall thickening but no evidence of calcified stone or distension.
          • A renal cyst measuring 2.5 cm in right middle pole is noted.
        • There are several ovoid-shaped enlarged lymph nodes in the hepatoduodenal ligament that may be benign reactive nodes.
          • Follow up is indicated.
        • There is no focal abnormality in the liver, biliary system, pancreas, spleen & left kidney.
        • There is no ascites.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion over the mesentery and omentum.
      • Impression:
        • S/P Mastectomy, left.
        • There is a cystic-like lesion in the subcutaneous fat layer of left lower chest wall. please correlate with clinical condition.
    • 2022-10-21 SONO - abdomen
      • Diagnosis
        • Fatty liver,mild
        • Suspected fatty infiltration of pancreas
        • Propable GB stone with cholecystopathy
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver,especially liver dome and S1 was diffcult to approach and easy missed
    • 2022-08-15 Patho - soft tissue nontumor/mass/lipoma/debridement
      • Skin and soft tissue, left chest wall wound, debridement — acute inflammation.
    • 2022-07-28 CXR
      • Atherosclerotic change of aortic arch
      • Borderline cardiomegaly
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • 2022-07-07 Foot Bilat
      • fracture at the base of the right 5th metatarsal bone
    • 2022-07-06 CXR
    • Atherosclerotic change of aortic arch
    • Enlargement of cardiac silhouette.
    • 2022-06-16 2D transthoracic echocardiography
        1. Adequate LV systolic function with normal resting wall motion
        1. Dilated LA, septal hypertrophy; LV diastolic dysfunction, Gr 1
        1. Trivial MR and trivial TR
        1. Preserved RV systolic function
        1. Minimal pericardiac effusion
    • 2022-05-16 Patho - breast mastectomy with regional lymph nodes
      • Diagnosis
        • Breast, left, modified radical mastectomy (S2022-8352A) —- Invasive carcinoma. Micro-papillary type.
        • Resection margin: free
        • Lymph node, left, sentinel lymph node biopsy with frozen section (F2022-228FS) — metastatic carcinoma (2/2)
        • Lymph node, left, axilla lymph node dissection (S2022-8352B) — Free (0/22)
        • pT2 pN1a (if cM0); anatomic stage: IIB, at least; pathology prognostic stage: IIA, at least.
      • Microscopic Description
        • For Invasive Carcinoma
          • Histologic type: Invasive carcinoma, micropapillary type
          • Size of invasive carcinoma (mm): 31 x 26 x 25 mm
          • Histologic grade (Nottingham histologic score): grade III (score 8,9)
          • Extent of tumor (required only if the structures are present and involved)
            • Skin involvement: Absent
            • Chest wall invasion deeper than pectoralis muscle: no tissue submitted
        • For Ductal Carcinoma In Situ: not present
        • Margins:
          • Negative, Closest margin (26 mm from deep margin)
        • Nodal status: Positive = 2/2 SLN and 0/22 left axilary LN
          • No. examined: 24
          • No. macrometastases (>2 mm): 2
          • No. micrometastases (>0.2 ~ 2 mm and/or >200 cells): 0
          • No. isolated tumor cells (<=0.2 mm and <=200 cells): 0
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy - no neoadjuvant therapy
        • Immunohistochemical Study: result of biopsy specimen: S2022-07648
          • ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, score= 0/1+), Ki-67 index: 5%.
    • 2022-05-13 Frozen resection
      • Preliminary diagnosis: SLN left - metstatic carcinoma (2/2)
    • 2022-05-13 Lymphoscintigraphy
      • The sentinel lymph node mapping was performed immediately after injection of 0.5 mCi of Tc-99m phytate (s.c) above the left breast. The sequential static images over the chest revealed a focal area of increased accumulation of radioactivity at the left axilla.
      • Impression: Probably a sentinel lymph node at the left axillary region.
    • 2022-05-12 Tc-99m MDP whole body bone scan
      • Increased activity in the lower C-spine and lower L-spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation.
      • Increased activity in the mandible. Dental problem may show this picture.
      • A hot spot in the left parietal area of the skull and some faint hot spots in the anterior aspect of bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and knees, compatible with benign joint lesions.
    • 2022-05-11 2D transthoracic echocardiography
      • Dilated LA
    • 2022-05-11 Lung Flow-Volume Curve
      • mild restrictive impairment
    • 2022-05-11 SONO - abdomen
      • renal cyst, left
    • 2022-05-02 Patho - breast biopsy
      • Diagnosis
        • Breast, left, sono-guide biopsy — invasive carcinoma
      • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells arranged in single-file or cord-like architecture and infiltrative growth pattern, and stromal fibrosis. The tumor cell shows round to oval nuclei, nuclear hyperchromasia, plemorphism,and dot-like nucleoli.
      • IHC stain — ER(+, strong intensity, >95%), PR(+, strong intensity, 70%), Her2/Neu: (-, 0/1+), Ki-67 index: 5%, E-cadherin(+).
    • 2022-05-02 SONO - breast
      • core needle biopsy
      • Left breast tumors, 2’ region and subareolar region, suspected malignancy, suggest biopsy.
      • BI-RADS: Category 4c: highly suspicious abnormality-biopsy should be considered.
    • 2022-03-21 Nerve Conduction Electromyography
      • Findings
        • normal motor DLs, CMAP amplitudes and NCVs of bil. median and ulnar n. Conduction slowing of bil. ulnar n. at elbow.
        • normal sensory DLs, lower SNAP amplitudes and normal NCVs of bil. ulnar n.
        • the F-wave latencies of bil. median and ulnar n. were normal.
      • Conclusion: bil. ulnar n. lesion at elbow
    • 2021-12-06 Neurosonology
        1. Minimal atherosclerosis in right CCA bifurcation.
        1. Adequate total VA flow volume (88 ml/min).
        1. Increased RI in right CCA, bilateral ICA and bilateral VA, indicating distal stenosis.
    • 2021-02-14 CXR
      • Normal heart size.
      • Tortous aorta with calcification is noted.
      • There is no evidence of destructive bone lesion.
      • Scoliotic alignment of the thoracolumbar spine is noted.
      • The lung fields are clear.
      • Clear bilateral costophrenic angle is noticed.
      • Patent airway is found.
      • Suggest clinical correlation
    • 2021-02-14 ECG
      • Normal sinus rhythm
      • Nonspecific ST abnormality
    • 2018-12-10 Flow-volume curve
      • FVC 78%, VC redueced.
    • 2017-09-28 Neck soft tissue
      • mild anterior and posterior spur formation in the lower C-spine
      • moderate decreased disc spaces in the C5/6 and C6/7 discs
    • 2017-01-25 CT - abdomen
      • Findings
        • Diverticulosis of cecum and ascending colon. Perifocal fat stranding of proximal A-colon
        • Bilateral renal cysts.
      • Impression:
        • Acute diverticulitis of A-colon
  • consultation
    • 2022-10-28 General and Gastrointestinal Surgery
      • Q
        • This 76-year-old woman patient is a case of Left breast cancer, pT2N1aM0, ER(+), PR(+), Her2 (-), stage IIA s/p MRM on 2022/05/13 s/p chemotherapy with AC by-T(Adriamycin 60mg/m2, Cyclophosphamide 600mg/m2) on 2022/06/16~2022/08/17 for 4 cycles. This time, for right chest pain radiation back pain developed. Abdominal echo on 2022/10/21 showed fatty liver, mild, suspected fatty infiltration of pancreas and propable GB stone with cholecystopathy. Lab deta with TBI showed increased (6.61–>2.71–>1.28–>1.27mg/dL). Now, for evaluate OP of GB stone. Thank you.
      • A
        • S: Due to suspected GB stones with acute cholecystitis, surgical evaluation is consulted.
        • O:
          • vital signs: stable, no fever
          • abdomen: soft, ovoid, decrease bowel sound, mild RUQ & R’t back tenderness, no Murphy’s sign
          • lab data: see chart
          • CT: GB wall thickness
        • A: Acute acalculous cholecystitis
        • P: NPO, adequate hydration, antibiotics treatment, and closely observation is suggested.
    • 2022-05-11 Rehabilitation
      • This 76 year-old women, she has left breast cancer withleft simple mastectomy + SLNB on 2022/05/13. We were consulted for rehabilitation for preventing complications and post-operation lymphedema.
      • Premorbid functional status
        • Walk ID, ADLs ID.
      • Physical examination
        • Consciousness: clear
        • Cognition: intact
        • MP: RUE/RLE: 5/5, LUE/LLE: 5/5
        • Functional status: ID
        • ADLs: ID
        • Bilateral shoulders PROM:
          • right shoulder pain . Right forward flexion PROM 0-160 with pain. ER 0-60 pain+
          • left shoulder no limitation.
        • Hand and arm circumference (R/L,cm):
          • Elbow joint above 5cm 35/34
          • Elbow joint below 5cm 27/27 rt handed
      • Imp
        • left breast cancer
        • partial mastectomy + SLNB 5/13
      • Plan
        • Rehabilitation programs: Bedside PT rehabilitation and home program education
        • Goal: Functional ability ID, maintain ROM, prevent post-OP complications
  • surgical operation
    • 2022-08-12 Excision of skin or subcutaneous tumor within 2cm
    • 2022-05-13 Simple mastectomy sentinel lymph node biopsy
      • Surgery
        • Left breast MRM (Modified Radical Mastectomy)
      • Finding
        • left breast tumors x2
        • size: 1cm
        • location: retroalreolar
        • size: 2cm
        • location: 2’/2.5cm
  • radiotherapy
    • 2022-05-19 OPD
      • Plan:
        • Adjuvant chemotherapy followed by radiotherapy is indicated for this patient with the following indicators: stage pT2N1a (cM0)
        • Goal: curative
        • Treatment target and volume: left chest wall to SCF
        • Technique: IMRT
        • Preliminary planning dose: 5000cGy/25 fractions of the left chest wall to SCF
  • chemoimmunotherapy
    • 2022-12-13 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-11-21 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-09-26 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-09-06 - docetaxel 60mg/m2 100mg 1hr - D(Q3W)
      • premed - dexamethasone 4mg + diphenhydramine 30mg + metoclopramide 10mg
    • 2022-08-17 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-07-28 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-07-06 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3
    • 2022-06-16 - doxorubicin 60mg/m2 100mg 10min + cyclophosphamide 600mg/m2 1000mg 1hr - AC(Q3W)
      • premed - dexamethasone 4mg + aprepitant 125mg D1-D3

[note]

  • Breast Cancer NCCN Evidence Blocks, version 2.2022, 2021-12-20
    • BCS (breast-conserving surgery) not possible (p20)
      • Mastectomy and surgical axillary staging + reconstruction (optional)
        • Adjuvant systemic therapy + post-mastectomy adjuvant RT
          • cN+ and ypN0: Strongly consider RT to the chest wall and comprehensive RNI (regional nodal irradiation) with inclusion of any portion of the undissected axilla at risk.
          • Any ypN+: RT is indicated to the chest wall + comprehensive RNI with inclusion of any portion of the undissected axilla at risk.
        • Adjuvant systemic therapy without adjuvant RT for any cN0,ypN0 if axilla was assessed by SLNB or axillary node dissection
    • Preoperative/Adjuvant therapy regimens (p55)
      • HER2-Negative
        • Preferred Regimens:
          • Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
          • Dose-dense AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
          • TC (docetaxel and cyclophosphamide)
          • Olaparib, if germline BRCA1/2 mutations
          • High-risk triple-negative breast cancer (TNBC): Preoperative pembrolizumab + carboplatin + paclitaxel, followed by preoperative pembrolizumab + cyclophosphamide + doxorubicin or epirubicin, followed by adjuvant pembrolizumab
          • TNBC and residual disease after preoperative therapy with taxane-, alkylator-, and anthracycline-based chemotherapy: Capecitabine
        • Useful in Certain Circumstances:
          • Dose-dense AC (doxorubicin/cyclophosphamide)
          • AC (doxorubicin/cyclophosphamide) every 3 weeks (category 2B)
          • CMF (cyclophosphamide/methotrexate/fluorouracil)
          • AC followed by weekly paclitaxel
          • Capecitabine (maintenance therapy for TNBC after adjuvant chemotherapy)
        • Other Recommended Regimens:
          • AC followed by docetaxel every 3 weeks
          • EC (epirubicin/cyclophosphamide)
          • TAC (docetaxel/doxorubicin/cyclophosphamide)
          • Select patients with TNBC: -Paclitaxel + carboplatin (various schedules) -Docetaxel + carboplatin (preoperative setting only)

==========

2022-12-14

  • The underlying conditions in this patient include: essential (primary) hypertension, hyperlipidemia, gout.
  • 2D transthoracic echocardiography (2022-12-06) revealed: LV posterior wall thickening, dilated LA; LV diastolic dysfunction Gr 2; Mild to moderate MR; mild TR; aortic valve sclerosis.
  • Available records of blood uric acid levels showed no exceeding the upper limit of normal.
    • 2022-10-22 Uric Acid 3.9 mg/dL
    • 2022-07-19 Uric Acid 5.1 mg/dL
  • Gout patients with established cardiovascular (CV) disease treated with febuxostat had a higher rate of CV death compared to those treated with allopurinol in a CV outcomes study. Consider the risks and benefits of febuxostat when deciding to prescribe or continue patients on febuxostat. Febuxostat is recommended only used in patients who have an inadequate response to a maximally titrated dose of allopurinol, who are intolerant to allopurinol, or for whom treatment with allopurinol is not advisable.
  • As an alternative to xanthine oxidase inhibitors, the uric aicd resorption suppressor benzbromarone might be another candidate for treating gout.

2022-09-07

  • A decline in renal function has been observed. Time series lab log:
    • Date // Creatinine // eGFR
    • 2022-09-06 1.22 45.55 (CrCl ~ 40 mL/min)
    • 2022-08-30 1.19 46.87
    • 2022-08-17 0.91 63.88
    • 2022-08-09 0.77 77.46
  • The kidneys excrete little docetaxel (~6%), therefore, the need for docetaxel dosage adjustments for renal dysfunction is unlikely.
  • Allegra (fexofenadine 60mg/tab) for GFR 10 to 50 mL/min: Recommended dose every 12 to 24 hours. A possible change is from BID to QD.
  • Promeran (metoclopramide 3.84mg/tab) for CrCl >10 to 60 mL/min: Administer ~50% of usual total daily dose. A change from TIDAC to BIDAC might be considered.
  • During this hospitalization, the blood pressure was well controlled. The laboratory data related to hyperlipidemia have not been updated since October 2021. A number of tests might be ordered, e.g., TC, LDL-C, Non-HDL-C, ApoB, TG, HDL-C, and ApoA-1.

2022-08-18

  • There was no evidence of intolerance.
  • The TPR and blood pressure were stable during this hospitalization and the lab results for 2022-08-17 were generally normal.
  • Underlying cardiovascular conditions are managed with Sevikar (amlodipine + olmesartan), Concor (bisoprolol) and Crestor (rosuvastatin) without issues.

2022-07-07

  • Since mid-June 2022, the patient has been receiving doxorubicin and cyclophosphamide.
  • An optional addition might be tamoxifen or an aromatase inhibitor. (A Comparison of Letrozole and Tamoxifen in Postmenopausal Women with Early Breast Cancer. https://www.nejm.org/doi/pdf/10.1056/NEJMoa052258 )

701362191

221214

  • diagnosis
    • 2022-07-18 discharge note
      • Malignant neoplasm of pyloric antrum
      • Gastric cancer s/p lap radical Subtotal gastrectomy with D2 dissection on 2022/03/07, pT4aN1M0, stage IIIA s/p chemotherapy with FOLFOX (from 2022/04/12~2022/06/21 for 6 cycles)
      • Type 2 diabetes mellitus without complications
  • exam findings
    • 2022-10-09 Wrist RT
      • Normal bone alignment
      • mild decreased right wrist joint space
    • 2022-08-10 SONO - abdomen
      • Normal sonographic study of the hepatobiliary system.
    • 2022-07-01 CT - abdomen
      • History: epigastric pain
        • UGI scope revealed gastric ca at lower body.
        • 20220223 CT:gastric cancer, cT3N0M0, cSTAGE:IIB
        • 20220308 subtotal gastrectomy PATHO: pT4aN1(if cM0); pstage IIIA
      • Findings:
        • S/P subtotal gastrectomy
        • S/P IUD retention within the endometrial cavity.
      • Impression:
        • S/P subtotal gastrectomy.
        • There is no evidence of tumor recurrence.
    • 2022-03-08 Patho - stomach subtotal/total (tumor)
      • Diagnosis:
        • Stomach, middle body, lesser curvature, laparoscpic subtotal gastrectomy — Poorly cohesive carcinoma with signet-ring cell differentiation
        • Cut-ends, proximal and distal, laparoscpic subtotal gastrectomy — Free
        • Lymph node, LN 1, dissection — Negative for malignancy (0/1)
        • Lymph node, LN 3, dissection — Metastatic carcinoma (2/8)
        • Lymph node, LN 4, dissection — Negative for malignancy (0/9)
        • Lymph node, LN 5, dissection — Negative for malignancy (0/3)
        • Lymph node, LN 6, dissection — Negative for malignancy (0/4)
        • Lymph node, LN 7,8,9,11p, 12a, dissection — Negative for malignancy (0/18)
        • Lymph node, LN14V, dissection — Negative for malignancy (0/1)
        • AJCC 8th edition Pathology stage: pT4aN1(if cM0); AJCC stage IIIA
      • Microscopic Description:
        • Histologic Type — Poorly cohesive carcinoma with signet-ring cell differentiation
        • Histologic Grade — Poorly differentiated
        • Tumor Extension — Tumor invades the serosa (visceral peritoneum)
        • Margins
          • Proximal margin: uninvolved by invasive carcinoma
          • Distal margin: uninvolved by invasive carcinoma
          • Radial margin: uninvolved by invasive carcinoma
        • Lymphovascular Invasion: present
        • Perineural Invasion: present
        • Regional Lymph Nodes — Number of lymph nodes examined: positive (2/44)
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply)
            • m (multiple primary tumors) r (recurrent) y (posttreatment)
            • Primary Tumor (pT) — pT4a: Tumor invades the serosa (visceral peritoneum)
            • Regional Lymph Nodes (pN) — pN1: Metastasis in one or two regional lymph nodes
            • Distant Metastasis (pM) (required only if confirmed pathologically in this case) — N/A
          • IHC stain— CK(+), CK20(focal+), CK7(+), CDX-2(+)
    • 2022-03-04 Patho - stomach biopsy
      • Tumor, gastric angle, biopsy — Poorly cohesive carcinoma with signet-ring cell differentiation
      • Microscopically, the sections show a picture of poorly cohesive carcinoma with signet-ring cell differentiation characterized by linear or individual tumor cells infiltrating in stroma.
      • Immunohistochemistry of CK(+) and Her2 (-, Dako score 0) for tumor cell.
      • Besides, colony of Helicobacter Pylori is not present in the submitted specimen.
    • 2022-02-23 CT - abdomen, gastric filling with water
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T3 (T_value) N:N0 (N_value) M:M0 (M_value) STAGE:IIB(Stage_value)
  • surgical operation
    • 2022-03-07 laparoscpe subtotal gastrectomy with LN D2 dissection
      • Finding
        • 3cm ulcerative mass at middle body lesser curvature with serosa involve
        • regional LN enlarge at station 3
        • peritoneal seeding (-)
        • ascite (-)
        • cT4aN1M0
  • chemoimmunotherapy
    • 2022-12-13 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-11-24 - oxaliplatin 85mg/m2 165mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-11-09 - oxaliplatin 75mg/m2 145mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-10-17 - oxaliplatin 65mg/m2 120mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr # Allergy with whole body skin redness rash with itch after chemotherapy with Oxalip
      • premed - dexamethasone 4mg + diphenhydramine 30mg + palonosetron 250ug + famodidine 20mg + aprepitant 125mg PO D1-D3
    • 2022-09-13 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 580mg 2hr + fluorouracil 300mg/m2 580mg 10min + fluorouracil 2400mg/m2 4500mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-08-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-07-18 - leucovorin 20mg/m2 40mg 10min D1 + fluorouracil 400mg/m2 600mg 10min D1 (CCRT)
      • premed - dexamethasone 4mg + metoclopramide 10mg D1
    • 2022-07-12 - leucovorin 20mg/m2 40mg 10min D1-4 + fluorouracil 400mg/m2 600mg 10min D1-D4 (CCRT)
      • premed - dexamethasone 4mg + metoclopramide 10mg D1-D4
    • 2022-06-21 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
      • premed - dexamethasone 4mg + palonosetron 250ug + aprepitant 125mg PO D1-D3
    • 2022-06-07 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-05-24 - oxaliplatin 75mg/m2 150mg 24hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 300mg/m2 600mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-05-10 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-04-26 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr
    • 2022-04-12 - oxaliplatin 85mg/m2 170mg 24hr + leucovorin 400mg/m2 800mg 2hr + fluorouracil 400mg/m2 800mg 10min + fluorouracil 2400mg/m2 5000mg 46hr

==========

2022-12-14

  • It has not been observed that there is an allergy resulting in a skin rash or itching after the addition of diphenhydramine and famodidine as the premedication since Oct 2022.
  • During this hospital stay, the FS blood sugar levels were around 200 mg/dL. The available blood sugar records indicate that the patient’s blood sugar levels almost always exceed the upper limit of normal for the past months. If no imaging is scheduled that requires iodinated contrast, metformin 500mg BID is recommended since her kidneys do not exhibit any insufficiency.

2022-11-25

  • Perhaps due to a lack of authorization from the patient, the recent 3-month prescription list is not available from PharmaCloud at present.
  • According to the admission note, the patient regularly takes both Amepiride (glimepiride) and meformin to control her type 2 DM.
  • For the renal hyperfiltration (2022-11-23 eGFR 133) was still noted and her preprandial blood sugar level is still high (173mg/dL 2022-11-25 07:02) under current single antidiabetic agent Amepiride (glimepiride), it is recommended that metformin be added to her active prescription as a patient-carried item if no imaging scheduled.

2022-11-10

  • A preprandial blood sugar level of 198mg/dL was recorded on 2022-11-10 morning.
  • The renal hyperfiltration (2022-11-03 eGFR 125) driven by increased glomerular filtration pressure and by glucose diuresis can affect renal O2 consumption that unleashes detrimental sympathetic activation. The sodium-glucose co-transporters inhibitors (SGLTi) can rebalance the reabsorption of Na+ coupled with glucose and can restore renal O2 demand, diminishing neuroendocrine activation. (ref: The Benefit of Sodium-Glucose Co-Transporter Inhibition in Heart Failure: The Role of the Kidney. Int J Mol Sci. 2022;23(19):11987. Published 2022 Oct 9. doi:10.3390/ijms231911987)
  • There is only one antidiabetic agent Amepiride (glimepiride) in the active prescription. The SGLT2i drugs empagliflozin, dapagliflozin, and canagliflozin are available in stock and could be considered if UTI is unlikely.

2022-10-18

  • This patient has been prescribed Amepiride (glimepiride) for months, which may cause body weight gain, however, her body weight has decreased by more than 15kg during the past seven months (85kg 2022-10-17 <- 101kg 2022-03-06). Is it an intentional diet cuased weight loss or an unintentional weight loss? Did insulin resistance result in body breakdown or poor dietary intake?
  • Pre-breakfast blood sugar level reached 215 mg/dL on 2022-10-18 under metformin and glimepiride. If fasting levels persist over 200 mg/dL for two consecutive days, acarbose, vidagliptin, or dapagliflozin might be added to the current medication list.

700105612

221212

  • exam findings
    • 2022-12-09 CT - brain
      • Indication: confusion
      • Findings
        • brain atrophy with prominent sulci, fissures and dilated ventricles.
        • confluent hypodensity at bilateral periventricular white matter, indicating leukoaraiosis.
        • no acute intracranial hemorrhage.
        • no definite skull lesion.
        • chronic left maxillary sinusitis.
      • Impression:
        • Brain atrophy and leukoaraiosis.
        • Chronic left maxillary sinusitis.
    • 2022-12-09 CXR
      • Cardiomegaly is noted.
      • Osteopenia of the bony structure is noted.
      • Senile fibrotic change is noted at lung fields.
    • 2022-11-04 Water’s view
      • Opacification of left maxillary sinus.
    • 2022-11-04 Nasopharyngoscopy
      • sticky post nasal drip
    • 2022-10-26 CXR
      • S/P coronary artery stent implantation.
      • Enlargement of cardiac silhouette.
    • 2022-02-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (82.2 - 29.0) / 82.2 = 64.72%
        • M-mode (Teichholz) = 64.7
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Trivial mitral and tricuspid regurgitation
      • Impaired LV relaxation
      • Mildly thick IVS and LVPW
    • 2022-02-09 CXR
      • Patchy opacity projecting in the right lower mediastinum shows stationary.
      • S/P coronary artery stent implantation.
    • 2022-02-09 ECG
      • Sinus rhythm with Premature supraventricular complexes and with occasional Premature ventricular complexes
    • 2022-09-23 CXR
      • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated.
      • S/P coronary artery stent implantation.
    • 2021-09-23 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (87.7 - 36.2) / 87.7 = 58.72%
        • M-mode (Teichholz) = 58.7
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • AV sclerosis with trivial AR, mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2021-08-26 Patho - gingival/oral mucosa biopsy
      • Bone, left maxilla, excisional biopsy — Dead bone with acute and chronic inflammation
      • Section shows squamous mucosa and dead bone with granulation tissue, fibrosis, and acute and chronic inflammation.
      • The immunohistochemical stain of CD138 shows no aggregation of plasma cells in bone.
    • 2020-12-07 CXR
      • Patchy opacity projecting in the right lower mediastinum is suspected. Follow up is indicated. Otherwise, Please correlate with CT.
      • S/P coronary artery stent implantation.
    • 2020-12-07 ECG
      • Sinus rhythm with Premature atrial complexes
      • Increased R/S ratio in V1, consider early transition or posterior infarct
    • 2020-11-03 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Myeloma.
      • IHC stains: CD138 : 10-15%, lambda light chain > kappa light chain. IgA: 10-15%, IgG: <5%.
      • Section shows piece(s) of bone marrow with 40-50% cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number. There are a few plasmacytoid cells present.
    • 2020-08-14 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Negative for malignacy (CD138+ plasma cell: < 5%)
      • Microscopically, it shows 3 % of cellularity, 1:1 of M:E ratio, presece of trilinegae cellular component and ocassional megakaryocytes.
      • Immunohistochemical stain reveals CD138(< 5%), CD71(+), CD20(-), CD117(-), Kappa(-), MPO(focal+), CD117(-).
      • NOTE: Clincal correlation is essential.
    • 2020-06-24 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (116 - 30) / 116 = 74.14%
        • M-mode (Teichholz) = 74
      • Septal hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis; degenerative changes of mitral valve with trivial MR.
      • Dilated proximal ascending aorta (35mm); mild aortic root calcification.
    • 2020-04-10 Patho - bone marrow biopsy
      • Bone marrow, iliac, history of myeloma (S2018-2795), biopsy — Compaible with replased of myeloma.
      • IHC stains: CD138: 10-15% of the nucleated cells, lambda > kappa, approximately 3:1.
      • Section shows one piece of bone marrow with 30 % cellularity and M:E ratio of approximately 3:1. There is aprroxomately 10-15% of the plasmcytoid cells demonstrated by IHC stain of CD138. lambda > kappa, approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
    • 2020-03-20 Patho - breast biopsy
      • Breast, right, sono-guided biopsy — Gynecomastia
    • 2020-03-20 SONO - breast
      • Subareolar duct development, both side, gynecomastia should be considered. Suggest clinical correlation.
    • 2019-03-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (105 - 36) / 105 = 65.71%
        • M-mode (Teichholz) = 65
      • Septal and RV hypertrophy with Gr I LV diastolic dysfunction and impaired RV relaxation.
      • Normal LV and RV systolic function.
      • Mild AV sclerosis; mild MR; mild PR.
    • 2018-10-25 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (102 - 30.3) / 102 = 70.29%
        • M-mode (Teichholz) = 70.3
      • Normal chamber size
      • Adequate LV and RV performance
      • Possibly impaired LV relaxation
      • AV sclerosis with trivial AR ; mild MR, TR and PR
      • No regional wall motion abnormalities
    • 2018-09-07 Surgical pathology Level IV
      • Bone marrow, iliac, biopsy — see description.
      • Section shows one piece of bone marrow with 50 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes. Megakaryocytes are adequate in number.
      • IHC stain shows approximately 10 % of CD138 (+) plasmacytoid cells with slightly more kappa than lambda light chain stain, suggestive of few residual neoplastic cells. Additional CD34 (+) <1%, CK (-).
    • 2018-04-03 MRI - T-spine
      • Indication: A case of myeloma, T, L spine survey, for chest pain
      • Findings:
        • Moderate degree of old compression fracture of T3 vertebral body.
        • Abnormal enhanced lesions in T3, T4, T5, T7, T8 T12, and L1 vertebrae (as hypointense on T1WI).
        • Mild degree of compression fracture of T9 vertebral body (hypointense on T1WI, hyperintense on STIR images), with abnormal enhancement.
        • Marginal spurs of multiple vertebral bodies.
        • Mild thickening of ligamentum flavum at T10-T11 level..
        • The visualizedl spinal cord shows normal size and signal intensity. There is no extrinsic compression of the cord.
      • Impression:
        • multiple myeloma with T4 and T9 compression fracture and small enhancing
        • lesions in multiple vertebrae.
    • 2018-03-19 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (111 - 28) / 111 = 74.77%
        • M-mode (Teichholz) = 74
      • Adequate LV systolic function with normal resting wall motion
      • Dilated LA, LV diastolic dysfunction, Gr 1
      • Mild MR, mild TR
      • Preserved RV systolic function
    • 2018-03-19 ECG
      • Sinus rhythm with Premature atrial complexes
    • 2018-02-20 Surgical pathology Level IV
      • Bone marrow, biopsy — Plasma cell myeloma
      • The sections show slightly hypercellular marrow (50%). Sheets of mature plasma cells with numerous Russell bodies in interstitium, account for 50% nucleated cells in CD138 immunostain. These plasma cells also reveal kappa light chain restriction and negative for lambda light chain.
    • 2017-04-17 CT - heart CTA
      • History:
        • 20110128
          • Admitted due to exertional dyspnea and palpitation, cardiac catheterlization was perforemd smoothly and reveaeld CAD, LAD. middle, right hand cath wound clear, still irregular heart rate and DOE, keep medication therapy.
          • History of abnormal LFT told in Cathay General Hospital even with lipitor for 10 mg ∕QD
        • 200812
          • Referred from chief Lin, hx of Palpitation, and short run of Af; palpitation when emotional upset. Palpitation and chest pain for 17 years.
          • Holter ECG in Cathay General Hospital showed occasional APC and VPCs with 4minutes of short run Af with no symptoms even with lipitor for 10 mg ∕QD
      • Nonenhanced ECG-gated CT for calcium scoring and enhanced spiral CT of heart and coronary arteries were obtained using 256-slice multidetector row CT scanner (iCT philips) showed:
        • Calcification of the coronary arteries (total calcium score=643, LMA=7.33, LAD=514.48, LCX=77.31, RCA=43.87)
        • Left main coronary artery: Patent
        • Left anterior descending coronary artery: calcified plaques in S6, S7, and S8, with severe stenosis in S7 and S8.
        • Visible diagonal branches: Patent
        • Left circumflex coronary artery: Patent
        • Visible obtuse marginal branches: Patent
        • Right coronary artery: Patent
        • Posterolateral and posterior descending branches: Patent
        • Pericardium : Unremarkable
        • Cardiac structure and morphology: Normal cardiac chamber size
        • Lungs: Unremarkable
        • Mediastinum and hilars: No mass lesion
        • Visible abdominal contents: Unremarkable
      • Impression
        • Total calcium score = 643, indicating extensive atherosclerotic plaque burden.
        • Atherosclerosis major coronary arteries with significant stenosis in LAD, S7 and S8.
        • No lung nodule.
    • 2017-04-12 24hrs Holtor’s scan
      • Sinus rhythm
      • Occasional isolated apcs
      • Rare apc couplets
      • A few isolated vpcs
      • No long pause
      • No significant tachyarrhythmia
    • 2017-03-06 MRI - L-spine
      • Mild cervical spondylosis.
      • Disc bulge with mild stenotic lateral recesses, L3-L4,L4-L5.
      • Multilevel degenerative disc disease.
  • consultation
    • 2022-12-12 Family Medicine
      • Q
        • The 76 y/o man has IgA Multiple myeloma, 20180223 proved with bone marrow study. VTD from 20180301, S/P autoPBSCT on 20190306, complicated with HSV-1 genital ulcer infection (20190401). S/P Lenalidomide + dexa. Daraturumab + Velcade + dexa. Kyrolip + dexa. IgA level in progress. Last time, he received chemotherapy as Kyrolip on 2022/11/11. He has poor intake for 3 weeks, just 1 meal a day and lay down all day. He denied take medicine as oral steroid and oral chemotherapy. This time, he has multiple bone pain for 2 weeks and in progress, and yellow snivel around 1 month (his wife not sure), so he was brought to our ED for help. At ED, the lab data showed anemia, mild elevated CRP level and hypokalemia. Due to confusion consciousness, brain CT was arranged at ER and showed 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. Under the impression of IgA MM without control and severe bone pain, and malnutrition, so he was admitted on 2022/12/09.
        • Due to disease progression, the patient’s family ask for palliative care. We need your help for further evaluation. Thank you very much.
    • 2022-12-12 Neurology
      • Q
        • Due to confusion consciousness, brain CT was arranged at ER and showed: 1. Brain atrophy and leukoaraiosis, 2. Chronic left maxillary sinusitis. We need your help for further evaluation and treatment suggestion. Thank you very much.
  • surgical operation
    • 20190306 autoPBSCT
  • chemoimmunotherapy
    • 2022-11-11 - Kyprolis (carfilzomib) 70mg/m2 100mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-09-21 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-09-07 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-08-17 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-08-03 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-07-20 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-07-06 - Kyprolis (carfilzomib) 70mg/m2 110mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-06-15 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
    • 2022-05-25 - Kyprolis (carfilzomib) 70mg/m2 115mg 1hr
    • 2022-05-04 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-04-20 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-04-06 - Kyprolis (carfilzomib) 70mg/m2 116mg 1hr
    • 2022-03-23 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
    • 2022-03-09 - Kyprolis (carfilzomib) 70mg/m2 118mg 1hr
    • 2022-03-02 - Kyprolis (carfilzomib) 50mg/m2 85mg 1hr
      • premed - diphenhydramine 30mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2022-03-02 - Kyprolis (carfilzomib) 20mg/m2 34mg 1hr
      • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2021-12-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
      • premed - diphenhydramine 50mg + dexamethasone 20mg + acetaminophen 1000mg
    • 2021-12-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-11-03 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-10-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-09-01 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-08-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-07-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-06-15 - Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-05-18 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-04-27 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-04-06 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-03-16 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-02-23 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 1000mg 3.5hr
    • 2021-02-02 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-29 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2021-01-26 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-22 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2021-01-19 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2021-01-04 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-31 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2020-12-28 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-21 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 3.5hr
    • 2020-12-14 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
    • 2020-12-11 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min
    • 2020-12-07 - Velcade (bortezomib) 1.3mg/m2 2.2mg SC 1min + Darzalex (daratumumab) 900mg 7hr
    • 2018-03-19 ~ 2018-11-28 - Velcade (bortezomib) 2.25mg SC (weekly, biweekly, triweekly)
    • 2020-11-13 ~ 2021-07-21 - Xgeva (denosumab) 120mg Q1M SC
    • 2018-04-06 ~ 2019-01-03 - Zobonic (zoledronic acid) 4mg IV (roughly monthly)
    • 2021-08-04 ~ 2022-11-25 - Endoxan (cyclophosphamide) 50mg BID PO
    • 2020-05-15 ~ 2020-10-29 - Revlimid (lenalidomide) 25mg QD PO
    • 2018-03-19 ~ 2020-01-31 - Thado (thalidomide) 50mg HS PO

[assessment]

  • FS blood sugar levels from 2022-12-10 to 2022-12-11 were approximately 300 to 400 mg/dL. If the reading on 2022-12-12 still exceeds 200 mg/dL (regular insulin 8 unit has been prescribed since 2022-12-11), then addition of basal insulin might be considered.

700071716

221209

{NSCLC, not completed}

  • diagnosis - 2022-12-09 discharge note
    • Right upper lobe lung cancer, adenocarcinoma, T2bN1M1b with bone metastasis, ECOG 1
    • Encounter for antineoplastic chemotherapy
    • Encounter for antineoplastic immunotherapy
    • Chronic viral hepatitis B without delta-agent
    • Hypertension
    • paronychia with granulation over toenail
    • Suspect folliculitis with secondary irriation eczema
    • mebomian gland dyusfunction
    • Dry eye
    • Reflux esophagitis LA Classification grade A
  • lab data
    • 2021-10-13 ROS1 FISH not detected
    • 2021-10-08 ROS1 IHC Negative
    • 2021-10-06 EGFR G719X not detected
    • 2021-10-06 EGFR Exon19 del not detected
    • 2021-10-06 EGFR S768I not detected
    • 2021-10-06 EGFR T790M not detected
    • 2021-10-06 EGFR Exon20 ins not detected
    • 2021-10-06 EGFR L858R detected
    • 2021-10-06 EGFR L861Q not detected
    • 2021-10-05 ALK IHC Negative
    • 2021-10-05 PD-L1 (22C3) TPS>=1% and <50%
    • 2021-09-22 Anti-HCV Nonreactive
    • 2021-09-22 Anti-HCV Value 0.05 S/CO
    • 2021-09-22 HBsAg Nonreactive
    • 2021-09-22 HBsAg (Value) 0.35 S/CO
    • 2021-09-22 Anti-HBs 7.64 mIU/mL
  • exam findings
    • 2021-09-22 Patho - lung transbronchial biopsy
      • Lung, right, CT-guide biopsy—adenocarcinoma, moderately differentiated
      • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
  • consultation
    • 2022-12-06 Dermatology
      • A
        • The patient had sufferred from pronychia with granulation formaiton. several itchy papules over expose area with mild vesicles was noted.
        • Under the impression of paronychia with granulation over toenail. suspected folliculitis with secondary irriation eczema.
        • The following sugeetion:
          • Do cryotherapy at Derma OPD and further wound care with tetracycline onit 1 tube topical bid use.
          • consider Doxycycline 1# bid and allgrea 1# bid po use for 7 days.
          • Ulex cream 1 tube topical bid over itchy papules of the trunk.
    • 2022-12-06 Ophthalmology
      • A
        • S: bilateral eye strain and pain for 2 days
        • O
          • bcva od 0.15(1.0/-2.5) os 0.1(1.0x-2.25)
          • pt 18/18 mmHg
          • pupil: 3mm+/+, 3mm+/+, no rapd
          • MGD
          • conj: np ou
          • K: cl ou
          • ac deep and clear ou
          • lens ns+
          • c/d: 0.5-6 neurorim ok
        • A
          • mebomian gland dyusfunction ou
          • dry eye ou
        • P
          • tear nature 1gtt qid ou
          • if s/s worsen, come back earlier
  • chemoimmunotherapy
    • 2022-12-06 - Opdivo (nivolumab) 100mg 1hr
    • 2022-12-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-11-14 - Opdivo (nivolumab) 100mg 1hr
    • 2022-11-10 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-10-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-09-27 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-09-06 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-08-16 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-07-26 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-07-05 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-06-14 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-05-24 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-05-03 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-04-12 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-03-22 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-03-01 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-02-08 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-01-11 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-12-21 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2022-11-30 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-11-09 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-10-19 - Avastin (bevacizumab) 7.5mg/m2 500mg 1hr
      • premed - diphenhydramine 30mg
    • 2021-10-07 ~ undergoing - Giotrif (afatinib 30mg) 1# QDAC
    • 2022-09-05 - Xgeva (denosumab) 120mg SC
    • 2022-08-13 - Xgeva (denosumab) 120mg SC
    • 2022-07-15 - Xgeva (denosumab) 120mg SC
    • 2022-06-13 - Xgeva (denosumab) 120mg SC
    • 2022-05-02 - Xgeva (denosumab) 120mg SC
    • 2022-04-08 - Xgeva (denosumab) 120mg SC
    • 2022-03-11 - Xgeva (denosumab) 120mg SC
    • 2022-02-07 - Xgeva (denosumab) 120mg SC
    • 2022-01-07 - Xgeva (denosumab) 120mg SC
    • 2021-12-10 - Xgeva (denosumab) 120mg SC

700191291

221209

  • lab data
    • 2022-04-21 ROS1 IHC
      • The immunostaining of the section slide labeled S2022-03626, using ROS1(SP384) antibody along with a Ventana autostainer system, revealed 1+ cytoplasmic staining, in over 50%, of tumor cells.
    • 2022-03-28 PD-L1 (22C3)
      • Tumor Proportion Score (TPS) assessment: TPS >= 50%
      • Tumor Proportion Score (TPS): 50%
    • 2022-03-21 ROS1 FISH
      • Rearrangement of ROS1 gene is NOT detected.
      • Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
    • 2022-03-18 EGFR gene mutation
      • The EGFR mutation testing was for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681, Insertions), 21 (L858R, L861Q) mutations of EGFR gene.
      • A point mutation was detected at exon 21 (L858R) of EGFR gene in this specimen.
    • 2022-03-17 ALK IHC
      • The immunostaining of the section slide labeled S2022-03626, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining of tumor cells.
    • 2022-03-03 Anti-HCV Nonreactive
    • 2022-03-03 Anti-HCV Value 0.04 S/CO
    • 2022-03-03 HBsAg Nonreactive
    • 2022-03-03 HBsAg (Value) 0.39 S/CO
    • 2022-03-02 Mycoplasma IgM Negative Index
    • 2022-03-02 Mycoplasma IgM Value 0.1 Index
  • exam findings
    • 2022-12-07 Tc-99m MDP whole body bone scan
      • Findings:
        • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • Impression:
        • All of above-mentioned bone lesions are old and most of them show stationary or less evident compared with the previous study on 2022-07-13, indicating partial response to current therapy.
        • There is still lung cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-12-06 MRI - brain
      • As compared with prior MRI (2022/07/12), markedly regression of the multiple nodules over bil. cerebellar and cerebral, no obvious edema was found.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
      • Paranasal sinusitis.
    • 2022-12-06 CT - chest
      • Indication: lung cancer restaging
      • Findings: Comparison was made with previous CT dated on 2022/07/12
        • Lungs:
          • normal appearance of RML, RLL, and left lung.
          • residual spiculated RUL tumor with corona radiata (26mm in longest dimension), in comparison with the previous study, the lesion is slightly decreasing in size.
          • Mediastinum and hila: no enlarged LN.
        • Vessels:
          • Aorta: normal caliber of thoracic aorta.
          • Central pulmonary arteries: normal caliber.
          • Heart: normal in size of cardiac chambers.
        • Pleura: minimal residual bilateral effusions.
        • Visible abdominal contents:
          • no abnormal density and size of visible portion of the liver, spleen, both adrenal glands, and pancreas
          • no enlarged lymph node.
        • Visualized bones: destructive lytic or blastic change in visualized bones with pathological compression fracture of many vertebral bodies, stationary.
      • Impression:
        • RUL cancer with slightly decrease in size of primary tumor and stationary of bony metastasis as compared with CT on 2022/07/12
    • 2022-12-05, -09-04, -08-08 CXR
      • osteolytic/blastic metastases in multiple bones of thoracic cage
      • a nodular opacity (ill-defined) over RUL, consistent a primary lung cancer, stationary
      • marginal spurs of multiple vertebral bodies due to spondylosis
      • Lt subpulmonary effusion?
    • 2022-07-13 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • IMPRESSION:
        • Most of above-mentioned bone lesions are old and show stationary or less evident compared with the previous study on 2022-03-09, indicating partial response to current therapy.
        • Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-07-12 MRI - brain
      • Findings: comparison 2022/03/08 MRI
        • Markedly regression of the multiple bil. cerebellar and cerebral nodules, no obvious edema was found
        • After IV contrast administration shows no obvious focal nodule.
        • Normal cisterns and sulcal systems.
        • Normal bilateral ventricular size and shapes.
        • Normal appearance of bilateral cochlear and vestibular nerves complexes.
        • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
      • Imp:
        • Markedly regression of the multiple bil. cerebellar and cerebral nodules
    • 2022-07-12 CT - chest
      • Findings: Comparison was made with previous CT dated on 20220303
        • Lungs:
          • normal appearance of RML, RLL, and left lung.
          • residual spiculated RUL tumor (26mm in longest dimension), in comparison with the previous study, the lesion is significantly dencreasing in size.
          • Mediastinum and hila: complete resolution of extensive lymphadenopathy in the visceral space and anterior prevascular space and Rtt hilum as compared with previous CT
        • Vessels:
          • Aorta: normal caliber of thoracic aorta.
          • Central pulmonary arteries: normal caliber.
          • Heart: normal in size of cardiac chambers.
        • Pleura: minimal residual bilateral effusions.
        • Visible abdominal contents:
          • Rt Lt bilateral renal cysts stone up to cm (longest axial diameter)
          • a hepatic cyst multiple hepatic cysts up to cm (longest axial diameter).
          • normal appearance of gallbladder. gall bladder stones up to cm.
          • no abnormal density and size of visible portion of the unremarkable of the liver, spleen, both adrenal glands, pancreas, and both kidneys. bile ducts: No dilatation.
          • no enlarged lymph node.
        • Visualized bones: destructive lytic or blastic in visualized bones with pathological compression fracture of many vertebral bodies, in regression.
      • Impression:
        • RUL cancer with significant decreased size of primary tumor and resolution of mediastinal-hilar LAPs, and regression bony metastasis compared with CT on 20220303
    • 2022-07-11, -06-04, -04-07, -03-28 CXR
      • osteolytic/blastic metastases in multiple bones of thoracic cage
      • a mass opacity (ill-defined) over RUL-anterior segment along the minor fissure,consistent with a primary lung cancer,stationary
      • marginal spurs of multiple vertebral bodies due to spondylosis
      • Rt and Lt subpulmonary effusion?
    • 2022-05-04 Mammography
      • BI-RADS category 1, Negative.
    • 2022-03-30 Whole body PET scan
      • Glucose hypermetabolism in the right upper lung and right mediastinal lymph nodes, compatible with the primary lung cancer with regional lymph nodes involvement.
      • Glucose hypermetabolism in the skeleton including sternum, multiple C-, T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs, highly suspected lung cancer with multiple bone metastases.
      • Right upper lung cancer with regional lymph nodes and multiple bone metastases, cTxN2M1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-03-09 Tc-99m MDP whole body bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi of radiotracer revealed increased activity in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs in whole body bone survey.
      • IMPRESSION: Highly suspected cancer with multiple bone metastases in the sternum, multiple T- and L-spine, sacrum, bilateral rib cages, scapulae, bilateral multiple pelvic bones, S-I joints, and femurs.
    • 2022-03-08 MRI - brain
      • Findings
        • Multiple bil. cerebellar and cerebral nodules, up to 14 mm in left parietal lobes.
        • After IV contrast administration shows well or heterogenous enhancement of the nodules.
        • Normal cisterns and sulcal systems.
        • Normal bilateral ventricular size and shapes.
        • Normal appearance of bilateral cochlear and vestibular nerves complexes.
        • MRA shows patency of the major vessels of the Willis circle, bilateral ICAs and vertebrobasilar trunk.
      • Imp: Multiple bil. cerebellar and cerebral metastases.
    • 2022-03-04 Patho - lung transbronchial biopsy
      • Lung, RUL, CT-duide biopsy—adenocarcinoma, poorly differentiated
      • Specimen submitted in formalin consists of 3 strips of tan, irregular tissue measuring up to 0.6 x 0.1 x 0.1 cm. All for section in one cassette.
      • Sections show solid nests, acinar and cribriform glandular cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal TTF-1(+), Napsin A(+), GATA3(-), p40(focal +), and CD56(-). The results are supportive for the diagnosis.
    • 2022-03-04 CXR
      • no pneumothorax or pleural effusion s/p transthoracic needle biopsy of RUL mass
      • osteolytic metastases in multiple bones of thoracic cage
      • bilateral pleural effusions
      • marginal spurs of multiple vertebral bodies due to spondylosis.
    • 2022-03-03 CT - chest
      • Indication: RUL mass
      • Findings
        • Chest:
          • Spiculated mass at right upper lobe up to 4.35cm in largest dimension is found. Lung cancer is considered.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Lymphadenopathy at bilateral mediastinum and bilateral axillary region.
          • Minimal atelectatic change at right middle lobe is found.
          • Bilateral pleural effusion is found.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Visible brain
          • Several enhanced nodules at brain parenchyma is found. Brain meta is considered.
          • There is no evidence of destructive bone lesion.
          • No evidence of ICH, SAH or SDH.
      • Imp:
        • Right upper lobe lung cancer with mediastinal lymphadenopathy, bone meta and brain meta.
    • 2022-03-01 CXR
      • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, stationary
      • small Rt pleural effusion
      • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
      • old fracture of Rt 4th and Lt 4th ribs
      • hazy area of increased opacity Lt lower lung zone
      • Normal heart size
    • 2022-03-01 SONO - chest
      • Right side minimal pleural effusion; thoracocentesis was not performed due to high risk of complications.
      • Left thorax: no pleural effusion.
    • 2022-03-01 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (120 - 46) / 120 = 61.67%
        • M-mode (Teichholz) = 61
      • Preserved LV and RV systolic function with normal wall motion
      • Dilated LA, grade 1 LV diastolic dysfunction
      • Mild AR, MR
    • 2022-02-26 CXR
      • a mass opacity (ill-defined) over RUL-anterior segmnmt along the minor fissur, high possibly of a malignant lesion suggest do CT study
      • small Rt pleural effusion
      • lytic change at Rt 3rd rib, left inferior scapular body and axillary border and may be left 5th rib too due to metastases
      • old fracture of Rt 4th and Lt 4th ribs
      • hazy area of increased opacity Lt lower lung zone
      • disc space narrowing and marginal spurs of vertebral bodies at multiple levels due to spondylosis, T-spine.
      • Normal heart size
    • 2022-02-18 CXR
      • An opacity in right middle lung zone; DDx: loculated pleural effusion, mass
      • Bilateral pleural effusion
      • Normal heart size and configuration
      • Left ribs old fracture
  • chemoimmunotherapy
    • 2022-12-05 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-10-03 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-05 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-08-08 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-07-11 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-04-19 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-29 - ramucirumab 10mg/kg 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-05-04 ~ undergoing - Giotrif (afatinib 30mg/tab) 1# QDAC

[note]

  • this patient EGFR L858R mutation detected, ROS1 (IHC 1+, FISH undetected)

  • NCCN v5.2022

    • EGFR L858R
      • Preferred
        • Osimertinib (category 1)
      • Other Recommended
        • Erlotinib (category 1)
        • or Afatinib (category 1)
        • or Gefitinib (category 1)
        • or Dacomitinib (category 1)
        • or Erlotinib + ramucirumab
        • or Erlotinib + bevacizumab,
    • ROS1
      • Preferred
        • Entrectinib
        • or Crizotinib
      • or Other Recommended
        • Ceritinib

701350013

221209

  • lab data

    • 2021-12-23 ALK IHC specimen S2021-17986
    • 2021-12-23 ALK IHC Negative
    • 2021-12-22 EGFR specimen S2021-17986
    • 2021-12-22 EGFR G719X not detected
    • 2021-12-22 EGFR Exon19 del not detected
    • 2021-12-22 EGFR S768I not detected
    • 2021-12-22 EGFR T790M not detected
    • 2021-12-22 EGFR Exon20 ins not detected
    • 2021-12-22 EGFR L858R detected
    • 2021-12-22 EGFR L861Q not detected
    • 2021-12-21 PD-L1(22C3) specimen S2021-17986
    • 2021-12-21 PD-L1(22C3) TPS < 1%
    • 2021-12-15 Anti-HCV Nonreactive
    • 2021-12-15 Anti-HCV Value 0.08 S/CO
    • 2021-12-15 HBsAg Nonreactive
    • 2021-12-15 HBsAg (Value) 0.33 S/CO
    • 2021-12-15 Anti-HBs 23.01 mIU/mL
  • exam findings

    • 2022-12-05, -11-09, -10-17, -09-21, -08-29, -08-03, -07-04,… CXR
      • an ill-defined nodular opacity with reticular opacities over Lt lower lung zone stationary
      • reticular opacities over Rt lower lung zone
      • mixed osteolytic and osteoblastic metastasis in spine
    • 2022-09-29 CT - chest
      • Indication: Left lower lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1
      • Findings
        • Chest:
          • Irregular mass like lesion attaching interlobar fissure at left lower lobe is found about 2.39cm in largest dimension. In comparison with CT dated on 2022-06-16, the lesion is stationary.
          • Calcified coronary arteries is found.
          • There is no evidence of mediastinal LAP
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • IMp: left lower lobe lung cancer with interlobar fissure attachment and bone meta. The primary tumor is stationary in size.
    • 2022-09-28 Tc-99m MDP bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
      • IMPRESSION: In comparison with the previous study on 2022/06/17, all of above-mentioned bone lesions are stationary, indicating multiple bone metastases in stable condition.
    • 2022-09-27 MRI - brain
      • Findings
        • Mild but generalized sulci widening and ventricle dilatation is seen in bilateral cerebral and cerebellar hemispheres.
        • The interhemispheric fissure is centered on the midline.
        • Sella and pituitary are normal. The parasellar structures are unremarkable.
        • There are no abnormalities in the cerebellopontine angle areas on both sides.
        • There are no abnormalities in the calvarium.
        • No abnormal enhancement after contrast administration.
      • Imp: No brain nodule or metastasis. Mild cortical brain atrophy.
    • 2022-06-17 Tc-99m MDP bone scan
      • In comparison with the previous study on 2022/02/11, all the previous bone lesions are less evident, suggesting multiple bone metastases with some resolution.
    • 2022-06-16 CT - chest
      • Findings
        • Chest:
          • Fibrotic mass at left lower lobe up to 2.47cm is found. In comparison with CT dated on 2022-02-10, the lesion regressed.
          • S/p port-A placement with its tip at Superior vena cava.
          • Calcified coronary arteries is found.
          • Fibrotic change at left lingula lobe, left lower lobe and right middle lobe and right lower lobe is found.
          • Calcified coronary arteries is found.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • The GB is well distended without soft tissue lesion
      • IMp: Left lower lobe lung cancer with bone meta. The left lower lobe primary tumor regressed.
    • 2022-02-11 Tc-99m MDP bone scan
      • The Tc-99m MDP bone scan at 3 hrs after injection of 20 mCi radiotracer revealed increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone.
      • IMPRESSION: The scintigraphic findings suggest multiple bone metastases.
    • 2022-02-10 CT - chest
      • Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis
      • Findings
        • Chest:
          • Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed.
          • Minimal left pleural effusion is found.
          • Calcified coronary arteries is found.
          • Linear atelectatic change at bilateral basal lungs is found.
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
        • Visible brain
          • No evidence of space occupying lesion in the brain parenchyma is found.
          • No evidence of ICH, SAH or SDH.
      • IMp:
        • left lower lobe lung cancer with primary tumor regression.
        • Bone meta. Suggest correlate with bone scan for comparison.
    • 2021-12-08 Whole body PET scan
      • Glucose hypermetablic lesion in the left lower lung, compatible with the primary lung cancer.
      • Glucose hypermetablic lesions in the left lower ribs, some T-spine, L1-3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, highly suspected lung cancer with distant metastases. Please correlate with other clinical findings for further evaluation.
      • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IVB (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2021-12-07 Patho - lung transbronchial biopsy
      • Lung, LLL, CT-guide biopsy — adenocarcinoma, poorly differentiated
      • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma.
      • The immunohistochemical stains reveal CK(+), TTF-1(+), Napsin A(+), p40(-), and CD56(-). The results are supportive for the diagnosis.
    • 2021-12-06 MRI - brain
      • No evidence of intracranial lesion.
  • consultation

    • 2022-06-09 Metabolism and Endocrinology
      • Q
        • This is a 52-year-old man with past history of Left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12; T3: LLL mass with parietal pleura invades, N0: no definite mediastinal LAPs, M1c: multiple bone metasatsis,
          • EGFR mutation: L858R (+), exon 19 (-), ALK(-), PD-L1: <1%; with chemotherapy and radiotherapy.
          • The lung cancer treatment regimen as below:
            • 1st chemotherapy with TKI Giotrif since 2021-12-29.
            • Angiogenesis inhibitor with Cyramza C1 since 2021-12-16.
            • Immunetherapy with nivo C1 on 2022-01-11 and Ipi C1 on 2022-03-28.
            • Radiotherapy 2400cGy/8 fractions to T7-8, T12-L3 and paraspinal mass, 2021-12-09 ~ 2021-12-22.
        • This time, he was admitted for TKI induced severe diarrhea, due to severe diarrhea, we hold chemotherapy and TKI with Giotrif.
        • Laboratory data showed TSH: 7.841 uIU/mL. So we sicerely need your help for evaluation. Thanks a lot!!!
      • A
        • S
          • This 52-year-old male, with past history of left lower lobe Lung cancer, adenocarcinoma, T3N0M1c with multiple bone metastasis, ECOG 1, diagnosed on 2021-12, was admitted for chemotherapy and immunotherapy. We were consulted for abnormal TFT.
        • O
          • BW: 57-58 kg
          • HR: 100-114
          • Possible related medication: Nivolumab
          • AST/ALT: 19/16
          • BUN/Cr: 20/0.67
          • Na: 128, K: 2.9
          • TSH/FT4: 7.841/1.01
          • ATPO, ATG, TSH receptor Ab: unavailable
          • ACTH/Cortisol: 16.9/21.26
          • Thyroid echo: nil
        • A:
          • Suspected immunotherapy related subclinical hypothyroidism
        • Suggestions:
          • Check anti-TPO Ab, Anti-thyroglobulin Ab
          • Recheck TSH/FT4 2 weeks later
          • No need of thyroxine supplement at this moment.
          • Arrange thyroid sonography
          • Endocrine OPD F/U. Contact us if needed. I’d like to follow up this patient.
    • 2022-04-19 Dermatology
      • Q
        • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy and PortA insertion for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72 -> 56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help.
        • After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis, he was admitted for CT-guided lung biopsy and further cancer staging work-up. He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted scheduled chemotherapy and port A insertion.
        • For skin rash of abdominal. We sinecrely need your professional evaluation, thank you!!
      • A
        • This patient suffered from generalized erythematous papules on whole trunk and scalp and 4 limbs for days.
        • Imp: Subacute dermatitis
        • Suggestion:
          • Zaditen (ketotifen) 1/ Bid
          • Xyzal (levocetirizine) 1 / Hs
          • Zalain Gel (sertaconazole) * 1 BT/Qd
          • Mycomb (nystatin, neomycin, gramicidin, triamcinolone) * 6 tubes/bid
    • 2022-03-25 Radiation Oncology
      • Q
        • consult for radiotherapy
        • This is a 52-year-old man who denied any systemic disease history. He was admitted for scheduled chemotherapy for LLL cancer with spine metastasis. According to his history, he was in his usual status of health until 2021/10, when he started to note left tronchanteric area tenderness, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72->56kg) in one month. Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help.
        • At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
        • He had started EGFR TKIs with afatinib since 2021.12.29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
        • Bone scan reveals increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. Some bone pain over SI and iliac joint.
        • We need your ptofessional expertise for help, thank you very much.
      • A
        • Subjective:
          • This is a 52-year-old man who denied any systemic disease history. He was in his usual status of health until 2021/10, when he started to note tenderness over left tronchanteric area, accompanied with left lateral thigh and bilateral sole numbness. Therefore, he went to local clinic for analgesic injection. However, on 2021/11/22 when he was working, another painful episode occurred and usual analgesic injection would not relieve the pain. Also, marked dyspnea on exertion was noted on the same day, when he had difficulty climbing stairs. The patient also mentioned body weight loss for 16kg (72->56kg) in one month.
          • Therefore, he first went to the NS OPD in Cardinal Tien Hospital for help. After spine MRI and chest CT image were obtained, he went to our OPD for help. At OPD, interpretation of the image revealed LLL spiculated tumor with pleural effusion and spine tumors (T9, T12, L1, and L2), suspected LLL cancer with pleura and bone metastases. Under the impression of LLL cancer with spine metastasis.
          • He had started EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge, NGS liquid biopsy.
          • Some bone pain over SI and iliac joint has been noted for weeks.
            • Previous RT: s/p RT to T7-8, T12, L1-3 spines, 3000cGy/10 fx, 2021/12/09-22.
            • Other disease: denied.
            • Family history: denied.
        • Objective:
          • General Condition-ECOG: 1.
          • PE, 2022/3/25: No SCF LAPs.
          • Pathology, CT-guided biopsy, 2021/12/07 10am: adenocarcinoma, poorly differentiated.
          • Images:
            • Chest CT, 2022/2/10: Spiculated mass at left lower lobe up to 2.95cm in largest dimension is found. (Se202 IM64). In comparison with previous CT performed at other hospital on 2021-11-24, the lesion regressed. Minimal left pleural effusion is found. Linear atelectatic change at bilateral basal lungs is found. Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
            • Bone scan, 2022/2/11: increased activity in multiple T- and L-spines, some bilateral ribs, left S-I joint and left iliac bone. IMP: The scintigraphic findings suggest multiple bone metastases.
        • Diagnosis:
          • Lung cancer, LLL, PD adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord s/p RT on 2021/12/22, under EGFR TKIs with afatinib since 2021/12/29. And this time is admitted for C5 Ramu 600mg, C4 Nivo 200mg free (20X10), Ipi 50mg charge; ECOG: 1.
        • Suggest: Radiotherapy.
          • Goal: Palliative.
          • RT Plan:
            • Target & Volume: left S-I joint and left iliac bone.
            • Technique: IMRT by linear accelerator.
            • Dose & Fractionation: 3000cGy/10 fractions.
        • Plan:
          • RT to bone metastasis is suggested for pain control. CT simulation is arranged on March 28, 10:30am. Possible treatment toxicity (radiation dermatitis) is told. To prevent heavy weight bearing and falling accidence was told.
    • 2022-01-17 Dermatology
      • Q
        • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
        • This time, skin rash over head and chest, we need your help, thank you a lot!
      • A
        • Skin finding: multiple erythematous papules with pustules on face, scalp and chest
        • Imp: acniform eruption due to EGFR TKI
        • Plan:
          • doxycycline 1# BID
          • clindamycin gel BID for scalp, face and chest
    • 2022-01-11 Dermatology
      • Q
        • He had started EGFR TKIs with afatinib since 2021.12.29. And is admitted for C2 Ramu 600mg, Nivo 200mg injection treatment.
        • However, TKI related side effect was noted. paronychia and some eash over face was noted. We need your help to evalaute his problems and give further suggestion. Thanks for your kindly help.
      • A
        • Skin finding: erythematous macules and patches on T area of face
        • Imp: seborrheic dermatitis
        • Plan:
          • rinderon-V cream (betamethasone) BID topical used
    • 2021-12-10 Thoracic Medicine
      • Q
        • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Cancer staging work-up revealed poorly differentiated adenocarcinoma, LLL of lung, with metastases to left lower ribs, some T-spines, L1 to L3 spines with adjacent left-sided soft tissue, left S-I joint, and left iliac bone, cT2aN0M1c, sage IVB.
        • We sincerely need your expertise for lung cancer treatment. Thank you very much!
      • A
        • Impression:
          • LLL lung cancer with lung to lung, bone metastasis, T4N0M1ic, stage IVB
        • Suggesion:
          • Check EGFR, ALK, PDL1 mutation
          • Bone radiotherapy
    • 2021-12-09 Painology
      • Q
        • This is a 52-year-old male patient without underlying disease. This time he has experienced low back pain with radiation to left leg since one month ago. Image studies were done at Cardinal Tien Hospital, and LLL lung cancer with T and L spine metastases is strongly suspected. He was admitted for cancer survey. After admission, we consulted Radiation Oncology for spine tumor radiotherapy. This time, we sincerely need your expertise for bone pain control. Thank you very much!
        • Regular medications:
          • Muaction 100 mg/SR tab (Tramadol)  1 tab     PO      TID     
          • Acetal 500 mg/tab (Acetaminophen)  1 tab     PO      TID     
          • Aelocon 50mg & 5mg/tab (Thiamine Disulfide & Riboflavin; B1 & B2)  1 tab     PO      BID     
          • Votan-SR 100mg/tab  1 TAB     PO      TID  
        • Morphine 5mg IV prnq6h use
      • A
        • S:
          • left lateral pelvis pain with radiation to inguinal area for weeks
        • O:
          • NRS (Numerical Rating Scale for pain measurement): 3-8 (after taking tramadol can remain 4-5 hours down to 3, it can be up to 8 if not well-timing; morphine IV 5mg can remain up to over night > 6 hours)
          • Touch pain, tenderness, allodynia. No rash, local heat or nodule
          • Tenderness at lateral and post waist and paraspinal area (Left L1-3 level) and left iliac
        • A:
          • Left lower lung cancer with multiple bone metastases, cTxNxM1c, stage IV
          • Susp L1-3 spine, susp left psoas or QL muscle? metastasis with intercostal nerve, ilioinguinal, genitofemoral nerve entrapement.
          • Diagnostic USG intervention: Left lumbar plexus block (T12-L1): reactive
          • US: a hypoechoic lesion over QL/Psoas muscle: soft tissue metastasis?
        • P:
          • According to latest NCCN guideline, you may shift tramadol to low dose oral morphine/oxycontin (for pain NRS > 4, low dose high potent opioids +- adjuvant medication and interventional treatment). Morphine 15mg PO Q6H-Q8H (or Oxycontin 10mg Q12H) was suggested first.
          • Due to multiple metastasis at bone/ soft tissue and his fear to intervention, I suggested that medication adjustment and RT would be better for him now.
        • Please record the pain scale and the PRN dose
    • 2021-12-06 Radiation Oncology
      • A
        • Objective:
          • General Condition-ECOG: 1. On wheel chair use due to bone pain.
          • PE, 2021/12/06: No SCF LAPs.
          • Pathology, CT-guided biopsy, 2021/12/07 10am: pending.
          • Images:
            • L spine MRI, 2021/11/23: bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord.
            • Chest CT, 2021/11/24: 23-mm tumor over LLL, small mediastinal LNs, minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord. Imp: cT1cN0M1c.
            • Brain MRI, 2021/12/06: No brain metastasis.
        • Diagnosis: Lung cancer, LLL, R/O adenocarcinoma, cT1cN0M1c, with minimal left pleural effusion, bone metastasis over T8, T12, L1, L2, with extensive paraspinal mass over left L2 which compresses the spinal cord; ECOG: 1.
        • Suggest: Radiotherapy.
        • Goal: Palliative.
        • RT Plan:
          • Target & Volume: bone metastasis over T8, T12, L1, L2.
          • Technique: IMRT by linear accelerator.
          • Dose & Fractionation: 3000cGy/10 fractions.
        • Plan:
          • RT to bone metastasis is suggested for pain control. CT simulation is arranged on Dec 07 11am. Possible treatment toxicity (radiation dermatitis and esophagitis) is told. To prevent heavy weight bearing and falling accidence was told. Diet education is given.
  • radiotherapy

  • chemoimmunotherapy

    • 2022-12-07 - Yervoy (ipilimumab) 50mg 30min
    • 2022-12-06 - Opdivo (nivolumab) 100mg 1 hr
    • 2022-12-05 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-11-12 - Yervoy (ipilimumab) 50mg 30min
    • 2022-11-11 - Opdivo (nivolumab) 100mg 1hr
    • 2022-11-10 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-10-20 - Yervoy (ipilimumab) 50mg 30min
    • 2022-10-19 - Opdivo (nivolumab) 200mg 1hr
    • 2022-10-18 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-23 - Yervoy (ipilimumab) 50mg 30min
    • 2022-09-22 - Opdivo (nivolumab) 100mg 1hr
    • 2022-09-21 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-09-01 - Yervoy (ipilimumab) 50mg 30min
    • 2022-08-31 - Opdivo (nivolumab) 100mg 1hr
    • 2022-08-30 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-08-05 - Yervoy (ipilimumab) 50mg 30min
    • 2022-08-05 - Opdivo (nivolumab) 200mg 1hr
    • 2022-08-04 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-07-06 - Yervoy (ipilimumab) 50mg 30min
    • 2022-07-05 - Opdivo (nivolumab) 200mg 1hr
    • 2022-07-04 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-06-13 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-05-18 - Yervoy (ipilimumab) 50mg 30min
    • 2022-05-17 - Opdivo (nivolumab) 200mg 1hr
    • 2022-05-16 - Cyramza (ramucirumab) 500mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-04-20 - Yervoy (ipilimumab) 50mg 30min
    • 2022-04-19 - Opdivo (nivolumab) 200mg 1hr
    • 2022-04-18 - Cyramza (ramucirumab) 600mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-28 - Yervoy (ipilimumab) 50mg 30min
    • 2022-03-25 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-24 - Cyramza (ramucirumab) 600mg 1.5hr
      • premed - dexamethasone 8mg + diphenhydramine 30mg
    • 2022-03-02 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-01 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-02-08 - Opdivo (nivolumab) 200mg 1hr
    • 2022-02-07 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-01-11 - Opdivo (nivolumab) 200mg 1hr
    • 2022-01-10 - Cyramza (ramucirumab) 600mg 2hr
    • 2021-12-16 - Cyramza (ramucirumab) 600mg 2hr
    • 2022-08-03, 2022-08-14 ~ 2022-11-01 undergoing - Vizimpro (dacomitinib) 15mg/tab 1# QD
    • 2021-12-29 ~ 2022-07-27 - Giotrif (afatinib) 30mg/tab 1# QDAC
    • 2021-12-05, 2022-02-28, 2022-04-17, 2022-05-15 - Xgeva (denosumab) 120mg SC

==========

2022-10-19

  • The disease is characterized by L858R(+), exon19del(-), ALK(-), and PD-L1<1%. This patient has been treated with oral afatinib(2021-12 ~ 2022-07)/dacomitinib(2022-08 ~ undergoing) and IV ramu(2021-12 ~)/nivo(2022-01 ~)/ipi(2022-03 ~). It appears that the current regimen is still effective to keep the disease stable (2022-02 and 2022-06 CT: regression; 2022-09 CT: stationary).

  • The serum potassium level in 2022-10-17 was 2.9 mmol/L, and it might be beneficial to add potassium supplements.

  • The main concern for the patient and his caregiver might be pain management. For patients who require four or more doses of short-acting opioids consistently each day, addition of a long-acting opioid should be considered based on the total daily dose. A controlled-release oxycondone regimen has been prescribed to the patient since 2022-10-18.

  • In the event that the patient’s goals are not met (uncontrolled pain persists), then administer an opioid dose equivalent to 10%~20% of the total opioid taken in the previous 24 hours and reassess effectiveness and adverse effects (at 15 minutes if administered IV or at 60 minutes if administered PO).

    • pain unchanged or increased => increase dose by 50%~100%
    • pain decreased but inadequately controlled => repeat same dose
    • pain improved and adequately controlled => continue at current effective dose as needed over initial 24h

700261909

221206

  • exam findings
    • 2022-12-05 CXR
      • Distention of stomach.
      • Ground glass opacity in bilateral lower lungs.
    • 2022-11-24 Patho - bone marrow biopsy
      • Bone marrow, iliac crest, biopsy — See description
      • The sections show normocellular marrow (20%). The CD71+ erythroid precursors are markedly decreased (10%). The myeloid cells show left shift in MPO stain. The CD61+ megakaryocytes are slightly increased, and few micromegakaryocytes are present. No increased CD34+ blasts. Scattered CD117+ immature cells (<3%) are present. Myelodysplastic syndrome can be considered in differential diagnosis. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2022-09-01 Patho - bone marrow biopsy
      • Bone marrow, right pelvic, biopsy — Suggested myelodysplastic syndrome
      • Sections show 10-70 % cellularity. The M/E ratio is about 4/1–5/1. Dysgranulopoiesis is seen. Anisocytosis and poikilocytosis are present. Atypical micromegakaryocytes are found about 4-7/HPF. No increase of blasts is noted. There are no granulomas, nor foreign malignant cells.
      • IHC stains: CD117: 2%; CD34: <1%; CD71: 10-30%; Hemoglobin A: 10-20%; CD138: 5%. The morphology is suggesting myelodysplastic syndrome. Please correlate with the bone marrow smear, peripheral blood smear and lab data for final diagnosis.
    • 2022-08-16 Panendoscopy
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis, antrum
    • 2022-07-28 SONO - abdomen
      • Liver cirrhosis with splenomegaly.
      • Left liver cyst (0.87x0.59cm).
      • S/P cholecystectomy.
    • 2022-07-12 CXR
      • Tortous aorta with calcification is noted.
      • Elevation of left hemidiaphragm is found.
    • 2022-07-06 ECG
      • Sinus rhythm with Premature atrial complexes
      • Nonspecific ST and T wave abnormality
      • Left atrial enlargement
    • 2021-03-16, 2020-09-18 SONO - nephrology
      • Parenchymal renal disease
    • 2019-11-22 CXR
      • Tortous aorta with calcification is noted.
      • Elevation of left hemidiaphragm is found.
      • Blunted left CP angle is found.
    • 2019-10-24 Flow-Volume Curve and Bronchodilator Test
      • Severe lung restriction
    • 2019-10-24, -10-22 CXR
      • Elevation of Lt hemidiaphragm may be due to LLL volume loss and fibrosis or bronchiectasis
      • bronchiectasis at Rt lung base
    • 2019-10-18 CXR
      • Elevated left hemidiaphragm.
      • Increased infiltration at RLL
  • chemoimmunotherapy
    • 2022-12-05 - Vidaza (azacitidine) 75mg/m2 100mg SC D1-D2

[assessment]

  • In the past, serum iron, total iron-binding capacity, ferritin, vitamin B12, and folate have been measured. Since the patient’s renal function appears to be in good condition, it is unlikely that the anemia is caused by low EPO levels.
  • No increase in blasts has been observed. WBC sometimes falls below normal range, RBC and HGB often fall below normal ranges. The results of the pathology indicated that MDS may be present. (with single lineage or multilineage dysplasia?) No cytogenetic del (11q, 5q, 12p, 20q,…) data available currently.
  • The patient is receiving azacitadine for the first time. Please monitor for any signs of intolerance.
  • The recommended dosing of azacitadine for patients with MDS: Initial cycle: 75 mg/m2/day for 7 days of a 28-day treatment cycle. Subsequent cycles: 75 mg/m2/day for 7 days every 4 weeks; dose may be increased to 100 mg/m2/day if no benefit is observed after 2 cycles and no toxicity other than nausea and vomiting have occurred. Patients should be treated for a minimum of 4 to 6 cycles; treatment may be continued as long as patient continues to benefit.

700307071

221206

{Left ovarian cancer (clear cell carcinoma) post Debulking surgery on 2022/06/08, pT2aN0M0, FIGO stage IIA}

  • family history
    • Father: esophageal cancer
    • Mother: lung adenocarcinoma
  • exam finding
    • 2022-11-15 CT - abdomen
      • S/P hysterectomy and oophorectomy.
      • Ground glass opacity, 0.6cm in RUL. Nature?
    • 2022-10-06 SONO - joint soft tissue
      • right shoulder supraspinatus tendinitis
      • limitation of passive movement in the glenohumeral joint, compatible with right shoulder adhesive capsulitis.
    • 2022-10-05 T-L spine AP + Lat
      • mild anterior spur formation at the middle and lower L-spine.
    • 2022-09-28 CXR
      • Atherosclerotic change of aortic arch
      • Scoliosis of the T-spine with convex to right side.
    • 2022-07-29 CXR
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • 2022-06-09 Patho - ovary (tumor)
      • pathologic diagnosis
          1. Ovary, left, BSO — Mixed clear cell carcinoma and endometroid carcinoma
          1. Lymph nodes, pelvic and para-aortic, bilateral, BPLND — Negative for malignancy (0/28)
          1. Soft tissue, labeled “tumor seeding on colon”, excision — Inflammation and fibrosis, no malignancy
          1. AJCC 8 th edition, Pathology stage: pT2aN0; stageIIA; FIGO stage IIA if cM0
      • macroscopic examination
          1. Procedure: ATH + BSO + omentectomy + BPLND + para-aortic LN dissection + tumor seeding on colon excision
          1. Specimen Size: 16.5 x 11.8 x 7.0 cm (Lt ovary), 2.5 x 1.0 x 0.6 cm (Rt ovary), 8.2 x 0.5 cm (Lt tube), 4.2 x 0.5 cm (Rt tube), 6.0 x 3.8 x 2.2 cm (uterus), 0.6 x 0.4 x 0.3 cm (colon tumor), 24 x 8.5 x 0.5 cm (omentum)
          1. Specimen Integrity
          • 3.1. Right ovary: Capsule intact
          • 3.2. Left ovary: Capsule ruptured
          • 3.3. Right fallopian tube: Serosa intact
          • 3.4. Left fallopian tube: Serosa intact
          1. Tumor Site: Left ovary
          1. Ovarian Surface Involvement: Present
          1. Fallopian tube Surface Involvement: Absent
          1. Tumor Size: Tri-cystic and aolid tumor, 16 x 11.8 x 7.0 cm
          1. Lymph Nodes: Six groups including left iliac, left obturator, right iliac, right obturator, left para-aortic and right para-aortic
          1. Representative parts are taken for section and labeled as: F2022-00264FSA1, FSA2, FSA3= left ovary tumor, A1= left tube, A2-A10= left ovary tumor. S2022-09335 A= left iliac LNs, B= left obturator LNs, C= right iliac LNs, D= right obturator LNs, E= left para-aortic, F= right para-aortic LNs, G1= cervix, G2-G3= uterine corpus, G4= right ovary and fallopian tube, G5= left parametrium, G6= right parametrium, H= omentum, I= tumor seeding on colon.
      • microscopic examination
          1. Histologic Type: Mixed clear cell carcinoma and endometroid carcinoma
          1. Histologic grade: High grade
          1. Implants: Not identified
          1. Other Tissue/Organ Involvement: Tumor invades uterine wall
          1. Peritoneal Fluid: Not submitted
          1. Regional Lymph Nodes: All lymph nodes are negative for tumor cells (0/28)
          • number of lymph node examined: 3 (left iliac), 7 (left obturator), 4 (right iliac), 6 (right obturator), 3 (left para-aortic) and 5 (right para-aortic)
          • number with metastases >10 mm: 0
          • number with metastases 10mm or less: 0
          • number with isolated tumor cells (<=0.2mm): 0
          1. Pathologic Stage
          • 7.1. Primary Tumor: pT2a (tumor extension on the uterus)
          • 7.2. Regional Lymph Nodes: pN0 (no regional lymph node metastasis)
          • 7.3. Distant Metastasis: Not applicable
          1. FIGO Stage: Stage IIA if cM0
          1. Lymphovascular invasion: Absent
          1. Perineural invasion: Absent
          1. Additional Pathologic Findings:
          • 11.1. Cervix: Chronic cervicitis with Nabothian cysts
          • 11.2. Endometrium: Atrophy
          • 11.3. Myometrium: Leiomyoma
          • 11.4. Ovary, right: Cortical inclusion cysts
          • 11.5. Fallopian tube, right: Para-tubal cyst
          • 11.6. Fallopian tube, left: Unremarkable
          • 11.7. Omentum: No remarkable change
          • 11.8. Specimen labeled “tumor seeding on colon”: Chronic and acute inflammatory cells infiltrate, fibrin exudate, and fibrosis
          1. IHC: Napsin A (rare + for clear cell carcinoma component), PR(+ in endometroid carcinoma), WT1(-), p53(wide type)
    • 2022-06-08 Frozen section
      • Ovary, frozen section — Malignant, favor clear cell carcinoma
    • 2022-06-08 Patho - colon biopsy
      • Colon, ileocecal valve, s/p cold snare polypectomy — Hyperplastic polyp with chronic inflammation.
    • 2022-06-06 Patho - stomach biopsy
      • Labeled as “30cm below the incisor, s/p biopsy(B)”, biopsy — benign squamous mucosa with abundant granular cytoplas, in favor of glycogenosis.
      • Stomach, LC site of antrum, s/p biopsy (A) — Chronic gastritis, H pylori NOT present
    • 2022-06-06 CT - abdomen, pelvis
      • Huge soft tissue mass at pelvis with solid and cystic component is found up to 16.5cm in largest dimension. Ovarian cancer is considered.
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1(T_value) N:Nx(N_value) M:M0(M_value) STAGE:____(Stage_value)
    • 2022-05-30 Gynecologic ultrasonography
      • huge ovarian mass 183mm x 105mm
    • 2022-05-30 SONO - abdomen
      • suspected liver parenchymal disease, mild
      • lower abdomen tumor: cause to be determined
    • 2020-04-29 Patho - stomach biopsy
      • Stomach, low body, biopsy — fundic gland polyp. No H.pylori present
    • 2017-07-26 Mammography
      • Impression: Dense breast.
          1. Asymmetry in axillary tail region of left breast, stationary.
          1. Benign calcifications in bilateral breasts.
      • BI-RADS: Category 2: benign findings. - annual screening.
  • surgical operation
    • 2022-06-08 Debulking surgery (ATH + BSO + BPLND + paraaortic LN disection + infracolic omentectomy), Bilateral ureteral catheterization
  • chemoimmunotherapy
    • 2022-12-05 - paclitaxel 175mg/m2 260mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-11-14 - paclitaxel 175mg/m2 270mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-10-24 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr (Owing to Leukopenia (ANC: 368) was noted on 20221011 and next will given Lenograstim x 3 post C/T, 2022-10-26 ~ 2022-10-28)
    • 2022-09-27 - paclitaxel 175mg/m2 250mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-09-06 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-08-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 500mg 2hr
    • 2022-07-15 - paclitaxel 175mg/m2 246mg 3hr + carboplatin AUC 5 530mg 2hr

==========

2022-09-28

  • If there is a suspicion of megaloblastic anemia (RBC 2.75 *10^6/uL, HGB 9.4 g/dL, MCV 104 fL, 2022-09-27), a vitamin B12 (cobalamin) and/or a vitamin B9 (folate) supplement might be beneficial to the patient.

701024299

221205

  • 2022-12-03 CXR

    • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
    • Bilateral pleural effusion.
  • 2022-11-21, -11-17 CXR

    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion?
  • 2022-11-18 SONO - chest

    • right side minimal amount of pleural effusion
    • left side small amount of pleural effusion, 290cc serosangious fluid was aspirated for analysis.
  • 2022-11-13 ECG

    • Sinus tachycardia
  • 2022-10-20 CT - abdomen

    • History and indication: ovary cancer with peritonal seeding right breast cancer with bone mets
    • Findings
      • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
      • S/P hysterectomy. Some tumors in peritoneal cavity.
      • Tiny liver cysts. A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.
      • Swelling of right chest wall and abdominal wall.
    • IMP:
      • Right breast cancers. Bil. pleural effusions. Enlarged LNs at left neck, mediastinum, bil. axillary regions, mesentery and retroperitoneum.
      • S/P hysterectomy. Some tumors in peritoneal cavity.
      • A metastases at left hepatic lobe. Progression of metastases at spleen and LUQ.
  • 2022-10-14 CXR

    • Right hemi-diaphragm elevation is noted, which may be due to eventration.
    • Borderline cardiomegaly
    • Blunting of right costal-phrenic angle is noted, which may be due to pleura effusion or thickening?
  • 2022-07-29 Whole body PET scan

    • In comparison with the previous study on 2021/12/09, the lesions in the right breast, two right supraclvicular lymph nodes, multiple right axillary lymph nodes and multiple bilateral parasternal lymph nodes are new. Primary breast malignancy with multiple lymph node metastases may show this picture. However, please correlate with the pathologic findings for further evaluation.
    • A new glucose hypermetabolic lesion in the the region about the skin of right upper back, compatible with a metastatic lesion.
    • The glucose hypermetabolic lesions in the left supraclavicular fossa, mediastinum, spleen, abdominal and pelvic cavities seem either new, more evident or larger in size, suggesting multiple metastases in progression. However, other lesions such as the lesions in the left pulmonary hilar region, pleura of right lung and left lobe of the liver are either a little less evident or disappeared.
  • 2022-07-28 CT - chest

    • History
      • 45 y/o female, a pt of ovarian CA wt peritoneal seeding, rpT3bN0 (If cM0); pStage: IIIB , FIGO stage: IIIB, s/p pre-Op NIPS wt Taxotere / Carbopaltin IV and Taxotere / Cisplatin IP Q3W x 4 finihsed in Oct 2020 s/p debulking Op on 11/30 20 by Dr Wu, s/p post-Op salvage C/T wt Taxotere/PF + IP C/T wt Taxotere / Cisplatin x 4 finished in Feb 2021 & s/p post-Op salvage Avastin 7.5mg/kg IV Q3W x 1yr since 3/9 21.
    • Findings
      • Chest:
        • Soft tissue mass/noduless at lateral breast up to 2.57cm and inner breast about 3.5cm in largest dimension. breast cancer is considered.
        • Lymphadenopathy at right axillary region, mediasitnum and paraaortic region. Lymphadenopathy from breast cancer or residual ovarian cancer is favored.
        • Very tiny nodule at right upper lobe is found.
        • No evidence of bilateral pleural effusion.
      • Visible abdomen:
        • Tiny low density nodules at S6 of liver about 0.34cm and 0.2cm in largest dimension. In comparison with CT dated on 2022-06-01, the lesions are stationary.
        • Low density change at splenic hilum is found. In progression.
        • The pancreas, both kidneys, adrenals are intact.
        • Suggest clinical correlation
    • Imp:
      • Right breast cancer with lymphadenopathy at right axillary, mediastinal and abdominal hepatic hilar and paraaortic region.
      • SPlenic hilar tumor, in progression.
      • Liver meta. Stable.
  • 2022-06-06 Patho - lymphnode biopsy

    • Labeled as “left supraclavicular fossa/ lymph node”, past history of ovarian and breast cancers, excision biopsy — metastatic carcinoma.
    • Section shows pieces of soft tissue with metastatic carcinoma
    • IHC stains: PAX-8 (+) and GATA-3 (-): pattern is in favor of ovarian origin rather than breast origin.
    • Residual lymph node-like tissue is present.
  • 2022-06-06 CT - abdomen

    • History and Indication:
      • 2020/08/05: Echo: susp pelvic mass with ascites.
      • OP: ATH + RSO 3 yr ago
      • 2020/08/05 CT: Cystic adenocarcinoma of ovary & carcinomatosis
      • 2020/11/30 PATHO: serous carcinoma, high grade, involved bilateral ovary, Fallopian tube and Peritoneum,rpT3bN0(If cM0); pStage:IIIB , FIGO stage: IIIB,
      • 20220309 CT: Metastases in the liver, spleen, and multiple LNs.
    • Findings:
      • S/P hysterectomy
      • Prior CT identified a metastasis 1.7 x 1.1 cm in S3 of the liver is not noted in the current CT that is c/w liver metastasis S/P C/T with complete response .
        • Prior CT identified two lobulated metastases 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail are noted again, decreasing in size to 2 cm and 1 cm that are c/w metastases S/P C/T with partial response .
        • Prior CT identiifed multiple metastatic nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space are noted again, stable in size that is c/w metastatic nodes S/P C/T with stable disease .
        • Prior CT identified A enlarged node with central low density measuring 2 x 1.2 cm in left side neck is noted again, stationary.
      • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
      • Mild ascites in the cul-de-sac is noted.
      • Others
        • There is no focal abnormality in the gallbladder, biliary system, & both kidney.
        • There is no bowel wall thickening and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
        • There is no focal lesion in the omentum.
    • Impression:
      • Metastasis in the liver shows complete response.
      • Metastases in the spleen shows partial response.
      • Metastatic nodes show stable disease
  • 2022-05-31 2D transthoracic echocardiography

    • LVEF = (LVEDV - LVESV) / LVEDV = (62 - 18) / 62 = 70.97%
      • M-mode (Teichholz) = 71
    • Preserved LV and RV systolic function with normal wall motion
    • Normal chamber size
    • Trivial MR
  • 2022-05-23 Patho - lymphnode biopsy

    • Lymph node, right axillary, score biopsy — positive for invasive carcinoma
    • Microscopically, it shows presence of invasive carcinoma nestes with necrosis and stromal fibrosis in a lymphoid background.
    • IHC stain — CK(+)
  • 2022-05-23 Patho - breast biopsy (no need margin)

    • Breast, right, core biopsy — invasive carcinoma of no special type
    • Microscopically, the breast shows invasive carcinoma characterized by proliferation of tumor cells with infiltrative growth pattern, ductal differentiation and stromal fibrosis with necrosis. The tumor cell shows hyperchromatic nuclei, plemorphism and high N/C ratio.
  • 2022-05-17 SONO - breast

    • Bil. fibroadenomas and cysts
    • BI-RADS: 2. benign finding
  • 2022-03-09 CT - abdomen

    • Findings:
      • S/P hysterectomy
      • There is a newly-developed poor enhancing mass 1.7 x 1.1 cm in S3 of the liver that is c/w liver metastasis.
        • There are two lobulated poor enhancing mass 3 cm and 2.5 cm in between the gastrosplenic ligament, spleen, and pancreatic tail that are c/w metastases.
        • In addition, There are newly-developed multiple enlarged nodes in the celiac trunk, hepatoduodenal ligament, para-aortic space and para-cava space that are c/w metastatic nodes.
        • A enlarged node with central low density measuring 2 x 1.2 cm in left side neck that is c/w metastatic node.
      • Prior CT identified a cyst 4 mm in S5/8 of the liver is noted again, stationary.
    • Impression:
      • Metastases in the liver, spleen, and multiple lymph nodes.
  • 2021-12-09 Whole body PET scan

    • Multiple glucose hypermetabolic lesions in the left supracalvicular fossa, mediastinum, left pulmonary hilar region, pleura of right lung, spleen, left lobe of the liver, abdominal and pelvic cavities, compatible with multiple metastatic lesions. Please correlate with other clinical findings for further evaluation.
    • Glucose hypermetabolism in the fat tissues in bilateral necks, bilateral supraclavicular fossae and bilateral paraspinal regions. Physiological FDG uptake is more likely.
  • 2021-11-26 CT - abdomen

    • Findings
      • S/P hysterectomy
      • The long segmental terminal ileum shows mild dilatation with feces-like material (Srs:302 Img:63-69) that may be partial obstruction?
        • The differential diagnosis include normal variation. please correlate with clinical condition.
        • In addition, there is a suspicious soft tissue nodule in the cul-de-sac that may be tumor seeding. The differential diagnosis include normal variation? Follow up is indicated.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy
      • Partial obstruction of the terminal ileum and a tumor seeding in the cul-de-sac is suspected.
        • The differential diagnosis include normal variation.
        • please correlate with clinical condition.
  • 2021-11-18 SONO - abdomen

    • Hepatic lesion, right lobe, suspected cyst.
  • 2021-08-27 CT - abdomen

    • Findings
      • S/P hysterectomy -There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2021-07-08 Gynecologic ultrasonography

    • ATH + BSO
    • minimal fluid
  • 2021-06-10 CT - abdomen

    • Findings
      • S/P hysterectomy. Minimal ascites in pelvic cavity.
      • Tiny liver cysts.
      • Some low attenuations in both kidneys.
    • IMP:
      • S/P hysterectomy. Minimal ascites in pelvic cavity. No evidence of tumor recurrence.
  • 2021-05-27 SONO - abdomen

    • pancreatic cystic lesion, body
  • 2021-03-10 CT - abdomen

    • Findings:
      • S/P hysterectomy
      • There is mild ascites in the pelvis.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst.
    • Impression:
      • S/P hysterectomy. There is no evidence of tumor recurrence.
  • 2020-12-01 Patho - soft tissue tumor, extensive resection

    • PATHOLOGIC DIAGNOSIS
      • Ovary and fallopian tube? right, labeled “right pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      • Round ligament of liver, peritonectomy — Involved by serous carcinoma
      • Appendix, appendectomy — Involved by serous carcinoma
      • Ovary and fallopian tube? left, labeled “left pelvic peritonum”, peritonectomy — Involved by serous carcinoma
      • Right diaphragm peritoneum, peritonectomy — Involved by serous carcinoma
      • PD tube with its tract, peritonectomy — Free of carcinoma
      • Ometum, omentectomy — Involved by serous carcinoma
      • AJCC 8 th edition, Pathology stage: ypT3bNx; stage IIIB; FIGO stage IIIB if cM0
    • MACROSCOPIC EXAMINATION
      • Procedure: Debulking surgery + peritonectomy + appendectomy
      • Specimen Size
        • Right pelvic peritonum (including right adnexa): three pieces, up to 3.2 x 2.8 x 2.5 cm
        • Round ligament of liver: 5.0 x 2.5 x 2.2 cm
        • Appendix: 4.0 x 1.0 x 1.0 cm
        • Left pelvic peritoneum (including left adnexa): three pieces, up to 3.4 x 2.9 x 2.8 cm
        • Right diaphragm peritoneum: multiple pieces up to 12.5 x 8.0 x 4.5 cm
        • PD tube with its tract: 8.0 x 0.9 cm with tract 5.0 x 1.2 cm
        • Omenum: 22.0 x 11.0 x 1.5 cm
      • Specimen Integrity: Fragmented
      • Tumor Site: Both adnexa
      • Ovarian Surface Involvement: Present
      • Fallopian tube Surface Involvement: Present
      • Representative parts are taken for section and labeled as: A1-A3= right pelvic peritonum (including right ovary and fallopian tube), B1-B3= round ligament of liver, C1-C2= appendix, D1-D3= left pelvic peritoneum (including left ovary and fallopian tube), E1-E3= right diaphragm peritoneum, F= PD tube with its tract, G1-G3= omentum
    • MICROSCOPIC EXAMINATION
      • Histologic Type: Serous carcinoma
      • Histologic grade: High grade
      • Ovary and fallopian tube? right, labeled “right pelvic peritonum”: Involved by serous carcinoma
      • Round ligament of liver: Involved by serous carcinoma
      • Appendix: Involved by serous carcinoma
      • Ovary and fallopian tube?left, labeled “left pelvic peritonum”: Involved by serous carcinoma
      • Right diaphragm peritoneum: Involved by serous carcinoma
      • PD tube with its tract: Chronic inflammation, fibrosis and free of carcinoma
      • Ometum: Involved by serous carcinoma
      • Pathologic Stage
        • Primary Tumor: ypT3b (macroscopic peritoneal metastasis beyond the pelvis 2 cm or less in greatest dimension)
        • Regional Lymph Nodes: Not submitted
        • Distant Metastasis: Not applicable
      • FIGO Stage: Stage IIIB if CM0
      • Additional Pathologic Findings: Psammoma bodies
  • 2020-11-30 Patho - ovary (tumor)

    • PATHOLOGIC DIAGNOSIS
      • Ovary, right, debulking surgery (s/p neoadjuvant treatment) — serous carcinoma, high-grade
      • Ovary, left, debulking operation — serous carcinoma, high-grade
      • Fallopian tube, right, debulking operation — involved by serous carcinoma
      • Fallopian tube, left, debulking operation — involved by serous carcinoma
      • Lymph node, right iliac, dissection — negative for malignancy ( 0 / 3 )
      • Lymph node right obturator, dissection — negative for malignancy ( 0 / 1 )
      • Lymph node, left iliac, dissection — negative for malignancy ( 0 / 4 )
      • Lymph node, left obturator, dissection — negative for malignancy ( 0 / 1 )
      • Pelvic mass, debulking surgery — involved by serous carcinoma
      • Omentum, debulking surgery — involved by serous carcinoma
      • pTNM: rpT3bN0 (If cM0); FIGO stage: IIIB; pStage:IIIB
    • MACROSCOPIC EXAMINATION
      • Operation Procedure: debulking surgery
      • Specimen type: bilateral ovaries, fallopian tubes, regional LNs, omentum
      • Specimen size:
        • right ovary: 4.2x 3.5x 2.2 cm;
        • left ovary: 5x 4x 2.5 cm;
        • right tube: 4.5 cm in length;
        • left tube: 4.5 cm in length;
        • uterus: not received
      • Tumor site: right and left ovaries
      • Tumor size: up to 1.3 cm in size
      • Tumor appearance: solid and papillary
      • Specimen integrity: Ovarian capsule ruptured (right)
      • Lymph node: (tissue size) up to 1 cm
    • MICROSCOPIC EXAMINATION
      • Histologic type: serous carcinoma
      • Histologic grade: high grade
      • Contralateral ovary involvement: present
      • Tumor side ovarian surface involvement: present
      • Contralateral ovary surface involvement: present
      • Right tube involvement: present
      • Left tube involvement: present
      • In situ adenocarcinoma in right and/or left fallopian tube: absent
      • Right adnexa soft tissue involvement: absent
      • Left adnexa soft tissue involvement: absent
      • Pelvic soft tissue involvement: present (labeled pelvic mass)
      • Uterine serosa involvement: non-applicable
      • Omentum involvement: present
      • Uterine Cervix involvement: N/A
      • Endometrium involvement: N/A
      • Myometrium involvement: N/A
      • Appendix involvement: N/A
      • Lymph nodes metastasis:
        • Group as specified No. Positive / No. Total
        • Right iliac ( 0 / 3)
        • Right obturator ( 0 / 1 )
        • Left iliac ( 0 / 4 )
        • Left obturator ( 0 / 1 )
      • Other organs or specimens involvement: none
      • Immunohistochemical stain shows WT-1(+), CK7(+), CK20(-)
  • 2020-11-18 Whole body PET scan

    • Glucose hypermetabolism in the left pelvis, compatible with the CT findings of much regression of ovary cancer and peritoneal carcinomatosis with residual tumor at the left ovary.
    • Glucose hypermetabolism in bilateral palatine tonsils, probably chronic inflammation/infection process.
    • Glucose hypermetabolism in bilateral pulmonary hilar regions, probably physiological uptake of FDG or reactive nodes.
    • Increased FDG accumulation in the colon and urinary bladder, physiological FDG accumulation may show this picture. However, please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
  • 2020-11-18 Gynecologic ultrasonography

    • ATH
    • Suspected Lt ovarian mass: 48x42mm
  • 2020-11-16 CT - abdomen

    • History and indication: ovary cancer with peritonal seeding
    • Findings
      • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).
      • Thyroid nodules (3-5mm).
      • Tiny liver cysts.
      • Some low attenuations in both kidneys.
      • S/P Port-A infusion catheter insertion.
    • IMP:
      • Much regression of ovary cancer and peritoneal carcinomatosis (residual tumor at left ovary).
  • 2020-10-28, -09-16, -09-15, -08-26, -08-25, -08-13 Body fluid cytology - ascites

    • Malignancy
  • 2020-08-13 Patho - peritoneum biopsy

    • Labeled as “ovary cancer with diffuse peritoneal seeding”, biopsy — adenocarcinoma
    • Section shows adenocarcinoma.
  • 2020-08-07 Patho - ovary biopsy/wedge resection

    • Labeled as “s/p 3 yr rt partial ovrain tumor excision, intraabd peritoenal tumor with ascite”, biopsy — adenocarcinoma, serous type, high grade.
    • Section shows piece of tissue with short papillae of neoplastic cells containing hyperchromatic nuclei and abundant eosinophilic cytoplasm.
    • IHC stains: PAX-8 (+), WT-1 (+), CK20 (-), a pattern of ovarian origin.
    • IHC stains: ER (+, 1-5%, moderate intensity); PR (+, 1-5%, moderate intensity).
  • 2020-08-06 Gynecologic ultrasonography

    • ATH + RSO
    • Imp:
      • Ascites
      • Suspected Lt ovarian mass (RI: 0.13) 144x106mm, malignancy cannot be ruled out.
  • 2020-08-05 CT - abdomen

    • Findings:
      • There is a large multilocular mixed cystic and solid masses in the pelvis that may be cystic adenocarcinoma of the ovary. please correlate with clinical history.
      • There is massive ascites and soft tissue nodules in the omentum and right perihepatic space (Srs:3, Img:25) that is compatible with carcinomatoais.
      • There is a small poor enhancing lesion 4 mm in S5/8 of the liver that may be cyst. The differential diagnosis include metastasis. Please correlate with sonography.
    • Impression:
      • Cystic adenocarcinoma of the ovary with carcinomatosis is highly suspected. please correlate with clinical condition.
      • A hepatic cyst 4 mm in S5/8 is suspected. The differential diagnosis include metastasis. Please correlate with sonography.
  • 2020-08-05 SONO - abdomen

    • Diagnosis
      • Suspected pelvic mass lesion
      • Ascites with peritoneal nodule; D/D: peritonitis, carcinomatosis
    • Suggestion
      • CT scan
      • GYN survey
  • 2020-05-16 Mammography

    • Impression: Dense breast. Probably benign calcifications in bilateral breasts.
    • BI-RADS: Category 2: benign findings.-annual screening.
  • consultation

  • chemoimmunotherapy

    • 2022-06-07 doxorubicin 50mg/m2 70mg 10min + cyclophosmamide 500mg/m2 700mg 1hr
    • 2021-11-16 bevacizumab 17.5mg/kg 375mg 1.5hr
    • 2021-10-26

700356362

221202

{Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1}

  • diagnosis
    • malignant neoplasm of appendix
    • secondary malignant neoplasm of retroperitoneum and peritoneum
    • hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease
    • anemia, unspecified
  • exam finding
    • 2022-11-17, -09-29 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-09-09 ECG
      • Sinus bradycardia with Premature atrial complexes
    • 2022-09-08 24hr portable ECG
      • Sinus rhythm
      • Occasional isolated apcs
      • Rare apc couplets
      • Rare episodes short run atrial tachycardia (longest: 11 beats)
      • Rare isolated vpcs
      • No long pause
      • No significant tachyarrhythmia
      • Frequent sinus bradycardia even at day-time, please correlate with clinical and drug history to r/o chronotropic incompetence
    • 2022-09-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (146 - 31) / 146 = 78.77%
        • M-mode (Teichholz) = 78
      • Mild septal hypertrophy with indeterminated LV filling pressure; moderately dilated LA.
      • Dilated LV with normal LV and RV systolic function.
      • Prominent aortic valve sclerosis with mild AR; mild MR; mild TR; mild PR.
      • Dilated aortic root with mild calcification.
      • Sinus bradycardia.
    • 2022-09-06 ECG
      • atrial fibrillation with slow ventricular response
    • 2022-07-08 Flow volume loop and volume time curve
      • mild restrictive ventilatory impairment
    • 2022-07-08 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (147 - 56) / 147 = 61.90%
      • Dilated LA, LV, Ao
      • Adequate LV, RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild MR,TR,AR
    • 2022-06-30 Electroencephalogram, EEG
      • normal awake EEG with alpha rhythm 9-10Hz.
    • 2022-06-07 CT - chest
      • Findings
        • Lungs:
          • lobular areas of consolidation and centrilobular nodular and branching opacities as well as septal thickening at LLL, RML and RLL, in progression.
          • centrilobular nodular and branching opacities at posterior RUL.
          • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
        • Mediastinum and hila: a 5 mm nodule in thymic bed.
        • Several mildly enlarged LNs in visceral space.
        • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
        • pulmonary arteries: normal caliber and well opacification.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small bilateral effusions.
        • Visible abdominal-pelvic contents: s/p peritoneal drains in place.
          • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites, and moderate free ascites.
          • several small Rt renal cysts.
          • unremarkable of the spleen, adrenal glands, the pancreas.
      • Impression:
        • lung infection in progression. hyperplastic reactive mediastinal LNs.
        • peritoneal carcinomatosis.
    • 2022-06-06 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular and linear opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-05-09 Chest XR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Nodular opacities projecting in right middle lung, right lower lung, and left lower lung are noted. Please correlate with CT.
    • 2022-04-12 CT - CTA, chest
      • Findings
        • Lungs:
          • lobular areas of consolidation and centrilobular nodular and branching opacities at RML and RLL. centrilobular nodular and branching opacities at posterior RUL.
          • subsegmental consolidation with centrilobular nodular and branching opacities at LLL.
          • ground glass nodule solid nodule at RUL RML RLL LUL LLL (up to 2. Mediastinum and hila: a 5 mm nodule in thymic bed.
        • Aorta: normal caliber, mild atherosclerotic change of descending thoracic aorta.
        • pulmonary arteries: normal caliber and well opacification.
        • Heart: normal in size of cardiac chambers.
        • Pleura: small Lt-sided effusion.
        • Visible abdominal-pelvic contents:
          • extensive and large soft-tissue mass at anterior peritoneal cavity, displacing and compressing liver surface, with Rt perihepatic loculated ascites.
          • several small Rt renal cysts.
          • unremarkable of the spleen, adrenal glands, the pancreas.
      • Impression:
        • no pulmonary embolism.
        • lung infection or aspiration pneumonia.
        • peritoneal carcinomatosis.
    • 2022-04-02 Chest PA/AP view
      • Supine chest image shows:
        • elongated and tortuosity of thoracic aorta and calcified atherosclerotic change at aortic arch
        • reticular opacities over Lt lower lung zone
        • marginal spurs of multiple vertebral bodies
    • 2022-03-28 Body fluid cytology - ascites
      • Atypia
      • Smears show mucinous material, neutrophils and reactive mesothelial cells.
    • 2022-01-17 Tc-99m MDP whole body bone scan
      • Faint hot spots in the left 11th costovertebral junction and both rib cages, the nature is to be determined (DJD, post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for further evaluation.
      • Suspected benign lesions in the maxilla, some T- and L-spine, bilateral shoulders, hips, and ankles.
    • 2022-01-17 MRA - brain
      • Mild general brain atrophy. Left mastoiditis. Bilateral chronic paranasal sinusitis.
    • 2022-01-13 CT - CTA, chest
      • Post op. change of the abodominal cavity.
      • Locualted effusion at RLQ of the abdomen. Nature?
      • No evidence of pulmonary embolism nor aortic dissection is found.
      • Some small patches at both lungs. suspected infection.
    • 2022-01-13 CT - brain
      • Mild ventriculomegaly. Intracraniaal artherosclerosis.
    • 2022-01-13 KUB
      • The psoas shadow is clear.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Increased intestinal gas is found.
      • Osteopenia of the bony structure is noted.
    • 2021-12-31 Patho - soft tissue tumor, extensive resection
      • pathologic diagnosis
        • Peritoneum, RUQ and right flank, peritonectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
        • Round ligament of liver, excision - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
        • Greater omentum, omentectomy - Pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1
      • microscopic examination
        • The sections show a picture of pseudomyxoma peritonei (mucinous carcinoma peritonei), grade 1, composed of abundant mucin with scant cohesive strips of low-grade mucinous epithelium.
    • 2021-12-27 Patho - pleural/pericardial biopsy
      • Lung, left, CT-guide biopsy - interstitial fibrosis and chronic inflammation - atypical pneumocyte present
      • Sections show alveolar lung tissue with interstitial fibrosis, chronic inflammatory cell infiltration and atypical pneumocyte proliferating along the alveolar wall.
      • No granuloma or malignancy is found.
      • IHC: CK7(+), CK20(-), TTF-1(+), Napsin A(+), and CDX2(-).
    • 2021-12-14 CT - lung/mediastinum/pleura
      • lung infection or aspiration pneumonia.
      • peritoneal carcinomatosis. RUQ free air due to infection or prior abdominal intervention.
    • 2021-12-06 Patho - peritoneum biopsy
      • diagnosis
        • Omentum, biopsy - metastatic mucinous adenocarcinoma, origin?
        • Peritoneum, biopsy - metastatic mucinous adenocarcinoma, origin?
      • IHC: CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor.
    • 2021-12-03 Colonoscopy
      • mixed hemorrhoid
      • no tumor was found in colonic lumen
  • consultation
    • 2022-09-08 Cardiology
      • Q
        • For bradycardia was noted last night, associated symptoms with syncope, chest tightness, we need your further evaluation and management.
        • The patient is an 72-year-old man with a history of Benign prostatic hyperplasia with Hamalidge OCAS control, Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), with IP chemotherapy (Docetaxel + cisplatin 60ml each with N/S 500ml and Gentamycin + Jusomin equally split to port-a at abdomen and oral chemotherapy with TS1 25mg/cap 3cap QD for one weeks and add IV chemotherapy.
      • A
        • S
          • This is a 72 years old man who was admitted for chemotherapy for appendiceal cancer.
          • We were consulted for near syncope survey. She is currently in abdominal pain for intraperitoneal assess route catheter infection.
        • O
          • Vital sign : stable
          • 2022/07/08 echography showing
            • EF: 66%
            • Dilated LA, LV, Ao
            • Adequate LV, RV systolic function with normal wall motion
            • Thick IVS, Impaired LV relaxation
            • Mild MR, TR, AR
          • EKG: sinus bradycardia with poor isoelectric line.
        • Impression
          • Near syncope rule out vaso-vagal. syncope or sick sinus syndrome
          • PD assess site infection under tapimycin
          • Sinus bradycardia.
        • Suggestion
          • Adequate pain control and fluid support
          • to check BP and HR at supine, sitting and standing position with 5 mins of interval to exclude postural hypotension
          • to check thyroid function and to arrange 24 H holter monitor due to marked sinus bradycardia episode.
          • Consider to consult neurology for neurogenic cause.
    • 2022-01-14 Neurology
      • Q
        • For seizure evaluation
        • This 72 y/o male has history of BPH. He just discharge on 20220108 due to mucinous adenocarcinoma of appendix with peritoneal metastatic, cT4aN1aM1, stage IVA, status post omentectomy and peritonectomy and PD tube inserted and intraperitoneal port implantation + HIPEC on 20211230.
        • According to his statement, he suffered from chest tightness, dyspnea since yesterday. He went to our ER for help on 20220113. His EKG data showed NSR, cardiac enzyme within normal range, D-dimer: 3730ng/ml. Unfortunately, he had seizure(hanging eyes) for 5 seconds at ER, Ativan and Keppra stat were given. Brain CT without constrast was done and showed mild ventriculomegaly, intracranial atherosclerosis. Chest CTA was done it revealed (1) no evidence of pulmonary embolism nor aortic dissection, (2) left pleural effusion and minimal right pleural effusion, (3) locualted effusion at RLQ of the abdomen. Nature?, (4) Some small patches at both lungs. suspected infection. Now, his con’s clear, stable of vital sign, pupil size 3.0 (OU) light reflux, four limbs muscle power 5point. We need your expertise for seizure evaluation and management. Thanks for your times.
      • A
        • Due to seizure at ER, we are consulted. Patient told he had no history of seizure and he didn’t remember during seizure attack. He also denied tongue biting, urinary/bowel incontinence, todd’s paralysis, diplopia, swallowing problem, slurred speech, limbs numbness or limbs weakness.
        • NE
          • Consciouness: E4V5M6
          • Visual field: no hemianopia
          • EOM: free
          • Pupil: 3.0/3.0 mm, Light reflex: +/+
          • Face: no central facial palsy
          • No dysarthria
          • no tongue deviation
          • Muscle power: 5/5
          • Babinski: down/down
          • Sensory: no hypoesthesia
          • FNF & HKS: no dysmetria
          • D dimer : 3700, Na 124, CRP 4.9
        • Assessment
          • Generalized tonic clonic seizure, 1st episode, suspected metastasis related or electrolyte imbalance
          • mucinous adenocarcinoma of appendix, stage IV A
        • Suggestion
          • Arrange EEG and MRA brain with/without contrast to r/o metastasis
          • Vit B6 1# bid po and Keppra 500mg bid po for seizure
          • We have given seizure educations to caution on driving scooter/car
    • 2022-01-06 Hemato-Oncology
      • Q
        • For further bidirectional chemotherapy evaluation
        • This 71 years old male has history of benign prostatic hyperplasia under medication treatment. According to his statement, he suffered from abdomen fullness for half year and body weight loss 4 kgs within 6 months, ever has tarry stool at 3 months ago. Then the symptom of RLQ pain worse since 2021-09, so he went to the Shin Kong Hospital for help.
        • On 2021-11-25 abdomen CT showed (1) Ruptured appendix mucinous cancer with peritoneal carcinomatosis, omental caking and hepatic surface implantation, (2) Focal peribronchial inflammation. And he was admitted to our Oncology ward for survey on 2021-11-29. During last admitted, he underwent laparoscopic examination with peritoneal tumor biopsy was done on 2021-12-06.
        • The pathology revealed metastatic mucinous adenocarcinoma. On 2021-12-14 following chest and abdomen CT was performed which showed (1) lung infection or aspiration pneumonia, (2) peritoneal carcinomatosis. Abdomen echo was done and showed no GB stone. Heart echo revealed LVEF: 80%, aortic valve sclerosis with mild AR; mild to moderate MR; mild TR; moderate PR. We check tumor marker showed CEA: 10.93ng/ml, CA-199: 283.12U/ml.
        • Under stable condition condition and fair oral intake, he was discharge on 20211215. After discharge, he was followed at GS OPD. He denied of poor appetite, no nausea or vomit, no tarry stool, no bloody stool, no abdomen fullness, no abdomen pain. Physical examination showed andomen ovoid and soft, no tenderness, no palpable mass. After fully explain, right hemicolectomy and cytoreductive surgery and HIPEC was suggested. This time, he was admitted to our ward for lung lesion biopsy and surgical intervention. However, during operation his PCI: 29/39 was noted, thus underwent omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. Now, he try to semi-liquid diet was smoothly, normal bowel function and stable condtion. We need your expertise for further bidirectional chemotherapy evaluation. Thanks for your times.
      • A
        • This 71 years old man is a case of Appendix cancer with peritoneal metastatic mucinous adenocarcinoma, cT4aN1aM1, stage IVA status post laparoscopic examination and biopsy on 2021/12/06, immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-), ECOG:0 s/p omentectomy, peritonectomy, CAPD and IP port implantation and HIPEC with oxaliplatin 300mg/m2 was done on 20211230. For bidirectional chemotherapy, we are consulted.
        • The impact of adjuvant chemotherapy following CRS/HIPEC in appendiceal mucinous neoplasms has not been well established due to rareness of this disease and lack of randomized trials. In the advanced-disease setting, available retrospective data suggest beneficial effect from systemic chemotherapy in moderate- to high‐grade appendiceal mucinous tumors.
        • Systemic therapy with FOLFOX/bevacizumab +/- IP chemotherpay as ajuvant chemotherapy may consider in this case
        • We will disucss with patient, thanks for your consultation
    • 2021-12-09 General and Gastroenterological Surgery
      • Q
        • for metastatic mucinous adenocarcinoma surgery, prepare the IP chemotherapy and on port-a evaluation
        • This time, he is admitted for colonfibroscopy examination and biopsy and staging, follow-up colonoscopy: no tumor was found in colonic lumen on 20211203, and he received the laparoscopy for tumor biopsy showed metastatic mucinous adenocarcinoma, origin? The immunohistochemical stains reveal CK7(-), CK20(+), CDX2(+), and PAX8(-). The results are in favor of GI tract (including appendix) tumor. So we need your help for metastatic mucinous adenocarcinoma (for peritoneum biopsy) surgery, prepare the IP chemotherapy and on port-a evaluation, thanks a lot!!
      • A
        • impression
          • psudomyxoma with peritoni, favor appendical mucinous adenocarcinoma related
        • suggest
          • radical right hemicolectomy with cytoreductive surgery and HIPEC is indicated
          • please arrange 2D echo and PFT first
          • please transfer to our survice next Monday
          • PPN support
  • surgical operation
    • 2021-12-30
      • omentectomy
      • RUQ and right flank peritonectomy
      • CAPD (continuous ambulatory peritoneal dialysis)
      • IP port implantation
    • 2021-12-06 Laparoscopic exploration and biopsy
      • Post-Op Dx: suspect pseudomyxoma peritoni        
      • Finding
        • Multiple white nodular lesions within omentum and peritoneal surface were noted. pieces were excised of them for biopsy.
        • Gelly like ascites about 100 ml and ascites cytology was done.
  • chemotherapy
    • 2022-12-01 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-11-18 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-11-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-10-17 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-09-30 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-08-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D7 + oxaliplatin 85mg/m2 100mg IVD 2hr + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr (The patient complaints poor intake due to the oral chemotherapy, so shift to TS1 25mg/cap 3cap QD for one week)
    • 2022-06-06 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-05-10 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-04-15 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 40mg + NaHCO3 70mg/mL 40mL] in N/S 500mL IP 1.5hr
    • 2022-03-25 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
    • 2022-03-04 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?
    • 2022-02-09 - TS-1 (tegafur + gimeracil + oteracil) 25mg/cap 50mg/m2 3# 75mg QD PO D1-D14 + + [docetaxel 40mg/m2 60mg + cisplatin 40mg/m2 60mg + gentamicin 80mg + NaHCO3 70mg/mL 80mL] in N/S 500mL IP 1.5hr x2 = 3hr ?

==========

2022-12-02

  • The vital signs are stable, and laboratory results indicate a grossly normal condition, except for hypomagnesemia (2022-12-01 1.6 mg/dL) which is being treated with magnesium sulfate injection.

2022-09-06

  • If neoadjuvant or adjuvant systemic chemotherapy is needed, a combination of fluoropyrimidine and an alkylating agent is recommended. 5-FU (TS-1) and oxaliplatin were included in the regimen used in the last hospitalization (2022-08-15). (ref: Lin, YL. et al. Consensuses and controversies on pseudomyxoma peritonei: a review of the published consensus statements and guidelines. Orphanet J Rare Dis 16, 85 (2021). https://doi.org/10.1186/s13023-021-01723-6 ).
  • Due to the patient’s poor intake caused by TS-1, the regimen has been changed to 7 consecutive days of administration. If this is also followed by a week of rest, thereby making the cycle 14 days, then the dose of oxaliplatin might need to be adjusted to accommodate this modification in cycle length.

2022-06-07

  • This case represents a patient with pseudomyxoma peritonei (PMP), who underwent omentectomy, RUQ, and right flank peritonectomy in 2021-12-30 along with hyperthermic intraperitoneal chemotherapy (HIPEC).
  • The patient has been receiving intraperitoneal treatment with [docetaxel + cisplatin + gentamicin] since 2022-02-09 in conjunction with oral TS-1, a regimen that has been outlined at doi:10.3390/cancers12082212.
  • Since records began in Nov 2021, certain items of lab results have been consistently outside normal ranges. These include low HGB (2022-06-07 8.7g/dL), low RBC (2022-06-07 2.61 106/uL), and high D-dimer (2022-06-06 6969.93 ng/mL FEU).
  • Anemia is rarely mentioned in PMP case reports, so it is possible that anemia could be caused by another condition which might be worth further investigation.
  • TPR and BP are generally normal and stable since this hospital stay from 2022-06-06.

2022-06-06

[drug identification]

Total 1 drug for identification.

The identified item is Vemlidy film-coated tablet containing tenofovir alafenamide 25mg which is indicated for the treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease.

The drug will be sent back to ward by the in-hospital porter.

2022-04-06

  • This is a patient with pseudomyxoma peritonei (PMP), s/p omentectomy, RUQ and right flank peritonectomy (2021-12-30) and hyperthermic intraperitoneal chemotherapy (HIPEC).
  • From 2022-02-09, he has been receiving intraperitoneal [docetaxel plus cisplatin + gentamicin] in combination with oral TS-1, a regimen which was published at doi:10.3390/cancers12082212.
  • Hypoosmolarity and hypoelectrolytemia are treated with appropriate electrolyte solutions.
  • A low WBC reading of 910/uL was recorded on 2022-04-05. G-CSF might be an option.

700561561

221202

{pancreatic cancer, endometrial cancer}

  • diagnosis
    • Pancreatic cancer with peritoneum metastasis s/p Laparoscopic exploration on 2022/02/25
    • Endometrial cancer, pT1bN0M0, Stage IB status post laparoscopic vaginal total hysterectomy on 2018/04/17
  • lab data
    • CEA
      • 2022-07-26 CEA 5.21 ng/mL
      • 2022-05-02 CEA 3.10 ng/mL
      • 2022-01-24 CEA 1.96 ng/mL
      • 2021-10-25 CEA 1.84 ng/mL
    • CA125
      • 2022-07-26 CA125 788.2 U/mL
      • 2022-05-02 CA125 460.8 U/mL
      • 2022-01-24 CA125 15.1 U/mL
      • 2021-10-25 CA125 5.8 U/mL
      • 2021-07-26 CA125 5.5 U/mL
      • 2021-04-26 CA125 3.5 U/mL
    • CA199
      • 2022-07-26 CA199 12024.11 U/mL
      • 2022-05-23 CA199 >19680.00 U/mL
      • 2020-04-13 CA199 23.72 U/mL
  • exam finding
    • 2022-11-28 CT - abdomen
      • Indication: Pancreatic cancer with peritoneal carcinomatosis
      • Findings
        • Abdomen and pelvis
          • Low density change at pancreatic tail about 4.74cm in largest dimension is found. pancreatic cancer is considered. In comparison with CT dated on 2022-09-05, the lesion is stationary.
          • Massive ascites is found. Cancerous peritontitis is considered first
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Low density lesion at S4 of liver about 2.5cm in largest dimension is found. Liver meta is considered. In progression.
          • No evidence of abnormal soft tissue mass at pelvic cavity.
          • The spleen, pancreas, both kidneys and adrenals are intact.
        • Visible chest
          • Cardiomegaly is noted.
          • No pleural effusion is found.
          • Clear bilateral basal lungs.
        • Suggest clinical correlation
      • Imp:
        • Pancreatic tail cancer with cancerous peritonitis and massive ascites. Stable.
        • Liver meta. In progression.
        • Bone meta. Please correlate with bone scan study.
    • 2022-11-16 CXR
      • Fracture of left clavicle, M/3.
      • Pleura effusion of right and left costal-phrenic angle
      • Atherosclerotic change of aortic arch
    • 2022-09-05 CT - abdomen
      • Indication: Pancreatic cancer with peritoneal seedings
      • Findings
        • Abdomen and pelvis
          • s/p ATH and BSO.
          • Low density lesion at pancreatic tail about 4.6cm is found. In comparison with CT dated on 2022-05-09, the lesion is stationary.
          • Massive ascites is found. Cancerous peritonitis is considered.
          • The GB is well distended without soft tissue lesion
          • Sclerotic and lytic changes of the bony structure is found. Bony metastasis is considered.
          • Low density lesion at S4 of liver about 0.7cm in largest dimension is found. suspected liver meta or others. Stationary.
          • There is no evidence of paraarotic LAPs.
        • Visible chest
          • Normal heart size.
          • The lung fields are clear.
          • No pleural effusion is found.
        • Suggest clinical correlation
      • Imp:
        • Massive ascites, suspected cancerous peritonitis
        • Pancreatic tail tumor, 4.6cm, stable. Pancreatic cancer is favored.
        • Bone meta. New.
        • Liver low density lesion. S4, meta?
    • 2022-06-14 SONO - abdomen
      • Gallbladder sludge
      • Asictes
    • 2022-06-10 CXR
      • S/P port-A implantation.
      • Fracture of left clavicle, M/3.
      • Pleura effusion of right and left costal-phrenic angle
      • Atherosclerotic change of aortic arch
    • 2022-06-09 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 18 dB HL; LE 24 dB HL
      • bil normal to moderate SNHL (sensorineural hearing loss)
    • 2022-05-25 Patho - peritoneum biopsy
      • Peritoneum, biopsy — Metastatic adenocarcinoma, origin? (please see microdescription)
      • Section shows fibroadipose tissue with metastatic adenocarcinoma.
      • The immunohistochemical stians reveal CK7(+), CD20(-), CDX2(focal weak +), GATA3(+), PAX8(-), and Calretinin(-).
      • The results are more favor pancreatic tumor than endometrial tumor.
    • 2022-05-25 Patho - omentum biopsy
      • Greater omentum, biopsy — Negative for malignancy
    • 2022-05-24 ECG
      • Sinus tachycardia
      • Low voltage QRS
    • 2022-05-24 SONO - abdomen
      • massive ascites
      • diffuse wall-thickening of small bowel, suspected carcinomatosis
    • 2022-05-13 Clavicle LT
      • Left M/3 clavicle fracture
    • 2022-05-09 CT - abdomen, pelvis
      • s/p ATH and BSO.
      • Massive ascites and bilateral pleural effusion is found.
      • Pancreatic body lesion about 5.53cm in largest dimension is found. Either meta or primary tumor should be D.D.
    • 2022-05-09 Gynecologic ultrasonography
      • p/s ATH + BSO
      • Ascites (+)
    • 2022-05-04 Gynecologic ultrasonography
      • Bil adnexa: s/p BSO
      • EM cancer post staging, ascites (+)
      • suspected tumor recurrence
    • 2022-05-04 KUB
      • Presence of ileus.
    • 2022-05-04 CXR
      • Fracture of left clavicle.
      • Left pleural effusion.
      • Presence of ileus.
    • 2022-04-01 Clavicle LT
      • Left M/3 clavicle fracture with displacement
    • 2022-01-26 CT - abdomen, pelvis
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver shows stationary.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2021-11-01 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2021-07-26 CT - abdomen, pelvis
      • S/P hysterectomy.
      • No evidence of tumor recurrence.
    • 2021-05-03 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Hepatic high echoic lesions, nature? fibrosis lesions?
        • GB stones
        • Fatty pancreas
      • Suggestion
        • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2021-05-03 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2020-10-07 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • Hepatic low echoic lesions, nature?
        • GB stones
        • Fatty pancreas
      • Suggestion
        • Please correlate with clinical information and other image studies, and follow sonography in 3-6 mon.
        • Please check tumor, hepatitis markers and LFTs q3-6 mon
    • 2020-07-27 CT - abdomen, pelvis
      • S/P hysterectomy.
      • No evidence of tumor recurrence.
    • 2020-04-13 SONO - abdomen
      • Diagnosis
        • Parenchymal liver disease
        • GB stones?
      • Suggestion
        • Please follow sonography in 3-6 mon.
    • 2020-04-13 Gynecologic ultrasonography
      • p/s ATH + BSO
      • no obvious uterine or ovarian lesion
    • 2020-01-03 CT - abdomen
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver is suspected. Follow up MRI 3 months later may be indicated.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2019-09-26 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2019-06-03 CT - abdomen
      • S/P hysterectomy. There is no evidence of tumor recurrence.
      • A lesion in S4 liver is suspected.
      • The gallbladder shows few small stones and posterior displacement by the S4 liver lesion.
    • 2019-02-25 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2018-11-27 CT - abdomen
      • s/p ATH and BSO.
      • No focal lesion in the pelvis
    • 2018-05-11 CT - abdomen
      • S/P hysterectomy.
      • Relative dirty mesentery fat plane, post-op change?
      • Loculated fluid density in right obturator region, suspected lymphocele or seroma, suggest follow up study.
    • 2018-05-11 Transvaginal Ultrasonography
      • No obvious uterine or ovarian lesion
    • 2018-04-18 Patho - laparoscopic vaginal total hysterectomy (LAVH), Level VI
      • Uterus, endometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, grade 1
      • Uterus, myometrium, laparoscopic vaginal total hysterectomy (LAVH) — Endometrioid adenocarcinoma, invading >1/2 of the thickness of the myometrium.
      • Uterus, cervix, laparoscopic vaginal total hysterectomy (LAVH) — Free.
      • Ovaries and fallopian tubes, bilateral, laparosocpic salpingo-oophorectomy (BSO) — Free
      • Lymph node, bilateral pelvic, dissection (BPLND) — Free (0/25)
      • Omentum, omentectomy — Free (with one lymph node free of malignancy 0/1)
      • AJCC 8th edition Pathology stage: pT1bN0 (if cM0); pStage: IB.
      • S2018-05404: ER (+, 90%), PR (+, 90%)
    • 2018-04-14 MRI - pelvis
      • Imaging Report Form for Endometrial Carcinoma
      • Impression:
        • Endometrial malignancy, cstage T1bN0Mx.
        • Right obturator lymph node, suggest follow up.
    • 2018-04-03 Surgical pathology Level IV
      • Uterus, endometrium, D&C — Adenocarcinoa with squamous metaplasia.
      • IHC: ER (+, 90%), PR (+, 90%), p40 (-), p16 (+, 70%), vimentin (+, 80%).
    • 2018-04-02 Gynecologic ultrasonography
      • Suspected endometrial hyperplasia
  • consultation
    • 2022-05-04 Obstetrics and Gynecology
      • Q
        • poor appetite after traffic accident in Feburary
        • diarrhea, nausea for 2 weeks
        • periumbilical fullness for 2 weeks
        • EGD at LMD last week: GERD
        • abdominal sono at LMD on 5/2: ascites
        • PH: Malignant neoplasm of endometrium S/P hysterectomy, R/T
        • Allergy: NKA
      • A
        • findings
          • a case of endometrial cancer post staging surgery (ATH + BSO + BPLND + omentectomy) + radiotherapy in 2018.
          • post op course was smooth without recurrence, checked by CT scan, sonar and tumor marker until 2022/2
          • c/o abdominal distension, poor appetite for 2 weeks (c/o: complaint of)
          • no fever nor pain
          • CA125: 15 -> 460 elevated
          • GYN sonar: ascites > 1000 c.c
          • PV – vaginal stump no mass palpated, seemed free
          • no bleeding
        • Imp
          • ascites,
          • suspected cancer recurrence
        • Suggestion:
          • consider to arrange abdominal tapping (+ send ascites cytology) if indicated
          • symptom treatment with gascon, etc
          • please arrange abdominal CT scan
          • scheduled 20220509 W1 GYN OPD for further Tx
  • surgical operation
    • 2022-05-25
      • Operation
        • Laparoscopic exploration
      • Finding
        • Massive turbid ascites, > 4000cc
        • Multiple peritoneal seedings, compatible with carcinomatosis
        • Culture: ascites*1
    • 2018-04-17
      • Diagnosis
        • endometrial cancer (adenocarcinoma)
      • PCS
        • 80424B
      • Finding
        • Uterus: enlarged, 12x10x7cm
        • endometrium – thickened, soft necrotic tissues at fundus; EM cancer cells likely
        • myometrium – seemed invaded by cancer
        • cervix eroded
        • bil adnexa: normal-looking, seemed free of cancer invasion
        • omentum, appendix, bowels: seemed free of cancer invasion
        • CDS: no fluid (send ascites washing cytology) but severe pelvic bowel adhesion (due to previous vertival laparotomy?) was noted between ant peritoneum, left pelvis and bowels; between uterus and ant bladder s/p LSC adhesiolysis
        • A 7mm JP drain was placed in CDS
    • 2018-04-02
      • Diagnosis
        • Suspected endometrial hyperplasia or cancer – EM 2.43cm
      • PCS
        • 80423B
      • Finding
        • Under IVGA, Hysteroscopic endometrial curettage were done.
        • Thickened endometrium noted with a lot of soft necrotic tissues, suspected endometrial hyperplasia or cancer
  • chemoimmunotherapy
    • 2022-11-09 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-26 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-19 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-10-05 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-09-28 - gemcitabine 800mg/m2 1300mg 30min + nab-paclitaxel 100mg/m2 160mg 90min
    • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
    • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 90min
    • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-08-04 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-07-08 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-06-21 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 120mg 90min
    • 2022-06-14 - gemcitabine 800mg/m2 1250mg 30min + cisplatin 20mg/m2 30mg 24hr

==========

2022-12-02

  • It should be noted that both serum creatinine and BUN increased 50% in the last two weeks (Cre 1.76 mg/dL 2022-11-30 <- 1.18 mg/dL 2022-11-16; BUN 33 mg/dL 2022-11-30 <- 20 mg/dL 2022-11-16), as well as bilirubin total exceeded 6 x ULN (6.95 mg/dL 2022-11-30).

  • 2022-11-30 eGFR 31.2

    • gemcitabine for patients with altered kidney function:
      • CrCl >= 30 mL/minute: IV: No dosage adjustment necessary (Cetina 2004; Delaloge 2004; Li 2007; Lichtman 2007; Venook 2000).
      • CrCl <30 mL/minute: IV: No dosage adjustment necessary. However, risk of hematologic toxicity may be increased in these patients, which may require gemcitabine dose modification (Cetina 2004; Li 2007; Lichtman 2007; Mir 2005; Tanji 2013; Venook 2000).
    • nab-paclitaxel for patients with altered kidney function:
      • CrCl <30 mL/minute: There are no dosage adjustments provided in the manufacturer’s labeling (insufficient data).
  • 2022-11-30 bilirubin total 6.95 mg/dL, ALT 442 U/L, AST 342 U/L

    • gemcitabine for patients with hepatic Impairment - there are no dosage adjustments provided in the manufacturer’s labeling. The following adjustments have been reported:
      • Transaminases elevated (with normal bilirubin): No dosage adjustment necessary (Venook 2000).
      • Serum bilirubin > 1.6 mg/dL: Use initial dose of 800 mg/m2; may escalate if tolerated (Ecklund 2005; Floyd 2006; Venook 2000).
      • Dosage adjustment for hepatotoxicity during treatment: Discontinue if severe hepatotoxicity occurs during gemcitabine treatment.
    • nab-paclitaxel for patients with hepatic Impairment
      • Not recommended in case of AST > 10x ULN or bilirubin > 5x ULN
  • It is suggested to ensure that the patient’s kidney and liver function are in good condition prior to the chemotherapy.

2022-07-29

  • Tumor markers
    • CEA
      • 2022-07-26 5.21 ng/mL
      • 2022-05-02 3.10 ng/mL
      • 2022-01-24 1.96 ng/mL
      • 2021-10-25 1.84 ng/mL
    • CA125
      • 2022-07-26 788.2 U/mL
      • 2022-05-02 460.8 U/mL
      • 2022-01-24 15.1 U/mL
      • 2021-10-25 5.8 U/mL
      • 2021-07-26 5.5 U/mL
      • 2021-04-26 3.5 U/mL
    • CA199
      • 2022-07-26 12024.11 U/mL
      • 2022-05-23 >19680.00 U/mL
      • 2020-04-13 23.72 U/mL
  • In recent months, tumor markers have trended upward. The current regimen has been used to treat patients since mid-June 2022 (still less than 2 months).
  • FOLFIRINOX vs Gemtabine plus Nab-Paclitaxel, there is disagreement among studies regarding the choice between the two. references:
    • Klein-Brill A, Amar-Farkash S, Lawrence G, Collisson EA, Aran D. Comparison of FOLFIRINOX vs Gemcitabine Plus Nab-Paclitaxel as First-Line Chemotherapy for Metastatic Pancreatic Ductal Adenocarcinoma. JAMA Netw Open. 2022;5(6):e2216199. doi:10.1001/jamanetworkopen.2022.16199
    • Riedl JM, Posch F, Horvath L, et al. Gemcitabine/nab-Paclitaxel versus FOLFIRINOX for palliative first-line treatment of advanced pancreatic cancer: A propensity score analysis. Eur J Cancer. 2021;151:3-13. doi:10.1016/j.ejca.2021.03.040
    • Chun JW, Lee SH, Kim JS, et al. Comparison between FOLFIRINOX and gemcitabine plus nab-paclitaxel including sequential treatment for metastatic pancreatic cancer: a propensity score matching approach. BMC Cancer. 2021;21(1):537. Published 2021 May 11. doi:10.1186/s12885-021-08277-7
    • Tahara J, Shimizu K, Otsuka N, Akao J, Takayama Y, Tokushige K. Gemcitabine plus nab-paclitaxel vs. FOLFIRINOX for patients with advanced pancreatic cancer. Cancer Chemother Pharmacol. 2018;82(2):245-250. doi:10.1007/s00280-018-3611-y

2022-07-06

  • No mutation test results were found for BRCA1/2 or PALB2. A change in the regimen from gemcitabine + cisplatin to gemcitabine + nab-paclitael has been made in late June 2022. Whereas FOLFINOX or modified FOLFINOX (not used in this case) should be limited to patients with an ECOG of 0 or 1.
  • There has been a low potassium level of 1.9 mmol/L on 2022-07-05. A KCl injection, oral potassium gluconate, and a spironolactone dose have been prescribed.

701450418

221201

  • exam findings
    • 2022-10-04 Pelvis and Bilat. Hip. Lat.
      • Narrowed joint or discal space with bony sclerosis but without acute fracture, bone destruction or dislocation.
    • 2022-10-03 CXR
      • Left pleural effusion. A LLL tumor mass.
      • No cardiomegaly by cardiac/thoracic ratio.
      • Post operative appearance in or at the area of TL spine.
      • Presence of numerous small miliary-like lesions in bilateral lung fields, metastases should be rule out.
    • 2022-09-28 T-L spine AP + Lat.
      • Presence of spondylolisthesis at L4/5, grade I.
      • Presence of anterior wedge deformity or body collapse of the thoracic or lumbar spine due to compression fracture(s) L2.
      • S/P posterior longitudinal transpedicular spine screws and rods fixation.
    • 2022-09-27 EGFR mutation
      • A deleteion was detected at exon 19 of EGFR gene in this specimen.
      • The EGFR mutation testing was based on real-time PCR technique for detection of exons 18 (G719X), 19 (Deletions), 20 (T790M, S7681I, Insertions), 21 (L858R, L861Q) mutations of EGFR gene. The limit of detection (LoD) of this test was 10% mutant gene of whole EGFR gene.
    • 2022-09-29 PD-L1 (22C3)
      • Tumor Proportion Score (TPS) assessment: TPS < 1%
    • 2022-09-29 PD-L1 28-8 IHC
      • Tumor cell (TC) staining assessment: TC < 1%
      • Percent of PD-L1 expression in tumor cells (TC): < 1%
    • 2022-08-11 PD-L1 (SP142)
      • Pathologic Report for PD-L1 (SP142) Assay (Ventana) - S2022-16383
        • Tumor type: adenocarcinoma
        • Tumor location: lung
        • Testing assay: SP142 Assay (Ventana)
        • Testing platform: BenchMark XT
        • Detection system: OptiView DAB IHC Detection Kit and OptiView Amplification Kit
        • Control slide result: Pass,
        • Adequate tumor cells present (>=50 viable tumor cells): Yes,
      • Result:
        • Tumor cell (TC) staining assessment: TC category: TC < 1%
        • Tumor-infiltrating immune cell (IC) staining assessment: IC category: IC < 1%
      • Note:
        • TC scoring: TC are scored as the percentage of viable tumor cells showing membrane staining of any intensity.
        • IC scoring: IC are scored as the proportion of tumor area (including associated intratumoral and contiguous peritumoral stroma) that is occupied by discernible staining of any intensity of tumor-infiltrating immune cells.
    • 2022-09-26 Patho - lung transbronchial biopsy
      • Lung, left, CT-guide biopsy — adenocarcinoma, moderately differentiated
      • Sections show neoplastic acinar glandular cells infiltrating in a fibrotic stroma.
    • 2022-09-21 Whole body PET scan
      • Glucose-hypermetabolic lesions in the left upper and lower lungs with pleura involvement, highly suspected lung cancer with lung to lung mets and malignant pleural effusion.
      • Glucose hypermetabolic lesions in bilateral mediastinal and right pulmonary hilar lymph nodes, highly suspected lung cancer with regional lymph nodes metastases.
      • Increased uptake of FDG in the right adrenal gland, L2 spine, and left frontal skull, highly suspected lung cancer with multiple distant metastases.
      • Left lung cancer with lung to lung, bilateral mediastinal and right pulmonary hilar lymph nodes, right adrenal gland, L2 spine, and left frontal skull metastases, cT4N3M1c, stage IVB (AJCC 8th ed.), by this F-18-FDG PET/CT scan.
    • 2022-09-20 MRI - brain
      • No obvious brain or intracranial nodule or metastasis 2. r/o Focal left frontal skull metastasis.
  • consultation
    • 2022-11-30 Rehabilitation
      • A
        • Assessment
          • Left lower lobe lung cancer with bilateral lung to lung meta, mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta
          • Multiple bone metastases with L2 pathological fracture
        • Plan
          • Rehabilitation programs: Bedside PT, OT rehabilitation programs; apply ant. AFO for left drop foot
          • Goal: improve ADL, muscle power and endurance
    • 2022-11-09 Rehabilitation
      • Assessment
        • Malignant neoplasm of lower lobe, left bronchus or lung
        • Secondary malignant neoplasm of bone
        • Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25
        • Chronic viral hepatitis B without delta-agent
      • Plan
        • Rehabilitation programs: Bedside PT and OT rehabilitation programs
        • Goal: improved ADL and muscle power, ambulate with device under supervision
    • 2022-11-10 Dermatology
      • Q
        • This 48-year-old woman patient is a csae of Left lung adenocarcinoma with pathology fracture of L2 status post L2-L3 laminectomy, fixation and postero-lateral spinal fusion on 2022/09/12 s/p TKI with Afatinib from 2022/10/25. This time, for whole body skin red rash after TKI. Now, for evaluate whole body red rash therapy. Thank you.
      • A
        • The patient had sufferred from exfoliative reddish plaques with scales over face and mutiple pustular lesions over chest/back.
        • Under the impression of seborrheic dermatitis (immunocompressed state?) and follculitis on the trunk.
        • The following sugeetion:
          • Oral doxycycline and broen-C 1# bid po for 5 days.
          • For face, Free gel 1 tube topical bid use over large area first and consider Rinderon-V cream 2 tube topical bid over reddish itchy area.
          • For trunk, Clindamycin gel 1 tube topical bid use on the pustular lesions.
    • 2022-09-23 Oral and Maxillofacial Surgery
      • Q
        • This 48 years old female patient was diagnosed of lung cancer with bone metastatic. She had underwent L2, L3 laminectomy and fixation and posterior-lateral fusion cause by L2 pathological fracture with spinal stenosis. We had keep lung cancer treatment, and prepare use denosumab. We need your professional evaluation and recommendation for dental evaluation. Thank you very much for your time!
      • A
        • O:
          • Full mouth chronic periodontitis
          • Fair oral hygiene.
          • No visible caries was notd.
        • P:
          • Explain the finding to the patient.
          • Home care instrcution.
          • OPD follow up
    • 2022-09-21 Hemato-Oncology
      • A
        • Impression:
          • LEFT LOWER LOBE lung cancer with bilateral lung to lung meta. Mediastinal lymphadenopathy, lumbar spine pathological fracture, right adrenal meta and probably liver meta, cT4N3M1c, StageIVB
        • Suggestion:
          • family meeting has been arranged on 20220922 18:00
          • Arrange Chest CT guide biopsy for EGFR gene mutation test, PD-L1
          • May check Anti Hbc, HbsAg, Anti-HCV
          • Consult oral surgery for denal evaluation (prepare use denosumab which has been associated with osteonecrosis of the jaws)
          • We woukd like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us know.
    • 2022-09-14 Rehabilitation
      • A
        • Assessment
          • suspected left L1-L3 radiculopathy due to multiple bone metastases with L2 pathological fracture
        • Plan
          • Keep pain control medication
          • suggest waist support when sitting up
          • futher L-spine image could be follow up if pain exaggerates
  • chemoimmunotherapy
    • 2022-10-25 ~ 2022-11-08 Giotrif (afatinib 30mg) 1# QDAC

[note]

  • Giotrif (afatinib 30mg) nasogastric tube feeding - Alternative Methods of Administration (package insert 20210526)
    • If dosing of whole tablets is not possible, GIOTRIF tablets can be dispersed in approximately 100 mL of noncarbonated drinking water. No other liquids should be used. The tablet should be dropped into the water without crushing it, and stirred occasionally until the tablet is broken up into very small particles (approximately 15 minutes). The dispersion should be consumed immediately. The glass should be rinsed with approximately 100 mL of water which should also be consumed. The dispersion can also be administered through a gastric tube.

[assessment]

  • In accordance with NCCN recommendations for NSCLC (guideline version 5.2022), osimertinib is preferred for patients with EGFR exon 19 deletion, along with erlotinib, afatinib, and dacomitinib.
  • Giotrif (afatinib) was prescribed to the patient during 2022-10-25 and 2022-11-08.
  • As of 2022-11-30, there were no extrem results in the lab test, and the patient’s vital signs remained stable.
  • There is no issue with the active prescription.

700341408

221130

{This 80-year-old man patient is a case of Diffuse large B-cell lymphoma, Non-GCB type, at the right maxillary gingiva and tuberosity, Ki-67 index >95%, Lugano stage II, IPI score: 1, Low risk group, PS:0}

  • past history
    • Hyperlipidemia
    • Arrythmia
    • Coronary artery disease, with middle left anterior descending artery myocardial bridge
  • operation history:
    • s/p appendectomy
    • pituitary macroadenoma s/p transsphenoisia reemoval of pituitary adenoma on 20131105.
    • tumor excision over mesenchymal origin tumor over left buttock on 20210304 showed benign fibrotic cystic wall tissue  
  • family history
    • There is no family history of cancer, hypertension, mental diseases or asthma.
    • No members of the family with diabetes.
  • exam findings
    • 2022-11-29 ECG
      • Sinus tachycardia
      • Nonspecific ST abnormality
    • 2022-11-24, -11-14, -10-27, -08-17 CXR
      • Atherosclerotic change of aortic arch
    • 2022-11-16 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (58 - 16) / 58 = 72.41%
        • M-mode (Teichholz) = 72
      • Mild septal hypertrophy with Gr I LV diastolic dysfunction.
      • Normal LV and RV systolic function.
      • Aortic valve sclerosis with mild AR; prominent posterior mitral annulus calcification with mild MR; moderate TR; mild PR.
    • 2022-11-03 SONO - abdomen
      • Hepatic calcification, right lobe
      • Renal cysts, both
      • Renal lesion, LK, favor angiomyolipoma
    • 2022-11-02 MRI - nasopharynx
      • Indication: He was just proved lymphoma in his mouth. He was referred by a local dentist because of an oral tumor. According to his statement, he notes this mass aroud one month ago. He has history of pitutary problem, hypertension for years.
      • Findings
        • metallic artifacts in the oral cavity
        • mild mucosal thickening in the bilateral maxilalry sinuses.
        • mucasal thickening in the upper esophagus. Please correlate with other image modality.
        • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
        • no neck LAP.
      • IMP:
        • a multi-lobulated heterogeneous enhancing tumor, about 33mm, in the head of the right medial pterygoid muscle, inferior aspect of the maxillary sinus and right upper buccogingival mucosa.
        • mucosal thickening in the upper esophagus.
    • 2022-09-29 Sonography - thyroid gland
      • Normal size of the thyroid gland.
      • A heterogenic nodule (0.47x0.78cm) in left thyroid gland.
    • 2022-09-20 Myocardial perfusion SPECT with persantin
      • Probably mild myocardial ischemia at the lateral wall.
    • 2022-09-19 ECG
      • Sinus bradycardia
      • T wave abnormality, consider anterolateral ischemia
    • 2022-09-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (49.8 - 11.9) / 49.8 = 76.10%
        • M-mode (Teichholz) = 76.1
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild to moderate MR and TR, mild AR and PR
      • Mildly thick IVS and LVPW
    • 2022-09-03 ECG
      • Atrial flutter with variable A-V block
      • Nonspecific ST and T wave abnormality
      • Abnormal ECG
    • 2022-09-03 ECG
      • Possible atrial flutter with 2:1 AV conduction
      • ST & T wave abnormality, consider anterolateral ischemia
      • Abnormal ECG
    • 2022-08-18 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (67.5 - 15.3) / 67.5 = 77.33%
        • M-mode (Teichholz) = 77.3
      • Adequate LV,RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR, TR
    • 2022-08-16 Whole body PET scan
      • Glucose hypermetabolism in a focal area involving the right maxillary sinus, right nasal cavity, soft palate and right oropharynx, in the left maxillary sinus and in two left submandibular lymph nodes, compatible with lymphoma.
      • Glucose hypermetabolism in a focal area in the pituitary fossa, compatible with a macroadenoma. However, please correlate with other clinical finidngs for further evaluation and to rule out other possibilities.
      • Increased FDG accumulation in both kidneys and bilateral ureters. Physiological FDG accumulation may show this picture.
    • 2022-08-02 Patho - gingival/oral mucosa biopsy
      • Pathologic diagnosis
        • Oral cavity, right maxillary gingiva, incisional biopsy — Diffuse large B-cell lymphoma, Non-GCB
      • Macroscopic description
        • Operation procedure: incisional biopsy
        • Topology: Oral cavity, right maxillary gingiva
        • Specimen size and number: 2 pieces, up to 1.2x 0.8x 0.4 cm
      • Microscopic examination
        • Histology type: B-cell neoplasms - Diffuse large B-cell lymphoma (any subtype)
        • Immunohistochemical stain profiles: C-myc(+, >40%), CD3(-), CD20(+), CD10(-), CD56(-), Cyclin D1(-), Bcl-6(+),Bcl-2(+),MUM-1(+), CK(-), Ki-67 index: > 95%.
    • 2022-05-26 SONO - abdomen
      • Diagnosis
        • Hepatic cysts, bilateral lobes
        • Fatty infiltration of pancreas
        • Pancreatic cystic lesion, neck-body
      • Suggestion
        • Hepatic lesion may be masked by fatty liver background
    • 2022-05-18 MRI - sella
      • Indication: for follow up brain tumor. patient had diplopia pituitary macroadenoma, s/p resection 7 yrs ago. residual tumor enlarging in size recently. S: for SRS arrangement. check prolactin level, consider surgical intervention. PATIENT REQUEST FOR STEREOTACTIC RADIOSURGERY. for follow up image study.
      • Findings
        • The high SI on T1WI in the posterior lobe of the pituitary gland was preserved.
        • a pituitary gland tumor, about 15mm x 16mm x 17mm, in the pituitary fossa and suprasellar cistern. The pituitary stalk was elevated. The lesion revealed low SI on T1WI and heterogeneous high SI on T2WI. Tumor invasion to the left cavernous sinus was noted. Tumor encasement of the left caverous ICA was noted.
        • unremarkable change in the bony middle cranial fossa
        • some white matter gliosis in the bilateral frontal and parietal lobes.
      • IMP: pituitary gland macroadenoma with invasion to the left cavernous sinus and tumor encasement of the left cavernous ICA.
    • 2022-04-14 Sonography - thyroid gland
      • Normal size of the thyroid gland.
      • Some hypoechoic nodules (0.26x0.36cm, 0.41x0.69cm) in left thyroid gland.
  • consultation
    • 2022-09-03 Cardiology
      • A
        • O
          • ECG: suspected atrial flutter or atrial tachycardia (less than 24 hours)
          • CxR: RLL infiltration; L’t pleural effusion
          • SBP 140 mmHG;
          • PH of thyroxine supplement;
        • Suggestion
          • Amiodarone infusion for possibly atrial flutter; concor 0.5# st and qd if SBP > 110 mmHg.
          • F/U Tn-I level; if further elevation, may admit to ICU for close monitoring.
          • Check thyroid function.
          • Infection survey and empiric antibiotic for suspected pneumonia.
          • Arrange 2D echo after admission.
    • 2021-01-14 Cardiology
      • Q
        • Hx of myocadial bridge
      • A
        • I was consulted for elevated troponin I of a 79-year-old man who visited to ED acute onset of chest pain relieved by SL NTG this morning.
        • S
          • No cold sweating and radiation pain.
          • Episodes of chest pain for 4 times in recent months.
          • Hx of myocardial bridge in 2017.
        • O
          • 2021/01/14 07:12 hs-Troponin I = 16.5 pg/mL;
          • 2021/01/14 09:45 hs-Troponin I = 71.8 pg/mL;
          • No chest pain on visit
          • No signicant murmur, no pitting edema
          • EKG: TWI from V1-6 on admission to ED, then resolution of TWI at V1-2, persistent TWI at V4-6
          • Beside cardiace echo: normal wall motion.
        • Impression:
          • Elevated troponin I due to myocardial bridge is more likely
          • Angina pectoris due to myocardial bridge
        • Suggestion:
          • Regular medication for myocardial bridge with angina pectoris is suggested. Please prescribe Diltiazem (30) 0.5# BID and Coxine 0.5# BID PO (may hold Diltiazem if SBP <90mmHg or dizziness)
          • Option for cardiac catheterization was explained to the patient and his wife; if they want to recieve cardiac cathetertization, please call me (before noon).
          • The patient was informed to observe the symptoms and also informed about the warning sign.
          • CV OPD follow up if they choose to discharge
  • chemoimmunotherapy (R-mCHOP)
    • 2022-11-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-10-17 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-09-21 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5
    • 2022-08-26 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1000mg 1hr + liposome doxorubicin 30mg/m2 50mg 1hr + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 40mg TID D1-D5

[assessment]

  • WBC 410/uL 2022-11-30 <- 580/uL 2022-11-29. For (febrile) neutropenia, filgrastim and cefepime have been used. The results of the blood culture are pending.
  • The heart rate is volatile (63 ~ 122 beat/minute), 2022-11-29 ECG showed sinus tachycardia and nonspecific ST abnormality. Please continue to monitor the hemodynamic parameters.

701125676

221130

{Esophageal cancer, cT2N2Mo stage III, Port-A insertion at left cephalic vein on 20220922, jejunostomy tube insertion at abdomen on 20220922}

  • lab data
    • 2022-09-16 HBsAg High Reactive
    • 2022-09-16 HBsAg Value 551.57 IU/mL
    • 2022-09-16 Anti-HBc Reactive
    • 2022-09-16 Anti-HBc-Value 8.41 S/CO
    • 2022-09-16 Anti-HCV Nonreactive
    • 2022-09-16 Anti-HCV Value 0.07 S/CO
  • exam finding
    • 2022-11-02 Tc-99m MDP whole body bone scan with SPECT
      • Increased activity in the left iliac crest and bilateral acetabula, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in both rib cages, maxilla, some T- and L-spine, sacrum, bilateral shoulders, and S-I joints.
    • 2022-11-01, -10-03, -09-27, -09-21 Abdomen - standing (diaphragm)
      • S/P compression plate and screws fixation at right ilium and right acetabulum.
    • 2022-09-16 CT - chest
      • Indication: Malignant neoplasm of esophagus, unspecified.
        • He was referred on account of due to difficult of swallowing and chest dyscomfort for about one week. PES and biopsy showed esophageal cancer (at New Taipei City Hospital)
      • Findings
        • Chest:
          • Dilated upper and middle third esophagus with narrowing at lower third extending to EG junction is found.
          • Enlarged lymph nodes are found at gastric cardiac region. (n=5)
          • Paraseptal Emphysematous change over both apical lungs is found.
          • No evidence of bilateral pleural effusion.
        • Visible abdomen:
          • The liver, spleen, pancreas, both kidneys and adrenals are intact.
          • There is no evidence of paraarotic LAPs.
          • There is no ascites accumulation at abdominal cavity.
      • Imp:
        • Lower third esophageal cancer with regional lymphadenopathy
      • Imaging Report Form for Esophageal Carcinoma
        • Impression (Imaging stage): cT2N2M0, Stage III
    • 2022-09-15 CXR (New Taipei City Hospital SanChong Branch)
      • No cardiomegaly.
      • Prominent bronchovasculature over bilateral lung fields.
      • No blunting of bilateral costo-phrenic angles.
    • 2022-09-13 Pathology (New Taipei City Hospital SanChong Branch)
      • Diagnosis
        • S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation.
      • MACROSCOPIC:
        • Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section.
      • MICROSCOPIC:
        • Histological diagnosis: Adenocarcinoma.
        • High grade dysplasia (including severe dysplasia and carcinoma in situ): present.
        • Invasive carcinoma: present.
        • Lymphovascular invasion: absent.
        • Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa.
        • Comment: No Helicobactor bacillus found on Giemsa stain.
        • Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
    • 2022-09-17 UGI panendoscopy (New Taipei City Hospital SanChong Branch)
      • swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
    • 2018-05-05 SONO - abdomen (Nephrology)
      • Left parapelvic renal cyst.
      • Suspected left small renal stone.
  • consultation
    • 2022-11-01 Dermatology
      • Q
        • for skin rash at the face.
        • This time, he is admitted for C2 CCRT with PF on 2022/11/01, and the skin rash at the face noted, so we need your help, thanks a lot!!
      • A
        • The patient had sufferred from bilateral facial reddish flush/papules with fine scales on the nasalfold and cheek area.
        • Under the impression of seborrheic dermatitis.
        • The following sugeetion:
          • Free gel 1 tube topical bid use for facial erythema region
          • If severe itchy sensation, consider futisone cream 1 tube topical bid PRN use on these itchy area.
    • 2022-09-22 Radiatoin Oncology
      • A
        • S:
          • For preoperative CCRT due to low third esophageal carcinoma.
          • PI: The patient suffered from dysphagia and chest discomfort since 2022-8. He went to New Taipei City Hospital SanChong Branch for help. The Panendoscopy and biopsy showed esophageal cancer. Under the personal reason, he was referred to our Hematology Oncology. Followed-up chest CT (Sep 16,22) showed Lower third esophageal cancer with regional lymphadenopathy cT2N2M0, stage III.
          • Family history: (-)
          • Cancer site specific factors: Alcohol (quit); Smoking (+); Betel nut (quit).
          • Personal Hx: DM(-); HTN(-)
          • Allergy(-)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 0
          • PE: neck and bil SCF: neg.
          • UGI panendoscopy (2022-09-07, New Taipei City Hospital SanChong Branch): swelling and irregular mucosa which was easily contact bleeding was found at EC junction post biopsy was taken.
          • Pathology (2022-09-13, New Taipei City Hospital SanChong Branch): S22-4658 Esophago-cardia junction, endoscopic biopsies, Adenocarcinoma, moderate to poorly differentiation. MACROSCOPIC: Quantity: one tissue fragments, 0.5 x 0.2 x 0.2 cm in size. All for section. MICROSCOPIC: Histological diagnosis: Adenocarcinoma. High grade dysplasia (including severe dysplasia and carcinoma in situ): present. Invasive carcinoma: present. Lymphovascular invasion: absent. Histologic grade: G2, moderately to poorly differentiated with focal individually cells infiltration throughout muscularis mucosa. Comment: No Helicobactor bacillus found on Giemsa stain. Immunohistochemical stains: the tumor cells showed cytoplasmic stains for CK7 and nuclear stain for STAB2.
          • CXR (2022-09-15, New Taipei City Hospital SanChong Branch): No cardiomegaly. Prominent bronchovasculature over bilateral lung fields. No blunting of bilateral costo-phrenic angles.
          • CT scan of lung (2022-09-16): Lower third esophageal cancer with regional lymphadenopathy, AJCC stage cT2N2M0 (stage III).
        • A:
          • Adenocarcinoma, moderate to poorly differentiation of the low third esophagus to EG junction, AJCC stage cT2N2M0 (stage III).
        • P: Radiotherapy is indicated for this patient with the following indicators: AJCC stage cT2N2M0 (stage III)
          • Goal: curative
          • Treatment target and volume: esophageal tumor, periphjeral involved, to regional involved nodal area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractions of the esophageal tumor, periphjeral involved, to regional involved nodal area, and 5040cGy/28 fractions of the esophageal tumor and involved nodal lesions.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1530, 2022-9-26.
  • radiotherapy
    • 2022-10-03 ~ 2022-11-17 - 4500cGy/25 fractions (15MV photon) of the esophageal tumor, periphjeral involved, to regional involved nodal, and 5040cGy/28 fractions of the reduced area.
  • chemoimmunotherapy
    • 2022-11-29 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1600mg 24hr D1-D4 (PF, CCRT)
    • 2022-11-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1650mg 24hr D1-D4 (PF, CCRT)
    • 2022-10-03 - cisplatin 75mg/m2 120mg 4hr D1 + fluorouracil 1000mg/m2 1700mg 24hr D1-D4 (PF, CCRT)

[assessment]

  • In one month, there has been a substantial loss of weight, almost ten kilograms (52.3kg 2022-11-29 <- 61.1kg 2022-10.27).
  • A low serum creatinine level (0.68mg/dL 2022-11-29) was noted. Creatinine generation could be reduced in the setting of low skeletal muscle mass.
  • It is recommended that intake be increased.
  • In terms of the active prescription, there is no problem.

700021863

221128

{Protocol: Capsule suspension preparation and NG tube dispensing procedures for Xtandi (enzalutamide, 160mg dose)}

The following in-situ oral dosing syringe suspension preparation and NG tube dispensing procedures were identified as being facile and which essentially eliminate human exposure to capsule components:

Utensils: Tweezers, medical grade scissors, 2-3mL oral dosing syringe, 20mL oral dosing syringe, NG tube, and one 2-3 oz (60-90 mL) glass or plastic dosing container (e.g., beaker or med cup).

Materials: Ethanol, 95%, Deionized water, 4x40mg enzalutamide capsules

  • Prepare 40-50mL of 90% v/v ethanol:water. Transfer 30mL to a container. Cover if not used immediately. Use as reservoir for subsequent steps.
  • Swipe-clean the dosing container, tweezers and scissors with alcohol wipes.
  • Using tweezers and scissors carefully cut a small vent, ~2mm long, through a soft gel capsule wall-just enough to vent internal pressure. Note: cut vent over dosing cup since some material may flow out of the vent hole. Place vented capsule in dosing cup. Repeat for remaining 3 capsules.
  • Using tweezers and scissors, slowly cut each capsule in half laterally. Allow capsule contents (enzalutamide in Labrasol) to empty into dosing cup (fill material flows out easily). Repeat for all capsules. Note: all 8 capsule shell pieces and fill contents will be in in the dosing cup.
  • Hold each capsule shell piece with tweezers and rinse the inside and outside into the dosing cup using 90% ethanol. Use 1-2mL per capsule half (2-3mL syringe). Discard rinsed capsule shells.
  • Withdraw 10mL of ethanol solution and rinse the tweezers and scissors into the dosing cup.
  • Withdraw and dispense solution back into dosing cup at least 5 times to ensure a homogeneous mixture.
  • Withdraw the solution into the dosing syringe.
  • Slowly dispense through the NG tube.
  • Withdraw the remaining ~10mL of 90% ethanol, rinse dosing cup, withdraw into dosing syringe, cap and shake, and dose through the NG tube. Flush tube with 6mL of water.

Please prepare two vials of 99.5% alcohol (drug code ‘CALCO01’), add one ml of purified water, take eight ml of the solution to dissolve one split capsule of 40 mg Xtandi, and tube feed this solution containing enzalutamide with prandial.

701321501

221125

{Mesenchymal chondrosarcoma, high grade}

  • exam finding
    • 2022-11-17, -10-20, -09-22, -08-22, -07-21 Sinoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30, no evidence of tumor
    • 2022-11-01 MRI - nasopharynx
      • Clinical information: Right maxillary sinus sarcoma s/p Right total Maxillectomy on 2022-03-30, patho: high grade mesenchymal chondrosarcoma, pT4aN0M0, Grade 3
      • Findings:
        • The current study was compared to the prior one obtained on 2022/08/09.
        • Known a case of right maxillary sinus sarcoma S/P operation and flap reconstruction. Progression of abnormal enhancing lesion over right face, near the reconstructive area. Suggest tissue proof to rule out recurrence.
        • Paranasal sinusitis.
        • The right parotid gland enhance as before. It is consistent with post-radiation inflammation.
        • S/P resection of right submandibular gland.
    • 2022-08-09 MRI - nasopharynx
      • Post total right maxillectomy, no obvious residual tumor or mass. No neck LAP.
    • 2022-07-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (87 - 25) / 87 = 71.26%
        • M-mode (Teichholz) = 70
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, and trivial TR
      • Preserved RV systolic function
    • 2022-06-09, 2022-05-26, 2022-05-12, 2022-04-28 Sinoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30
    • 2022-05-26 Hearing Test
      • Tymp:
        • R’t type B; L’t type As.
      • ART:
        • R’t and L’t contra absent.
      • PTA
        • Reliability FAIR
        • Average RE 60 dB HL; LE 23 dB HL.
        • R’t moderate to profound MHL.
        • L’t normal to moderate HL.
        • (masking dilemma)
    • 2022-04-21 Nasopharyngoscopy
      • Right maxillary sinus sarcoma s/p op on 2022-03-30
    • 2022-03-31 Patho - oral cancer (wide excision + lymph node)
      • Pathologic diagnosis
        • Maxillary sinus, right, total maxillectomy — Mesenchymal chondrosarcoma, high grade
        • Lymph nodes, right neck, selective neck dissection — Negative for malignancy (0/31)
        • Submandibular gland, right, neck dissection — No remakable change
        • Pathology stage: pT1N0; Stage IIA if cM0
      • Macroscopic examination
        • Surgical Procedure(s): Total maxillectomy + right selective neck dissection
        • Specimen Type:
          • Main location: Maxillary sinus
          • Lymph node dissection: Yes, including right neck level I, level II, and level III
        • Specimen Integrity: intact
        • Specimen Size: 6.2 x 5.5 x 5.4 cm
        • Tumor Site: Maxillary sinus; Laterality: Right
        • Tumor Focality: Single focus
        • Tumor Size: 6.0 x 4.5 x 4.0 cm, 0.5 cm from posterior margin
        • Mucosal Surface : Ulcerated
        • Gross Tumor Extension: Tumor invades submucosa
        • Representative parts are taken for section and labeled: A1-A2 = level I LN + submandibular gland, B = level II LNs, C = level III LNs, D = pterygoid plate, E = zygoma with soft tissue, F1 = tumor + posterior margin, A2 = tumor + lateral margin, F3 = tumor + upper margin, F4-F10 = tumor, G = posterior nasal margin, H = temporalis margin.
        • F2022-00138FSA1 = post. nasal margin, post. orbital floor and post. oral floor margin; FSA2 = lat. margin, masseter margin, and tempolais margin; FSA3 = orbital lat. margin and lat pterygoid margin; FSA4 = med. pterygoid margin and tissue near zygoma; FSE = posterior nasal margin (re-excision).
      • Microscopic examination
        • Histologic Type: Mesenchymal chondrosarcoma
        • Histologic Grade: G3 (poorly differentiated, high grade)
        • Mitotic Rate: 6/10 high power fields
        • Necrosis: Present (10%)
        • Microscopic Tumor Extension: To submucosa
        • Margins: Margins free, Distance from closest margin: 0.5 cm (posterior margin)
        • Lymph-Vascular Invasion: Not identified
        • Perineural Invasion: Not identified
        • Neck Lymph Nodes, Right: Negative (0/31)
          • Number of LN examined: 11 (level I), 9 (level II), and 11 (level III)
          • Number of LN metastasis: 0
        • Submandibular gland, right: Unremarkable and free of tumor
        • Pterygoid plate, right: Involved by tumor
        • Zygoma with soft tissue, right: Free of tumor
        • Post nasal margin, right: Free of tumor
        • Temporalis margin, right: Free of tumor
        • Post nasal margin and temporalis margin, received frozen section: Involved by tumor
        • Surgical margins received for frozen section, including post. orbital floor, post oral floor margin, lat margin, masseter margin, tempolais margin, orbital lat margin, lat pterygoid margin, med pterygoid margin, tissue near zygoma, and posterior nasal margin (re-excision): Free of tumor
    • 2022-03-30 Frozen section
      • Post. nasal margin #1, right, frozen section — Involved by tumor
      • Temporalis margin, right, frozen section — Favor inflammation but tumor involvement can not be excluded
      • Tissue near zygoma, right, frozen section — Favor inflammation
      • Post. orbital floor, post. oral floor margin, lat. margin, masseter margin, orbital lat. margin, lat. pterygoid margin, med. pterygoid margin; right, frozen section — Free of tumor
      • Posterior nasal margin #2, right, frozen section — Free of tumor
    • 2022-03-25 Nasopharyngoscopy
      • Right maxillary sinus sarcoma
    • 2022-03-22 SONO - abdomen
      • GB polyp
      • Pleural effusion, right
    • 2022-03-21 Whole body PET scan
      • Glucose hypermetabolism in the right maxillary sinus and adjacent facial soft tissue, compatible with the primary maxillary sarcoma. .
      • Glucose hypermetabolism in the left nasal cavity with left maxilla bone involvement, the nature is to be determined (another nasal cavity tumor or other nature ?), suggesting biopsy for further investigation.
      • Right maxillary sinus sarcoma, cTxN0M0; suspected left nasal cavity tumor, by this F-18 FDG PET scan.
    • 2022-03-18 CT - lung/mediastinum/pleura
      • Bilateral pleural effusion and lung partial collapse
      • suspected acute pancreatitis.
    • 2022-03-17 MRI - nasopharynx
      • Huge lobulated mass lesion (6.4cmx4.6cm) over right maxillary sinus with destruction of sinus walls, heterogeneous enhancement and cetral necrosis of this tumor. Highly suspect malignancy such as SCC or sarcomatous tumor.
      • Marked swollen change of right face and masticator space with subcutaneous fatty strandings.
    • 2022-03-15 Patho - gingival/oral mucosa biopsy
      • Oral cavity, right upper gingiva, biopsy — sarcoma
      • IHC: CK(-), Vimentin(+), SMA(focal +), CD34(-), CD56(-), and S-100(-). The Ki-67 is about 15%. The results are in favor of sarcoma. Please correlate with the clinical presentation and image study.
    • 2022-03-15 2D transthoracic echocardiography
      • Normal AV/MV with trivial MR
      • Normal LV chamber size and wall thickness
      • Preserved LV and RV systolic function
      • Mild PR, trivial TR, normal IVC size
    • 2022-03-14 CT - brain
      • IMP: Right maxillary sinus lesion as described.
      • DDX: malignancy, osteomyelitis, sinusitis.
    • 2022-03-14 ECG
      • Sinus tachycardia
      • Right superior axis deviation
  • consultation
    • 2022-04-12 Radiation Oncology
      • A: Mesenchymal chondrosarcoma, high grade, of the right maxillary sinus, stage pT1N0(cM0); Stage IIA, s/p operation (Rt. total Maxillectomy; Rt. selective neck dissection, level I~III; Tracheostomy; Tooth extraction of #46; free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity; reconstruction of right orbital bony frame with titanic microplates and screws).
      • P: Radiotherapy is indicated for this patient with the following indicators: margin involve and close (depend on HN tumor board conclusion).
        • Goal: curative
        • Treatment target and volume: right maxillary tumor bed area
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 6000 ~ 6600cGy/30 ~33 fractions
      • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his mother. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-04-25.
      • HN tumor board (2022-04-15). RTC: at 2pm, 2022-04-15.
    • 2022-03-23 Oral and Maxillofacial Surgery
      • This is a 43 year-old male patient suffering from osteosarcoma of right maxilla and is scheduled for surgical intervention including right hemi-maxillectomy next week.
      • This time, we were consulted for pre-OP and pre-RT dental evaluation
      • O:
        • Radiographic findings:
          • Progressive destruction of right maxilla with root resorption of tooth 14 was noted.
          • Residual roots of tooth 46 was noted.
        • Full mouth poor oral hygiene with periodontitis
      • P:
        • Took panoramic film to evaluate full mouth condition
        • Explained the findings and treatment plan to the patient and his family
        • Suggest extraction of residual roots 46 during surgery.
        • Oral hygiene instruction.
    • 2022-03-16 Gastroenterology
      • S
        • According to the patient, no HBV history
      • O
        • AST: x, ALT: 18, Bil T: 0.78, ALP: x, r-GT: x, Cr: 0.79
        • HBsAg(-), Anti-HBc(+), Anti-HCV(-)
        • Abdominal echo: nil
      • Impression
        • Occult or resolved HBV infection
      • Suggestion
        • No NHI indication for HBV medication now; if patient needed chemotherapy or immunotherapy, please tell us
        • GI OPD follow up
    • 2022-03-15 Hemato-Oncology
      • A
        • Impression:
          • Right maxillary sinus lesion. DDX: malignancy, osteomyelitis, sinusitis.
        • Suggestion:
          • Please check EB V EA/NA IgA, SCC, LDH
          • Pending pathology and culture result
          • Treat sepsis as your expertise
          • We wound like to follow up this case, thanks for your consultation. If there is any problem, please feel free to let us known.
    • 2022-03-15 ENT
      • Granular tumor with pus discharge at right upper gingiva and hard palate was noted.
      • Malignant tumor of right maxillary sinus with oral cavity involvement was highly suspected.
      • Biopsy was done smoothly.
      • Please pursue the pathologic result.
    • 2022-03-14 Oral and Maxillofacial Surgery
      • S: My right face swelling and my upper right gingiva ozzing
      • O:
        • Right face swelling was noted
        • 15 16 17 missing with a mass over upper right gingiva, about 5x7 cm, ulcerative surface was noted
      • A:
        • Impression: SCC or osteosarcoma
      • P:
        • Physical exam and explain the finding to the patient
        • Please prescribe curam for infection control
        • Admission in MICU for infection control and arrange OPD follow up
  • surgical operation
    • 2022-06-20
      • Right grommet insertion
    • 2022-03-30
      • free right anterolateral thigh flap resurfacing to the defect of right cheek, palate, and nasal cavity
      • reconstruction of right orbital bony frame with titanic microplates and screws
    • 2022-03-30
      • Rt. total Maxillectomy
      • Rt. selective neck dissection, level I~III
      • Tracheostomy
      • Tooth extraction of #46
  • radiotherapy
    • 2022-04-29 ~ 2022-06-16
      • 4000cGy/20 fractions of the right maxillary tumor bed area,
      • 5000cGy/25 fractions of the reduced right maxillary tumor bed area, and
      • 6600cGy/33 fractions of the right maxillary tumor bed.
  • chemoimmunotherapy
    • 2022-11-24 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-10-28 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-10-03 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-09-01 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-08-05 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-07-07 - mesna 800mg D1-5 + ifosfamide 1800mg/m2 3000mg 2hr D1-5 + doxorubicin 37.5mg/m2 65mg 20hr D1-2 (with mesna 800mg PRNQ4H)
    • 2022-05-03 ~ 2022-06-14 - cisplatin 40mg/m2 65mg 2hr (weekly x7, CCRT)

==========

2022-11-25

  • Despite the absence of tumor evidence by sinoscopy (2022-11-17), the nasopharynx MRI (2011-11-01) suggested a tissue proof to rule out recurrence for the abnormally enhancing lesions near the reconstruction area.
  • In addition to slight tachycardia (108 pulses per minute) and decreased SpO2 (94%), otherwise vital signs were unremarkable.
  • Except for slightly low serum potassium (3.3 mmol/L) and low HGB (11.3 g/dL), all lab results were generally normal on 2022-11-24.
  • The active prescription is working as intended.

2022-10-04

  • The available data now argues for adjuvant chemotherapy in mesenchymal chondrosarcoma, with little reliable data on craniofacial lesions in particular. The optimal drug combination to be employed has not been well-defined. (ref: Systemic treatment for primary malignant sarcomas arising in craniofacial bones. Front Oncol. 2022;12:966073. doi:10.3389/fonc.2022.966073)
  • In mesenchymal chondrosarcoma, treatment with Ewing sarcoma-like chemotherapy regimens may be considered, although data supporting its use is even more limited given its rarity. (ref: Systemic Therapy for Chondrosarcoma. Curr Treat Options Oncol. 2022;23(2):199-209. doi:10.1007/s11864-022-00951-7)
  • It was reported that ifosfamide-doxorubicin may be more beneficial in younger patients with >5 cm, high-grade, soft-tissue-sarcoma of the trunk or extremity in synovial-cell, dedifferentiated-liposarcoma, myxofibrosarcoma, round-cell-liposarcoma, undifferentiated-pleomorphic-sarcoma, and undifferentiated-sarcoma-not-otherwise-specified. (ref: The role of Ifosfamide-doxorubicin chemotherapy in histology-specific, high grade, locally advanced soft tissue sarcoma, a 14-year experience. Radiother Oncol. 2021;165:174-178. doi:10.1016/j.radonc.2021.10.019)
  • It was possible to treat soft tissue sarcoma using a regimen using a daily dose of mesna equivalent to that of ifosfamide. (ref: Crossover randomized comparison of intravenous versus intravenous/oral mesna in soft tissue sarcoma treated with high-dose ifosfamide. Clin Cancer Res. 2003;9(16 Pt 1):5829-5834.)
  • TPR, blood pressure, and SpO2 during the hospital stay, as well as lab data on 2022-09-29 were grossly stable or normal.

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{expired}

[exam findings]

  • 2022-11-22 Embolization (TAE) - abdomen
    • IMP: Active bleeding of ileocecal branch of SMA s/p TAE.
  • 2022-11-16 EGD
    • Diagnosis:
      • Reflux esophagitis LA Classification grade A
      • Superficial gastritis
      • Gastric polyps, body
    • Suggestion:
      • No active bleeder nor coffee ground material was noted during this exam.
      • Biopsy of polyp was NOT done due to suspected GI bleed setting
  • 2022-11-15 CT - abdomen
    • Clinical history: 37 y/o male patient with bloody stool twice today. denied abodminal pain
    • Past Histories: brain tumor appendectomy 2 weeks ago.
    • With and without contrast enhancement CT of abdomen - whole:
      • Irregular fluid accumulation (9.7x4.1cm) in right lower abdomen with air bubble retention, could be due to abscess formation.
      • Generalized low density over liver parenchyma, suggesting fatty liver.
      • Right lower lung collapse.
    • Impression:
      • RLQ abscess.
      • Fatty liver.
      • Right lower lung collapse.
  • 2022-11-15 ECG
    • Sinus tachycardia with short PR
    • Possible Left atrial enlargement
    • Left axis deviation
  • 2022-11-08 SONO - abdomen
    • Imp: Mild fatty liver.
  • 2022-10-31 L-spine AP + Lat (including sacrum)
    • mild scoliosis of the L-spine
    • unremarkable change in the width of the bony spinal canal
    • compession fractures at L3, L2, L1,T12, T11 and T10 vertebral bodies
    • mild decreased disc spaces in the upper L-spine discs
  • 2022-10-18 CXR (erect)
    • Enlarged cardiac shadow. Consolidation patches at bilateral lower lung field. Bilateral pleural effusion.
  • 2022-10-18 CT - abdomen
    • Dilatatation of appendix. Fat stranding at RLQ with minimal air density. Focal small bowel ileus.
    • Partial consolidation at bil. lungs.
  • 2022-08-09 MRI - brain
    • Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ill-defined mass lesions at the same areas. Marked progression of these heterogeneous enhancing tumors as compared with prior MRI (2022/05/10).
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2022-06-09 CXR
    • Linear band opacity over Rtmid lung zone, residual consolidation or atelectatic lung parenchyma
    • Fine recticular opacities at left midlung zone, residual inflammatory change or fibrotic change
  • 2022-05-10 MRI - brain
    • Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ille-defined mass lesions at the same areas. Progression of these heterogeneous enhancing tumors as compared with prior MRI (2021/12/16).
    • MR angiography of the brain shows normal intracranial vessel including circle of willis.
  • 2022-04-27 CXR
    • Extensive consolidation and ground glass opacity with air-bronchograms over bilateral lungs mainly involing upper lobes, with small Lt pleural effusion
    • Reduced lung volume
  • 2022-04-22 CT - lung
    • Consolidation over right upper lobe and left upper lobe and less significantly at right lower lobe and left lower lobe is found. Air-bronchogram is found. Pneumonia is considered.
  • 2022-04-21 CXR
    • Consolidations in bilateral parahilar regions, suspected pneumonia, suggest clinical correlation and further study.
    • Mild blunting of costophrenic angle, left side, could be due to pleural effusion.
  • 2022-02-14, 2022-02-07, 2022-02-04 CXR
    • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and chest walls.
    • Blunted costophrenic angles due to effusion, pleural change, atelectatic lungs, etc.
  • 2022-02-01 CXR
    • Enlarged cardiac shadow. Increased haziness at left hemithorax. Bilateral clear costophrenic angles.
  • 2022-02-01 CT - brain
    • Brain tumors and edema at left parietal and temporal lobes, significantly increased in size and extent, causing brain swelling and brain herniation. Condition in progression.
  • 2022-01-04 2D transthoracic echocardiography
    • LVEF = (LVEDV - LVESV) / LVEDV = (66 - 18) / 66 = 72.73%
    • Conclutions
      • Preserved LV and RV systolic function with normal wall motion
      • Normal chamber size
      • Trivial TR
  • 2021-12-16 MRI - brain
    • malignant left T-Parietal brain tumor (wild type Glioblastoma), significantly increase in size and extent as compared with MRI on 2021/11/4, possibly involving the scalp region.
  • 2021-12-14 CT - brain
    • Findings
        1. multiple hypodense brain tumors with vasogenic edema at left parietal and temporal lobes, the tumor size and extent of edema has significantly increased and causing marked brain swelling and mass effect. Minimal intratumoral hemorrhage is present.
        1. brain herniation with midline shift to right side and downward transtentorial herniation.
        1. previous postoperative change with a burr hole at left frontal skull, and left temporal-parietal skull craniotomy.
    • Impression:
      • Brain tumors and edema at left parietal and temporal lobes, significantly increased in size and extent, causing brain swelling and brain herniation.
  • 2021-12-13 SONO - abdomen
    • Hepatic hemangioma, right lobe
  • 2021-11-29 CT - brain
    • Post-op at left frontoparietal skull.
    • Left temporoparietal malignancy with mass effect and progression.
    • Focal ICH in left parietal lobe.
  • 2021-11-08 Frozen section
    • Findings: multiple tumors in the left supratentorial brain.
    • Diagnosis: Tumor, brain, frozen section — Glioblastoma
  • 2021-11-08 Patho - brain/meninges (tumor)
    • Brain tumors, left supratentorial region, FS + craniotomy — Glioblastoma, IDH-wild type
    • Microscopically, the sections show a picture of glioblastoma of the brain tissue consisting of hypercellularity with striking pleomorphism, hemorrhage, pseudopalisading necrosis and endothelial proliferation of vessels.
    • Immunohistochemistry shows GFAP(+), IDH-1(-), P53 and Ki67: increased activity and EGFR(+) for tumor.
  • 2021-11-04 CT - brain for navigator
    • Finding: A low density mass, about 36 mm x 32 mm x 30 mm, with irregular peripheral enhacning rim and central necrotic chnage in left parietofrontal lobe, associating with extensive perifocal edmea and causing effacement of adjacent cortical sulci and mild midline shift to right side.
    • IMP: Left parietofrontal necrotic tumor. D/D: metastasis, abscess.
  • 2021-11-04 MRA - brain
    • Finding: multiple heterogeneous enhancing lesions in the left temporal lobe and left parietal lobe with the largest one, about 37mm, in the left parietal lobe. Moderate to severe perifocal edema was noted. Heterogeneous enhancement was noted.
    • IMP: multiple tumors in the left supratentorial brain.
  • 2021-11-04 CT - brain
    • Finding: a nodular lesion, about 39mm, in the left parietal lobe with moderate perifocal edema
    • IMP: a nodular lesion in the left parietal lobe.

[MedRec]

  • 2022-11-15 ~ 2022-11-24 POMR Metabolism and Endocrinology Zhang JiaHui
    • Discharge diagnosis
      • Peritoneal abscess, pus culture yields Enterococcus faecium and quinolone -resistant Escherichia coli.
      • Bacteremia
      • Sepsis with septic shcok
      • Acute respiratory failure s/p intubation on 2022/11/22
      • Low gastrointestinal bleeding with hypovolemic shock
      • Multiple organ failure with metabolic acidosis and disseminated intravascular coagulation
      • Malignant neoplasm of parietal lobe
    • CC
      • Bloody stool twice for one day.
    • Present illness
      • A 37-year-old patient has medical history of left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on November 5th last year, with seizure, then the image showed left frontoparietal skull and left temporoparietal malignancy with mass effect and progression and focal intracerebral hemorrhage in left parietal lobe were find after the operation. However, the brain lesion with brain tumors and edema at left parietal and temporal lobes, which significantly increased in size and extent, and causing brain swelling and brain herniation in last December. Depression and chronic hepatitis were also noted.
      • He received chemotherapy after the operation, then the chemotherapy was changed to targeted therapy from this August to October because of the brain cancer recurred in this August. The targeted therapy was stopped due to acute appendicitis in this October, he underwent the drainage of appendix with drainage device, percutaneous endoscopic approach on October 18 this year. He has no allergic to food or drugs, nor travel, occupation, contact or cluster recently.
      • He presented in the emergency room with the symptoms of bloody stool twice today, with nausea and weakness and dissy and hypotension, poor appetite and bilateral flank pain (left > right ) were also noted. In the emergency department, GCS was E4V5M6. No Murphy’s sign or McBurney’s point tenderness. A blood tests showed leukocytosis with bandemia 10.6%, anemia, elevated c-reactive protein and activated partial thromboplastin time. Blood gas showed respiratory alkalosis and metabolic alkalosis. Chest x ray showed patch density at right lower lobe. A computer tomography of the abdomen revealed right lower abdomen abscess, irregular fluid accumulation(9.7x4.1cm) with air bubble retention and right lower lung collapse. A Sono-and CT-guide drainage was arranged and a 8 Fr. pig-tail catheter was placed for drainage. Cefotaxime and Pantoloc were given. He is hospitalized on 2022/11/15.
    • Course of inpatient treatment
      • During the hospital stay, we use parenteral Cefotaxime for empirical treatment of peritoneal abscess. Pig tail was indwelling. The pus discharge is submitted for pus culture. NPO except medications, PPI injection and electrolyte solution supplement due to suspect UGI bleeding. We also addition hemostatic agent and vitamin K1 for provided hemostatic. Panendoscopy was arranged, which report Reflux esophagitis LA Classification grade A. Superficial gastritis, Gastric polyps, body. Under excluded UGI bleeding, we give shift to oral PPI use, and try oral intake. Analgesic for pain control. Alk-p, serum calcium and albumin survey, excluded hypercalcemia.
      • Episode of fever up to 38.2 degree. Blood, uric acid and urine are submitted for blood culture, urinalysis and gout survey. Pyuria was excluded, but uric acid induce fever was considered, thus anti-gout agent was addition for anti-inflammation effected. Blood transfusion with LPRBC one unit for two days. Pus culture yields Enterococcus faecium and quinolone -resistant Escherichia coli. Antibiotic was change to Vancomycin and also was de-escalation of antibiotics Cefotaxime to cefuroxime. Intermittent high fever and pig tail without drainage amount, suspect pig tail. Contact radiology for pig tail revision, but radiology suggestion consulted general surgey for surgical drainage implacment. General surgey was conulted and phone contact VS 賴介文,suggest arrange non contrast or abdominal sonography for peritoneal abscess follow up.
      • Sudden of tachycardia, BP drop and abdominal pain. Normal saline and Dextran were hydration. Vasoconstriction pump use for maintain hemodynamic stable. Short of breath, exertional dyspnea and desaturation are noted. Inform family about patient critical condition and need intubation. Family agree intubation. Thus, he received intubation with fixed 24 cm with ventilator use. Tarry stool is noted, blood transfusion with LPRBC 2 unit. Antibiotic treatment with Vancomycin plus Cefepime for infection control. He will be transfered to MICU.
      • After transfer to ICU, ventialtor full supply and unstable of blood pressure combine massive amount bloody stool passage was found. NPO with adequate fluid for hydration and high dose PPI pump titration. Artery line and neck CVC were placement. Shock status, Albumin iv infusion and vasopressor agent with Levophed plus pitressin were titration. Ex-change antiboltic to IV Cravit, Cubicin, Doripenem plus IV Metronidazole were perscribed. Blood transfusion with LPRBC, FFP, Cryo and LRP were infusion for hypovolemic shock. Emergent contect contect radiology for TAE, impression of active bleeding of ileocecal branch of SMA s/p TAE. Correct imbalance of electrolyte. Well explain prognosis condition and highly mortalety rate to his family, they understood and refused any invade procedule, DNR was signed.
      • However, unstable of blood pressure under high dose vasopressor agent and poorly response with ventialtor high setting. The EKG reveal bradycardia then asystole, immeasurable pulsation and dilated pupil with inactive light reflex. The patient was prononcement expired at 12:29pm in 2022-11-24.

[consultation]

  • 2022-08-12 Radiation Oncology
    • Q
      • This 37-year-old man patient is a case of Left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on 2021/11/05.
      • This time, for headache from 2022/08/09. Brain MRI on 2022/08/09 showed 1. Known a case of left parietal-occipital GBMs S/P operative removal. Still presence of several ill-defined mass lesions at the same areas. Marked progression of these heterogeneous enhancing tumors as compared with prior MRI (2022/05/10). 2. MR angiography of the brain shows normal intracranial vessel including circle of willis.
      • Now, for evaluate whole brain radiotherapy. Thank you.
    • A
      • Palliative RT might help with limited symptoms relief. CT-simulation will be arranged on 20220815.
      • Plan to deliver 10~20 Gy/ 5~10 fx to the gross brain tumor. The exact dose schedule depends on the dose distribution with normal brain constraint considered after calculation.
      • RT will start around 20220817. Thank you very much.
  • 2022-04-25 Dermatology
    • Q
      • Under the impression of bilateral pneumonia, he was admitted to our ward for further management and treatment.
      • After admission, the patient has had right forearm herpes zoster since 2 months ago and treatment at INF OPD. Due to right forearm chronic erosion lesion, so we sincerly your help. TKS !!
    • A
      • This patient suffered from multiple group vesicles on R’t upper limb for months.
      • Imp: Post herptic neuralgia
      • Suggestion:
        • Arrange Ne-Na laser
        • mycomb *2 tubes/bid
  • 2022-02-02 Neurosurgery
    • Q
      • headache and progressive consciousness change in recent 2 days
      • no fever, no uri s/s, no dyspnea, no abdominal pain, no diarrhea, no tarry or bloody stool
      • 2021/12/16 Brain MRI: malignant left T-Parietal brain tumor (wild type Glioblastoma), significantly increase in size and extent as compared with MRI on 2021/11/4, possibly involving the scalp region.
      • 2021/12/14-2022/01/14 hospital stay, discharge diagnoses
        • Malignant neoplasm of parietal lobe
        • Left supratentorial region Isocitrate dehydrogenase wild type Glioblastoma post left temporo-parieto-occipital craniotomy with remove brain tumor on 2021/11/05
        • Headache
        • Nausea with vomiting, unspecified
        • Nontraumatic intracranial hemorrhage, unspecified
        • Abnormal results of liver function studies
        • Constipation, unspecified
      • Allergy: nil
      • Trauma hx: negative
    • A
      • A case of 36 y/o male; GBM s/p op/ CCRT;
      • Confuse status and headache noted;
      • F/U brain CT showed left PO residual/ relapse tumor with mass effect;
      • P: Control IICP/ IV hydration; further tumor excision?
  • 2022-01-12 Plastic and Reconstructive Surgery
    • Q
      • Owing to wound poor healing, we need your expertise for further management
    • A
      • assessment
        • scalp defect with bone and plate exposure, no pus, no infection sign now
        • patient is undergoing radiotherapy and chemotherapy now
      • plan and suggestion:
        • conservative treatment first, surgical intervention is not suitable for him due to C/T and R/T
        • caring wound with following method:
          • first day: prontosan bid (drip protosan gel into wound, then cover with white gauze) (about 600NT$)
          • 2nd day: duoderm gel bid (duoderm gel to fill the hole, then cover with white gauze) (about 300NT$)
          • 3rd day: Greenguard gel bid (greenguard fill the hole, then cover with white gauze) (about2000NT$)
          • then coming back to first day treatment method, 2nd day method, 3rd day method, and so on.
  • 2021-12-30 Gastroenterology
    • Q
      • The 36 y/o man has brain tumor /p op. No HBV and HCV, but his liver dysfunction without recovery, so we need your help for management. Thanks!
    • A
      • O
        • ALT 442 -> 181 -> 295
        • Bil(T) 0.44
        • rGT 254(20211209)
        • AlkP 85(20211209)
        • 20211213 abdominal echo: hemangioma
        • HbsAg(-)
        • Anti-HbsAb(+, low titer)
        • Anti-HbcAb(-)
        • Anti-HCV ab(-)
        • Anti-HAV ab IgM(-)
        • ceruloplasmin 0.128 g/L (Low)
      • A
        • abnormal liver function, cause?
      • P
        • Arrange cardiac sonography
        • Check ALP, rGT, TBI/DBI, PT, APTT, LDH to complete liver study
        • Regular/close monitor AST/ALT, TBI, PT, APTT, Ammonia, GGT, ALP
        • Avoid hepatic toxic agent if possible (or adjust dose), simplify medication
        • Stronger Neo Minophagen use (self-paid) 5 amp QD 3~5 days
        • Check alpha 1 antitrypsin (blood), 24hr urinary copper, blood copper
        • Consult ophthalmology for Kayser - Fleischer ring examination
        • Consider liver biopsy if his condition allows
  • 2021-12-16 Radiation Oncology
    • Q
      • Now, for evaluate whole brain ratiotherapy. Thank you.
    • A
      • CT-simulation will be arranged today. Due to the multiple tumors are still limited to Lt hemisphere, I’d consider partial instead of whole brain irradation for possible dose escalation.
      • Plan to deliver 60 Gy/ 30 fx to the gross brain tumors and the involved scalp region. RT will start around 20211220. Thank you very much.
  • 2021-11-30 Neurosurgery
    • Q
      • Headache, N/V since last night
      • No fever, no chills, no abdominal pain, no chest pain, no dyspnea, no focal weakness, no diarrhea, no discharge from OP wound
      • NKDA
      • PHx: Glioblastoma s/p left temporo-parieto-occipital craniotomy with remove brain tumor at parieto-occipital, Kocher EVD with ICP monitor 2021/11
    • A
      • a case of headache
      • P.H. malignant GBM s/p
      • conscious clear
      • no focal neurologic deficits
      • brain CT Post-op at left frontoparietal skull. Left temporoparietal malignancy with mass effect and progression. Focal ICH in left parietal lobe.
      • Plan:
        • consult oncologist for admission and CCRT
  • 2021-11-15 Hemato-Oncology
    • Q
      • Current problem: pathology showed Glioblastoma, IDH-wild type
      • We need your expertise for expertise for further management. Thanks a lot!
    • A
      • Accoring to NCCN guideline 2021, version2, CCRT (Temozolomide) is indicated for GBM.
      • Plan:
        • We will discuss with family and patient
        • We may take over this case if the sugical condition is stable for futher management.
  • 2021-11-15 Radiation Oncology
    • Q
      • Current problem: pathology showed Glioblastoma, IDH-wild type
      • We need your expertise for expertise for further management. Thanks a lot!
    • A
      • Adjuvant RT is indicated. CT-simulation will be arranged on 20211129.
      • Plan to deliver 60 Gy/ 30 fx to the preOP tumor bed and residual tumors. RT will start around 20211201 or 20211202. Thank you very much.
  • 2021-11-15 Rehabilitation
    • Q
      • His brain tumor pathologic showed Glioblastoma.
      • We need your help to do speech therapy and other rehabilitation program. Thank you very much.
    • A
      • A 36-year-old man presented with progressive headache, dizziness, nausea, vomiting and whole body weakness since last midnight. He denied any past systemic disease and surgical history was sinusitis status post operation about 10 years ago.
      • According to his and his family statement, he started to felt mild discomfort with headache and dizziness last night and the symptoms exacerbated in this early morning around 1 AM with severe headache, dizzness, nausea, and whole body weakness. Thus, he was sent to this emergency room very early in the morning. Laboratory studies showed no abnormal finding except mild hypokalemia. Brain CT revealed a nodular lesion about 39mm in the left parietal lobe, then MRI disclosed multiple tumors in the left supratentorial brain. Therefore, under the impression of left supratentorial brain tumor, he admitted for surgical intervention. we were consulted for further rehabilitation.
      • PE
        • 2021/11/15 05:30 T/P/R: 36.9 / 65bpm / 19bpm BP:108/67mmHg
        • height: 174.0 Body weight: 54.3 BMI:17.9
        • Consciousness: clear
        • Cognition: intact, oriented to time, person and place, could follow orders
        • Speech: no aphasia, no obvious dysarthria
        • Swallowing: take general diet without choking
        • Sphincter: urinary and stool continence
        • MP: RUE/RLE: 4/3, LUE/LLE: 4/3
        • Functional status: could perform bed mobility min A
        • BADL: needs mod assistance
        • MRS: 4 (needs follow-up)
      • Assessment
        • left parietal lobe glioblastoma post operation on 20211105
      • Plan
        • Rehabilitation programs: GYM first PT, OT rehabilitation programs
      • Goal: Ambulation with device CG
  • 2021-11-04 Neurosurgery
    • Q
      • Severe headache since today
      • First time of this symptoms
      • Nausea, vomiting, dizziness, weakenss
      • No fever, no URI symptoms, no chest pain, no abdominal pain, no trauma
      • Allergy: nil
    • A
      • a case of progressive headache
      • conscious clear
      • brain CT a nodular lesion, about 39mm, in the left parietal lobe with moderate perifocal edema
      • brain MRI multiple heterogeneous enhancing lesions in the left temporal lobe and left parietal lobe with the largest one, about 37mm, in the left parietal lobe. Moderate to severe perifocal edema. Heterogeneous enhancement.
      • Plan: risk benefit of brain surgery well explained to family and patient

[radiotherapy]

  • 2021-12-20 ~ 2022-01-28 completed RT to the Lt hemisphere: 46 Gy/ 23 fx. to the residual brain tumor: 60 Gy/ 30 fx

[chemoimmunotherapy]

  • 2022-10-12 - bevacizumab 10mg/kg 700mg 90min
  • 2022-09-28 - bevacizumab 10mg/kg 700mg 90min
  • 2022-09-12 - bevacizumab 10mg/kg 700mg 90min
  • 2022-07-21 ~ 2022-07-26 - temozolomide 320mg QDAC 5 days
  • 2022-06-23 ~ 2022-06-28 - temozolomide 320mg QDAC 5 days
  • 2022-05-19 ~ 2022-05-24 - temozolomide 320mg QDAC 5 days
  • 2022-04-19 ~ 2022-04-24 - temozolomide 320mg QDAC 5 days
  • 2022-03-22 ~ 2022-03-27 - temozolomide 320mg QDAC 5 days
  • 2022-02-24 ~ 2022-03-10 - temozolomide 120mg QDAC 14 days
  • 2022-01-20 ~ 2022-02-10 - temozolomide 120mg QDAC 21 days

==========

2022-10-12

  • Following standard brain RT and TMZ for multiple glioblastomas, the NCCN evidence blocks (2022-09-29 version 2.2002) recommends clinical trials, surgery for symptoms of large lesion, alternating electric field therapy, and palliative/best supportive care.

  • It has been reported in a review article that studies have been conducted using intra-arterial delivery of chemotherapeutics for the treatment of GBM, which may be considered as an optional last resort. (ref: A systematic review on intra-arterial cerebral infusions of chemotherapeutics in the treatment of glioblastoma multiforme: The state-of-the-art. Front Oncol. 2022;12:950167. Published 2022 Sep 23. doi:10.3389/fonc.2022.950167 )

  • In addition, there is also an article reported CAR T cell therapy and its potential to be integrated into the therapeutic paradigm for aggressive gliomas in the future. (ref: Clinical utility of CAR T cell therapy in brain tumors: Lessons learned from the past, current evidence and the future stakes [published online ahead of print, 2022 Oct 3]. Int Rev Immunol. 2022;1-19. doi:10.1080/08830185.2022.2125963 )

700361559

221123

  • diagnosis - 2022-11-05 discharge note
    • Malignant neoplasm of biliary tract, unspecified
    • Malignant neoplasm of biliary tract, unspecified, sarcomatoid carcinoma with biliary differentiation, CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-) with LN metastases and tumor seeding ( carcinomatosis), stage IV
    • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis),cT4 N2 M1, Stage:IVB
    • Urinary tract infection, site not specified
    • Hypoalbuminemia
  • history - 2022-11-05 discharge note
    • HTN with medicine control for 20+ years
    • CAD with medicine control for 20+ years
    • BPH
    • Unclear liver disease, tumor or inflammation, since Aug 2021, initial admission at ShuangHo Hospital that UTI also told.
    • Liver abscess drainage was performed at ward on 2022/05/22
    • COVID-19 infection on 2022/05/28
  • exam findings
    • 2022-11-20, … CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
      • Blunting of right and left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Prominence of bilateral hilar shadows are noted, which may be engorged central pulmonary vessels or adenopathy, please correlate clinically and follow-up.
    • 2022-11-11 ECG
      • Normal sinus rhythm
      • Low voltage QRS
      • Nonspecific T wave abnormality
      • Abnormal ECG
    • 2022-11-11 KUB
      • Degenerative joint disease of lumbar spine with marginal osteophytes.
      • Surgical clips retention over epigastric region.
      • Ileus with gas-filled distended bowel loops of the abdomen.
    • 2022-10-31 Abdomen
      • Spondylosis of the L-spine is noted.
      • Ascites is highly suspected.
    • 2022-10-18 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Sarcomatoid carcinoma with biliary differentiation
      • The specimen submitted consists of three strips of yellow gray soft tissue, labeled liver, measuring up to 0.6 x 0.1 x 0.1 cm. All for section.
      • The sections show a picture of sheets of poorly differentiated, polygonal and spindle-shaped neoplasic cells, arranged in short fascicles. Neither glandular nor squamous differentiation can be found.
      • IHC shows: CK(+), CK7(+), CK20(-), p63(-) and Hepatocyte(-). The finding is consistent with sarcimatoid carcinoma with biliary differentiation. Suggest clinic correlation.
    • 2022-10-17 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in both rib cages, some T- and L-spine, sacrum, bilateral sternoclavicular junctions, shoulders, elbows, S-I joints, hips, and knees.
    • 2022-07-22 CT - abdomen
      • History: liver abscess
        • 20220517 CT:Multicystic lesion in Rt lobe liver 10cm suspected abscess
        • A tumor 1.7cm in S6 with rim enhancement, suspected cholangiocarcinoma 20220519 S/P drainage was performed.
      • Indication: S5 tumor in progress.
      • Findings:
        • There is a heterogeneous lobulated soft tissue mass in the medial subhepatic space, directly attached the gallbladder, measuring 4.8 cm in size at the largest dimension.
          • Gallbladder cancer is highly suspected.
        • There is an ill-defined hypodense mass lesion measuring 3 cm in S5 of the liver. During dynamic study, this mass shows poor contrast enhancement in arterial phase and portal venous phase images, and mild centropedal enhancement in delayed phase images
          • Metastasis is highly suspected.
          • The differential diagnosis include Cholangiocarcinoma.
        • There are several enlarged nodes in the hepatoduodenal ligament that are c/w metastatic nodes.
          • In addition, There are lobulated soft tissue lesions in the periportal area of the liver hilum and ligamentum teres. Metastatic nodes are highly suspected.
        • There are several soft tissue nodules in RUQ omentum that are c/w tumor seeding.
          • In addition, There are few enhancing soft tissue lesions in bilateral lower pelvis that may be tumor seeding?
        • Prior CT identified multicystic lesions in right hepatic lobe is noted again, marked decreasing in size that is c/w liver abscess S/P catheter drainage and antibiotics treatment with near complete response.
        • Non-visualization of the spleen is noted. please correlate with clinical condition.
        • Several gallstones are noted.
        • Others
          • There is no focal abnormality in the biliary system, pancreas, & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Adeocarcinoma of the gallbladder with liver metastasis, lymph nodes metastases, and tumor seeding (carcinomatosis) is highly suspected.
          • According to American Joint Committee on Cancer(AJCC) staging system, 8th edition for gallbladder cancer: T4 N2 M1, Stage:IVB
        • A poor enhancing mass 3 cm in S5 liver is noted.
        • Metastasis is highly suspected.
        • The differential diagnosis include Cholangiocarcinoma.
  • chemoimmunotherapy
    • 2022-11-02 - irinotecan liposome 70mg/m2 125mg 1.5hr + leucovorin 400mg/m2 700mg 1hr + fluorouracil 2400mg/m2 4000mg 46hr

[assessment]

  • Fatal neutropenic sepsis occurred in 0.8% of patients receiving irinotecan (liposomal). Severe or life-threatening neutropenic fever or sepsis occurred in 3% and severe or life-threatening neutropenia occurred in 20% of patients receiving irinotecan (liposomal) in combination with fluorouracil and leucovorin.
  • When irinotecan is suspected of causing acute gastroenteritis, UGT1A1 genotyping might be utilized to confirm the homozygous state (homozygous UGT1A1*28).
  • Atropine 0.5mg SC is recommended as a premedication prior to the use of irinotecan in the next chemotherapy if there is no contraindication.

700568782

221122

  • diagnosis - 2022-11-10 discharge note
    • Right breast invasive carcinoma with liver and bone metastasis, cT4N1M1, stage IV. ECOG:0
    • Viral hepatitis B without hepatic coma
    • Upper Gastrointestinal Bleeding, vomit OB: 3+
    • Reflux esophagitis, lower esophagus, LA classification, grade B
    • Gastric ulcer
    • Superfical gastritis
  • exam findings
    • 2022-11-21 CXR
      • Ground glass opacity in RLL.
    • 2022-11-10 Patho - stomach biopsy
      • Stomach, AW of antrum, biopsy — Non-atrophic chronic gastritis, Helicobacter Pylori: NOT present
    • 2022-11-10 Panendoscopy
      • Reflux esophagitis, lower esophagus, LA classification, grade B
      • Superfical gastritis, antrum
      • Gastric ulcer, antrum, AW, s/p biopsy
    • 2022-11-08 CT - abdomen
      • Clinical history: 54 y/o female patient with breast cancer with liver mets, elevated TBI and liver dysfunction.
      • Findings
        • Diffuse liver tumors in both lobes of the liver, suggesting liver metastasis. Progression as compare with CT study on 20220505.
        • Presence of gallbladder stones.
        • Unremarkable change of the spleen, pancreas and both kidneys.
        • No enlarged lymph node in the paraaortic region.
        • Presence of ascites.
        • Bilateral pleural effusion with right lower lung collapse.
        • Diffuese osteoblastic and osteolytic lesions in the bones, could be due to bone metastasis.
      • Impression:
        • Liver metastasis and ascites with progression.
        • Diffuse bone metastasis.
        • Bilateral pleural effusion with right lung collapse.
        • GB stones.
    • 2022-11-07 ECG
      • Normal sinus rhythm
      • ST & T wave abnormality, consider anterior ischemia
      • Prolonged QT
      • Abnormal ECG
    • 2022-11-05 KUB
      • Diffuse bony metastases of the lower T-spine, L-spine, sacrum, and bilateral ilium.
    • 2022-11-05 CXR
      • Right hemi-diaphragm elevation is noted, which may be due to eventration.
      • Osteoblastic bony metastases in the lower T-spine and L-spine are noted after correlate with prior CT.
    • 2022-10-28 Whole body PET scan
      • Findings
        • There was increased FDG uptake in the some mediastinal lymph nodes and in multiple focal areas in the liver.
        • There was increased FDG uptake in multipe bones including the skull, mandible, multiple C-, T- and L-spines, sternum, bilateral multiple ribs, bilateral clavicle, bilateral scapulae, sacrum, bilateral pelvic bones, bilateral humeri and femurs.
      • Impression
        • Glucose hypermetabolism in multiple focal areas in the liver and in multipe bones as mentioned above, suggesting multiple liver and bone metastases.
        • Glucose hypermetabolism in some mediastinal lymph nodes. Metastatic lymph nodes should be considered.
    • 2022-10-28 ENT Hearing Test
      • Tymp:
        • Bil type A.
      • ART:
        • R’t contra absent.
        • L’t WNL.
      • E-tube function test:
        • Bil poor.
      • PTA
        • Reliability FAIR
        • Average RE 18 dB HL; LE 19 dB HL.
        • Bil WNL.
    • 2022-10-27 Sonography of hepatobiliary system
      • Findings
        • Bil. liver tumors (up to 6.39cm).
        • Moderate amount ascites.
        • Gallbladder stones (0.65cm, 1.10cm).
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
        • Normal appearance of pancreatic head. The other portions of pancreas masked by gastric/bowel gas.
        • Normal appearance of spleen.
        • No evidence of pleural effusion.
        • Normal appearance of kidneys.
      • IMP:
        • Bil. liver tumors (up to 6.39cm). Moderate amount ascites. Gallbladder stones (0.65cm, 1.10cm).
    • 2022-10-27 CXR
      • Consolidation at RLL.
    • 2022-05-09 Tc-99m MDP whole body bone scan
      • Highly suspected multiple bone metastases in multiple T- and L-spine, sternum, bilateral multiple ribs, sacrum, bilateral S-I joints, left ischium, bilateral humeri, and femurs.
      • Increased tracer uptake in the skull and hips, the nature is to be determined, suggesting follow-up with bone scan in 3 months for investigation.
    • 2022-05-05 CT - abdomen
      • Findings
        • S/P right breast operation.
        • Bil. liver metastases (up to 6.5cm). AP shunt at right hepatic lobe. Bil. liver cysts (up to 2.6cm).
        • Multiple bony metastases.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Tiny gallbladder stones (2-3mm).
        • Patency of portal vein.
        • No ascites, nor enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
        • No abnormal density at bilateral basal lungs.
      • IMP:
        • S/P right breast operation.
        • Multiple liver and bony metastases.
    • 2022-03-18 SONO - abdomen
      • Metastasis 9 cm in S4 liver is highly suspected.
        • Please correlate with contrast enhanced dynamic CT.
        • Several hepatic cysts on both lobes.
      • Two polyp-like lesion 1.29 cm and 0.86 cm in the gallbladder are suspected.
    • 2022-01-18 Patho - breast biopsy (no need margin)
      • PATHOLOGIC DIAGNOSIS
        • Breast, right, partial mastectomy — Invasive carcinoma of no special type, s/p CDK 4/6 inh + AI treatment
        • Resection margin: involved
        • Lymph node, right left axilla/ sentinel, lymphadenecomy — Not received
        • AJCC 8 th edition, Pathology stage: Anatomic stage: ypStage IV, ypT2Nx (if cM1)
      • MACROSCOPIC EXAMINATION
        • Breast: Size: 4.5 x 3.1 x 3.0 cm
        • Skin: Size: 4.1 x 1.3 cm.
        • Nipple: Not Included
        • Tumor: Size: 2.8 x 2.0 x 1.7 cm.
        • Resection Margin: involved
        • Lymph node: Not received
        • Representative sections are taken and labeled as: A1-6.
      • MICROSCOPIC EXAMINATION
        • FOR INVASIVE CARCINOMA
          • Histologic type: Invasive carcinoma of no special type
          • Size of invasive carcinoma: 2.8 x 2.0 x 1.7 cm.
          • Histologic grade (Nottingham histologic score): grade II (score 7)
            • Tubule formation: score 3
            • Nuclear pleomorphism: score 3
            • Mitotic count: score 1
          • Extent of tumor (required only if the structures are present and involved)
          • Skin involvement: Absent; The immunohistochemical stain of CK7 is negative.
          • Chest wall invasion deeper than pectoralis muscle: not received
        • FOR DUCTAL CARCINOMA IN SITU
          • Tumor size (cm): several foci, measuring up to 0.5 x 0.25 cm, intermix with invasive carcinoma.
          • Nuclear grade: 3
          • Architectural pattern: Non-comedo (solid and cribriform)
          • Tumor necrosis: Present
        • Margins: Involved ( unspecified margin)
        • Nodal status: Not received
          • number of lymph node examined: Not received
          • number with macrometastases (>2mm): Not received
          • number with micrometastases (>0.2~2mm and/or >200 cells): Not received
          • number with isolated tumor cells (<=0.2mm and <=200 cells): Not received
        • Treatment Effect: Response to presurgical (neoadjuvant) therapy (if patient received)
          • In the Breast: Probable or definite response to presurgical therapy in the invasive carcinoma
          • In the Lymph nodes: No lymph nodes removed
        • Lymphovascular invasion: present
        • Perineural invasion: present
      • IMMUNOHISTOCHEMICAL STUDY
        • ER (Ab): Positive (strong, 80 %)
        • PR (Ab): DCIS: Positive (strong, 10%); IDC: Negative
        • HER-2/Neu (Ab): DCIS: Positive (3+); IDC: Equivocal (2+)
          • The HER2/NEU In-Situ Hybridization Test from Taipei Institute of Pathology is NEGATIVE.
          • There is NO amplification of HER2 detected.
        • Ki-67: < 5%
    • 2022-01-17 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Nonspecific ST abnormality
    • 2021-12-31 SONO - abdomen
      • Diagnosis
        • Fatty liver,mild
        • Suspected liver cyst,left
        • Liver tumors,bil.Propable metastases
        • Suspected GB polyp
      • Suggestion
        • OPD f/u
        • Please correlate with other image
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
  • consultation
    • 2022-11-09 Family Medicine
      • Q
        • This time, she has nasuea and vomit and poor intake, so she was admission for supprtiva care ( IVF & Bfluid ) on 11/5 22. Howevee, the patient’s condition, liver function worse, and request the combine hospice care, so we need your help, thanks a lot!!
      • A
        • 54-year-old female, right breast cancer with liver and bone metastasis
        • Consciousness clear, ECOG 2
        • We will arrange hospice combine care and follow her condition

[assessment]

  • There was an increase in serum bilirubin (both direct and total), AST, ALT, and ammonia as a result of poor liver function.
  • Presently, Baraclude (entecavir), Baogan (silymarin) and Lactul Syrup (lactulose) are used to treat liver insufficiency symptoms.
  • Hospice combined care has been arranged.
  • Her edema in the lower extremities might be mitigated by the use of albumin (2.8 g/dL 2022-11-05).

700361615

221121

{drug identification}

requesting drug identification for 4 items.

the 3 items are identified as following while the other 1 item remains unknown.

  • Broen (l-cysteine 20mg, bromelain 20000unit)
  • Acetal (acetaminophen 500mg)
  • Sodicon (dextromethorphan 15mg)

The drug will be sent back to ward by the in-hospital porter.

700952001

221121

  • diagnosis 20221001 discharge
    • Infiltrating duct carcinoma of left breast, pT2N0M0 post MRM (20131017), ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%, bone metastases
    • Essential (primary) hypertension
  • exam findings
    • 2022-11-18 KUB
      • Fecal material store in the colon.
      • Spondylosis of the L-spine is noted.
      • S/P total hip arthroplasty, left hip and the screw penetration into the pelvis.
    • 2022-11-18 CXR
      • Spondylosis of the T-spine
      • Few nodular opacity projecting in the left upper and middle lung are suspected. Please correlate with CT.
      • S/P partial Mastectomy, left.
    • 2022-10-25 L-spine AP + Lat (including sacrum)
      • Straightening alignment of lumbar spine. Degenerative change of the spine with marginal spur formation. Status post left total hip replacement.
      • Multiple geographic areas of sclerotic bone change in visible bones with pedicle involvement, compatible with bone metastases.
    • 2022-10-25 Pelvis + Lt. Hip Lat
      • Status post left total hip replacement. Mild osteoarthritis change of right hip joint with joint space narrowing (more at superior aspect), subchondral sclerosis and marginal spur formation.
    • 2022-10-25 CXR
      • Ill-defined faint patch at LUL.
      • Degenerative change of the spine with marginal spur formation.
    • 2022-10-25 CT - brain
      • Brain atrophy.
    • 2022-10-25 ECG
      • Sinus tachycardia
      • Left axis deviation
    • 2022-09-17 MRI - brain
      • Bony metastases at skull, clivus and C2 vertebral body.
      • Suspected metastases at pituitary stalk and gland.
    • 2022-09-16 CT - chest
      • Left breast cancer s/p MRM with bilateral lung meta, liver meta and mediastinal lymphadenopathy, in progression.
      • Bone meta. Please correlate with bone scan study.
    • 2022-06-17 CT - chest
      • S/P mastectomy at left side.
      • Bilateral lung meta and mediastinal lymphadenopathy
      • Liver meta
      • Bone meta.
    • 2022-04-28 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20210702, more new bone lesions are noted, suggesting multiple bone metastases in progression.
    • 2022-02-05 CT - abdomen
      • S/P mastectomy at left side
      • Suspected bone meta at L1
      • S/p Total hip replacement over left side is found. The nails of the S/p Total hip extends to pelvic cavity.
    • 2021-07-02 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 20200210, the lesions in the left 10th costovertebral junction, L1 spine and sarum are new. Bone metastases should be considered frist.
      • The lesion in the L5 spine is a little more evident. Either degenerative spine disease in a little more severe status or bone metastasis may show this picture. Please correlate with other clinical findings for further evaluation.
      • Suspected benign lesions in the maxilla, L2 spine, right sternoclavicular junction, bilateral shoulders, S-I joints and knees.
    • 2021-05-14 SONO - abdomen
      • Fatty liver, mild to moderate
      • Suspected fatty infiltration of pancreas
    • 2020-02-10 Tc-99m MDP whole body bone scan
      • A hot spot at the left femoral head and neck, the nature is to be determined, suggesting further investigation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in the maxilla, L2-5 spines, right sternoclavicular junction, bilateral shoulders, S-I joints, and knees.
    • 2020-02-07 Pelvis & Lt. Hip Lat
      • Osteoporotic change at the left femoral head is noted.
      • Chip fracture or Marginal osteophyte formation at the lateral aspect of left acetabulum is noted. please correlate with clinical condition or CT.
    • 2018-03-09 Bone densitometry - spine
      • AP L-spines, BMD of L1-4 0.763 gms/cm2, about 2.1 SD below the peak bone mass (76%) and 0.1 SD above the mean of age-matched women (102%).
      • IMP: Osteopenia.
    • 2018-03-09 Bone densitometry - hip
      • Left hip, BMD is 0.530 gms/cm2, about 2.6 SD below the peak bone mass (66%) and 0.7 SD below the mean of age-matched people (90%).
      • IMP: Osteoporosis
  • consultation
    • 2022-09-20 Radiation Oncology
      • Q
        • This 72-year-old woman had past history of 1) infilltrating duct carcinoma of left breast, pT2N0M0, grade II ER: positive (90%), PR:40%, Her2/neu:equivocal (2+)–FISH NEGATIVE , P53(-), Ki- 67 index: 30%. post MRM (2013/10/17).
        • She received the chemotherapy with AC followed by hormone therapy on 2013 then was regularly followed up at ONC OPD. Bone scan on 2022/04/22 showed in comparison with the previous study on 2021/7/2, more new bone lesions are noted, suggesting multiple bone metastases in progression.Then she started the CDk4/6 inhibitor with Kisqali and Femara from July 2022 to August 2022. Hold due to leukopenia and general weakness.
      • A
        • A: Infiltrating ductal carcinoma, grade II, of the left breast, ER: positive (90%), PR:40%, Her2/neu:equivocal (2+, FISH: negative), stage pT2N0(cM0), s/p MRM and chemotherapy, with multiple including liver and bone metastases.
        • P: Radiotherapy is indicated for this patient with the following indicators: Bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
          • Goal: palliation
          • Treatment target and volume: whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
          • Technique: 2D
          • Preliminary planning dose: 3000cGy/15 fractions of the whole brain including bony metastases at skull, clivus, C2 vertebral body, pituitary stalk and gland.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her family (husband and son). They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1030, 2022-09-28.
    • 2022-09-08 Oral and Maxillofacial Surgery
      • Q
        • 20220819 Xgeva
        • However, gingiva swelling was noted today, we need your expertise for further management, thanks
      • A
        • For gingiva swelling
        • O:
          • Poor oral hygiene with lots of calculus was noted of full mouth.
          • Tenderness and swelling of right chin was noted.
          • Abscess with sinus tract of right anterior mandible. Pus discharged was noted. Residual root of 42 s/p RCF with gingiva inflammation was noted
          • Breast cancer under Xgeva treatment
        • A:
          • Periapical abscess with sinus tract of tooth 42
        • P:
          • Explained the finding to patient and her family.
          • Periodontal emergency of right mandible.
          • Suggest systemic antibiotics treatment.
          • OPD follow up
  • chemoimmunotherapy
    • 2022-10-07 ~ undergoing - Aromasin (exemestane)
    • 2022-10-07 ~ undergoing - Afinitor (everolimus)
    • 2022-03-25 ~ undergoing - Arimidex (anastrozole)
    • 2021-09-10 ~ 2022-03-29 - Kisqali (ribociclib)
    • 2021-07-16 ~ undergoing - Xgeva (denosumab)
    • 2017-01-06 ~ 2022-03-XX - Femara (letrozole)

==========

2022-11-21

  • The results of the uric acid lab showed an upward trend and indicated an increased risk of renal damage. It may be possible to consider Feburic (febuxostat 80mg) 0.5# QD without the need of adjusting the dose based on the current level of liver function.
    • 2022-11-18 Uric Acid 8.6 mg/dL
    • 2022-10-31 Uric Acid 6.7 mg/dL
    • 2022-09-30 Uric Acid 6.1 mg/dL

2022-10-26

  • Cell plasticity constitutes the ability of cancer cells to rapidly reprogramme their gene expression repertoire, to change their behaviour and identities, and to adapt to microenvironmental cues. These features also directly contribute to tumour heterogeneity and are critical for malignant tumour progression. (ref: Breast cancer as an example of tumour heterogeneity and tumour cell plasticity during malignant progression. Br J Cancer 125, 164–175 (2021). https://doi.org/10.1038/s41416-021-01328-7). It is likely that the available gene assay results “ER:positive (90%), PR:40%, Her2/neu:equivocal(2+, FISH negative), P53(-), Ki-67 index 30%” were obtained long ago (MRM in 2013). A new gene expression assay might be beneficial.
  • The use of Aromasin (exemestane) and Afinitor (everolimus) has been started since Oct 2022 after a CT image (Sep 2022) indicated that the disease was in progress.
  • It does not appear that there is a problem with the active prescription.

700569043

221118

{drug identification}

It was requested that four drugs be identified.

The items identified are as follows:

  • Lipanthyl Supra (fenofibrate 160mg)
  • Trajenta (linagliptin 5mg)
  • Crestor (rosuvastatin 10mg)
  • Bentomin (metformin 500mg)

These drugs will be sent back to ward by an in-hospital porter.

701196725

221118

  • diagnosis - 2022-11-04 discharge note
    • Colon adenocarcinoma with obstruction s/p right hemicolectomy on 2021/12/01, pT4aN2bcM0(7/15), G2, LVI(+), PNI(+), CRM(-), stage IVA with liver metastasis s/p chemotherapy with Avastin(5mg/kg)(self pay)/FOLFIRI(Campto 120mg/m2, LV 400mg/m2, 5FU 400mg/m2 and 2400mg/m2) from 2022/03/18~2022/05/26 for 4 cycles, patient refuse therapy with bilateral lungs, pleura, liver, peritoneal and retroperitoneal metastases s/p palliative chemotherapy with FOLFIRI from 2022/09/12
    • Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
    • Type 2 diabetes mellitus without complications
    • Chronic viral hepatitis B without delta-agent
    • Essential (primary) hypertension
    • Unspecified hemorrhoids
  • exam finding
    • 2022-11-02 CT - abdomen
      • History:
        • 20211120 CT:Dilatation of small bowel and collapse of colon, r/o obstruction at ileocecal valve. Suspect wall thickening of terminal ileum and Small bowel feces sign in distal ileum +.
        • 20211124 colonoscopy: One ulcerative tumor with about 1/2 circumferential involvement at ICV and extending to A-colon.
        • 20211201 S/P right hemicolectomy:pT4aN2b, if cM0, stage IIIC
        • 20220712 CT:Peritoneal carcinomatosis, lung and liver metastases.
      • Findings:
        • Prior CT identified multiple hypodense masses on both hepatic lobes are noted again, increasing in size and number that are c/w liver metastases with progressive disease.
        • Prior CT identified few metastases on both lung are noted again, mild increasing in size that is c/w progressive disease.
        • There is massive ascites and soft tissue nodules in the omentum and mesentery that is c/w carcinomatosis. Please correlate with ascites cytology.
        • S/P right hemicolectomy
        • Few small gallstones are noted.
        • There is no hyper-or hypodense lesion in the biliary system, pancreas, spleen & both kidney.
        • There is no lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass.
      • IMP:
        • Peritoneal carcinomatosis, lung and liver metastases show progressive disease.
    • 2022-09-27 All-RAS + BRAF mutations assay
      • All-RAS mutations assay
        • Detection range
          • KRAS codon 12, 13, 59, 61, 117, 146
          • NRAS codon 12, 13, 59, 61, 117, 146
        • Results
          • Detected (KRAS codon 12 GGT>GAT, p.G12D)
        • Interpretation
          • The current study and treatment guidelines indicate that patients with RAS mutation may not benefit from the anti-EGFR antibody treatment. Patients with no RAS mutation are more likely to have disease control by using anti-EGFR antibody treatment.
      • BRAF mutations assay
        • Detection range
          • BRAF codon 600: p.V600M, p.V600L, p.V600E, p.V600A, p.V600G, p.V600K, p.V600R
        • Results
          • There was no variant detected in the BRAF gene.
        • Interpretation
          • The current study and treatment guidelines indicate that patients with BRAF mutation maynot benefit from the anti-EGFR antibody treatment. Patients with no BRAF mutation are more likely to have disease control by using anti-EGFR antibody treatment.
    • 2022-09-06 SONO - abdomen
      • Chronic liver parenchymal disease
      • c/w liver and lymph node metastasis
      • Ascites
      • Minimal pleural effusion
    • 2022-09-05 Patho - stomach biopsy
      • Esophagus, 25 cm to EC junction, biopsy — Ulcer, with no viable tissues
      • Microscopically, it shows necrotic debris, granulation tissue,and abundant lymphocytic and leukocytic infiltrate. No viable tissue is seen.
      • Immunohisotchemical stain reveals CK(-), CD20(-), CD3(-), LAC(focal+),and CMV(-).
    • 2022-09-05 Patho - stomach biopsy
      • Stomach, angle, biopsy — ulcer with Helicobacter infection
      • Microscopically, it shows ulcer with ulcerative debris, focal intestinal metaplasia and leukocytic infiltrate.
      • Mild Helicobacter-like bacilli are seen.
    • 2022-09-02 CXR
      • Tortous aorta with calcification is noted.
      • Increased pulmonary vasculature is found.
    • 2022-09-02 KUB
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Stool impaction at the abdominal cavity is noted.
    • 2022-09-02 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis with ulceration, LA-D
        • Superficial gastritis, s/p CLO test
        • Gastric ulcer, angle, s/p biopsy*4
        • CLO test (+)
      • Suggestion
        • PPI pump and algitab
        • Pursue pathology
        • GI OPD for HP eradication after discharge
    • 2022-07-12 CT - abdomen
      • Findings
        • S/P colon operation.
        • A nodule (5.4mm) at LLL.
        • Some soft tissues in peritoneal cavity with ascites.
        • Multiple liver tumors.
        • Some calcifications in peritoneal cavity.
        • Normal appearance of spleen, pancreas, adrenals and kidneys.
        • Tiny gallbladder stones.
        • Intact bony structures.
        • No enlarged lymph node.
        • No obvious extraluminal free air.
        • No abnormal density of heart.
      • IMP:
        • S/P colon operation. Peritoneal carcinomatosis, lung and liver metastases.
    • 2022-05-27 SONO - abdomen
      • Diagnosis
        • Liver cirrhosis with borderline splenomegaly
        • Hepatic hypoechoic lesions, multiple, both lobe, suspected metastases
        • Gallbladder polyp
        • Cholecystopathy
        • Small amount ascites
      • Suggestion
        • Please correlate with other image study
    • 2022-03-01 CT - abodmen, pelvis
      • Clinical history: 71 y/o male patient with cecal cancer s/p OP and C/T.
      • Findings
        • S/P right colectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        • There are several low density tumors (up to 1.4cm) in both lobes of the liver, suspected liver metastasis.
        • Presence of gallbladder stone.
      • Impression:
        • S/P right hemicolectomy with regional dirty mesentery fat plane, post-op change? Suggest follow up.
        • Liver tumors, suspect liver metastasis.
    • 2021-12-02 Patho - colon segmental resection for tumor
      • PATHOLOGIC DIAGNOSIS
          1. Tumor, ascending colon, right hemicolectomy — Adenocarcinoma
          1. Resection margins, bilateral, ditto — Free from tumor
          1. Lymph node, mesocolic, dissection — Tumor metastasis (7/15) with extracapsular extension (3/7)
          1. Appendix, right hemicolectomy — Tumor emboli present, but no direct invasion
          1. AJCC pathologic stage — pT4aN2b, if cM0, stage IIIC
      • MICROSCOPIC EXAMINATION
          1. Histology: adenocarcinoma
          1. Histology Grade: G2-3: moderately to poorly differentiated
          1. Depth of invasion: visceral peritoneum and some tiny nodules at ileal wall
          1. Angiolymphatic invasion: Present
          1. Perineural invasion: Present
          1. Discontinuous extramural tumor extension: NOT identified
          1. Circumferential (radial) margin of rectosigmoid: NOT involved
          1. Lymph node metastasis, mesocolic: tumor metastasis (7/15)
          1. Lymph node metastasis, IMA / SMA: N/A
          1. Extranodal involvement: Present (3/7)
          1. Pathological TNM Stage: pT4aN2b
          1. Type of polyp in which invasive carcinoma arose: N/A
          1. Additional pathologic findings: focal tumor necrosis
          1. TNM descriptors: N/A
          1. Tumor regression grading S/P CCRT: N/A
    • 2021-11-26 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (162 - 47) / 162 = 70.99%
        • Dilated LA, LV
        • Adequate LV, RV systolic function with normal wall motion
        • Thick IVS, Impaired LV relaxation
        • Mild MR,TR,AR
    • 2021-11-25 Patho - colorectal polyp
      • Colon, ileocecal valve, biopsy — Adenocarcinoma, moderately differentiated
      • IHC: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2021-11-24 Colonoscopy
      • Diagnosis
        • Suspect advanced colon cancer, ICV, s/p biopsy(A), terminal ileum maybe involved.
        • Colon polyp, proximal T-colon, s/p cold polypectomy(B) and clip
        • Colon polyp, T-colon, s/p hot polypectomy(C) and clip
        • ICV stenosis.
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-11-23 Small bowel series
      • Small bowel dilatation, suspected partial obstruction at distal small bowel. Suggest clinical correlation
    • 2021-11-20 CT - abdomen
      • Imaging Report Form for Colorectal Carcinoma
      • Impression ( Imaging stage ): T:T4(T_value) N:N2(N_value) M:M0(M_value)
    • 2021-11-20 KUB
      • Dilatation of small bowel and collapse of colon, suspected obstruction
    • 2021-11-20 ECG
      • Sinus tachycardia
      • Right bundle branch block
    • 2021-11-11 Abdomen - standing (diaphragm)
      • Stool retention in the colon
    • 2021-11-05 Small Intestinal Series
      • Normal haustration of the jejunum and ileum.
      • The peristasis of the small intestine is intact.
      • No evidence of stenotic or obstructive lesion in the study.
      • The transit time is 4 hours
    • 2021-11-04 Abdomen - standing (diaphragm)
      • Presence of ileus.
    • 2021-11-02 CT - abdomen
      • Dilated intestines and colon, suspected enterocolitis
    • 2021-11-02 KUB
      • Dilated bowel gas, suspect ileus. Degenerative change of the spine with marginal spur formation. Calcified nodules in the pelvic cavity, could be urinary bladder stone.
    • 2021-11-02 ECG (emergency)
      • Sinus tachycardia
      • Right bundle branch block
      • Minimal voltage criteria for LVH, may be normal variant
      • T wave abnormality, consider inferolateral ischemia
    • 2019-09-24 ECG
      • Right bundle branch block
      • Nonspecific T wave abnormality
  • consultation
    • 2021-11-25 Colon and Rectal Surgery
      • Q
        • This is a 70-year-old male patient with the underlying diseases DM, HCVD under medicine control. This time, he is presented with LUQ abdominal pain and fullness, nausea sensation, no stool passage, and intermittent fever for 2 days .
        • He had ileus on 20211103, and AAD on 20211105 under small serious normal. Under the impression of ileus again, he came to our ward to do further management and examination.
        • On 20211120 abdominal CT, Small bowel dilatation, suspected obstruction, Suspect wall thickening of terminal ileum with regional lymphadenopathy.
        • On 20211124 colonscope found suspect advanced colon cancer, ICV, s/p biopsy, terminal ileum maybe involved.
        • We had arranged him to do 2D heart echo and PFT.
      • A
        • A: Tumor of cecum with partial obstruction
        • P: The operaion of right hemicolectomy is indicated
    • 2021-11-22 General and Gastroenterological Surgery
      • Q
        • This is his second-time intestinal ileus, so we would like to consult your expertise for him. Does he need the surgery survey?
      • A
        • A: ileus, suspected colonic lesion ot terminal ileum lesion with mechanical obstruction
        • P: Please arrange colonoscopy to rule out colonic lesion ot terminal ileum lesion. If no colonic lesion ot terminal ileum lesion, but symptoms persisted, laparoscopy exam may be considered.
  • chemoimmunotherapy
    • 2022-11-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-11-02 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-10-17 - bevacizumab 5mg/kg 300mg 90min + irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-09-27 - irinotecan 150mg/m2 250mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-09-12 - irinotecan 120mg/m2 200mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-08-16 ~ 2022-08-30 - UFT (tegafur 100mg, uracil 224mg)/cap 2# BID PO
    • 2022-06-14 ~ 2022-08-09 - Xeloda (capecitabine 500mg/tab) 1# TID PO
    • 2022-05-26 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-04-25 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-03-18 - bevacizumab 5mg/kg 300mg 90min + irinotecan 120mg/m2 220mg 90min + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4400mg 46hr (Avastin + FOLFIRI, Q2WK)
    • 2022-02-23 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-02-09 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-01-19 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)
    • 2022-01-05 - bevacizumab 5mg/kg 300mg 90min + oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 400mg/m2 700mg 10min + fluorouracil 2400mg/m2 4200mg 46hr (Avastin + FOLFOX, Q2WK)

==========

2022-11-18

  • CT imaging on 2022-11-02 revealed peritoneal carcinomatosis and lung and liver metastases and a progressive disease was present.
  • In the past two months, more than 10 kg of weight have been lost (63 kg 2022-11-17 <- 74 kg 2022-09-22). The use of appetite stimulants (e.g. megestrol) may be beneficial.
  • Based on the updated elevated bilirubin levels, there are no issues associated with the irinotecan dose.

2022-10-18

  • The patient with mCRC has received FOLFOX/FOLFIRI plus bevacizumab since early 2022.
  • Regorafenib might be an option as a subsequent treatment if the patient’s disease becomes resistant, and would be covered by the national health insurance program without prior use of cetuximab or panitumumab due to the detected KRAS mutation (2022-09-27 All-RAS + BRAF mutations assay). Regorafenib does not require dosage adjustment in patients with mild or moderate hepatic impairment (total bilirubin 1.79mg/dL 2022-10-11 < 3 times ULN), closely monitor for adverse effects. The drug can be administered orally 160 mg once daily for the first 21 days of each 28-day cycle; continue until disease progression or unacceptable toxicity.
  • Lonsurf (trifluridine/tipiracil) is also covered by NHI, however the drug is not recommended for this patient due to his total bilirubin > 1.5 times ULN.

2022-09-28

  • The serum glucose level remains within acceptable limits with the use of patient-carried Uformin (metformin), Amepiride (glimepiride), and Januvia (sitagliptin).
  • Human albumin is used to treat hypoalbuminemia (3.2g/dL 2022-09-22) associated with liver cirrhosis (ABD Sono 2022-09-06).
  • The total bilirubin level was 1.51mg/dL (above 1.5 x ULN, 2022-09-22); the treated dose of irinotecan was 150mg/m2 (2022-09-27), not exceeding the recommended limit of 200mg/m2.

701446396

221118

  • diagnosis
    • Right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26
    • Unspecified viral hepatitis B without hepatic coma.
  • exam findings
    • 2022-11-09 SONO - breast
      • Diagnosis: Bil. fibroadenomas
      • Suggestion: regular OPD follow up
      • BI-RADS: 2. benign finding
    • 2022-11-02 Mammography
      • Impression: Dense breast. Probably benign calcifications in bilateral breasts. Suggest clinical correlation and follow up.
      • BI-RADS: Category 2: benign findings.-annual screening.
    • 2022-08-29 Patho - soft tissue tumor, extensive resection
      • Ovarian Fallopian tube Peritoneum Cancer Checklist (Based on AJCC 8th ed. and FIGO 2014)
      • PATHOLOGIC DIAGNOSIS
        • Ovary, right, oophorectomy with frozen section (F2022-400) — Clear cell adenocarcinoma, high grade.
          • IHC stains: Napsin-A (+), P53: (wild type), PAX-8 (+), CK20 (-), ER (-, 0%)
        • Ovary, left , salpingectomy (S2022-14311) — Free.
        • Fallopian tube, right, salpingectomy — Free
        • Fallopian tube, left, salpingectomy — free
        • Uterus, corpus, total hysterectomy — myoma; No malignancy.
        • Uterus, cervix, total hysterectomy — free
        • Omentume, omentectomy — free
        • Lymph node, dissection — free
        • pT1a pN0 (if cM0); AJCC/FIGO pStage: IA, at least.
          • NOTE: According to AJCC staging manual 2017 8th edition page 10. “Pathologist should not report any M category unless appropriate for the specimen evaluated. Only the managing physician can assign cM0 after taking into account physical examination, image, and other information”. However, the pathologists are ordered by this hospital adminstration (including the chiefs of cancer committee, medical department and radiation oncology) to assign the “cM” category, although pathologists are not in the position of doing so.
      • MICROSCOPIC EXAMINATION:
        • Histologic type: clear cell adenocarcinoma
        • Histologic grade: ghigh grade
        • Contralateral ovary involvement: absent
        • Tumor side ovarian surface involvement: absent
        • Contralateral ovary surface involvement: absent
        • Right tube involvement: absent
        • Left tube involvement: absent
        • In situ adenocarcinoma in right and/or left fallopian tube: absent
        • Right adnexa soft tissue involvement: absent
        • Left adnexa soft tissue involvement: absent
        • Pelvic soft tissue involvement: absent
        • Uterine serosa involvement: absent
        • Omentum involvement: absent
        • Uterine Cervix involvement: absent
        • Endometrium involvement: absent
        • Myometrium involvement: absent
        • Appendix involvement: not received
        • Largest Extrapelvic Peritoneal Focus - none
        • Peritoneal/Ascitic Fluid-Negative for malignancy (normal/benign)
        • Regional Lymph Nodes: - free
        • Other organs or specimens involvement: none.
    • 2022-08-26 Frozen section
      • Preliminary diagnosis: right ovary: malignant
    • 2022-08-26 Patho - stomach biopsy
      • Gastric polyp, cardia, biopsy — Compatible with fundic gland polyp
    • 2022-08-24 ECG
      • Normal sinus rhythm
      • Possible Left atrial enlargement
      • Septal infarct, age undetermined
      • Abnormal ECG
    • 2022-08-15 CT - abdomen
      • Findings
        • Cystic tumor, 13.8cm in the pelvic cavity, with soft tissue component, suspected right ovarian malignancy.
        • Liver cyst, 0.77cm in S2.
        • Soft tissue tumor, 2.7cm in the uterine fundus region, suspected uterine myoma.
      • Imaging Report Form for Ovarian Carcinoma
        • Impression (Imaging stage): T:T1(T_value) N:N0(N_value) M:M0(M_value) STAGE: Ia (Stage_value)
    • 2022-08-15 Gynecologic ultrasonography
      • Suspected pelvis mass: 109X75mm with papillary: 25x19mm
      • Suspected pelvis mass or uterine myoma: 98x77, RI: 0.47
      • Adenomyosis
  • consultation
    • 2022-10-28 Chinese Medicine
      • Q
        • The 59 y/o woman has right ovarian cancer (Clear cell adenocarcinoma) pT1a pN0 ; AJCC/FIGO pStage: IA, at least. post debulking surgery on 2022/08/26. She was admitted for chemotherapy. She asks for your help for assessment.
  • surgical operation
    • 2022-08-26 debulking surgery (total abdominal hysterectomy + bil salpingo-oophorectomy + BPLND + partial omentectomy) + enterolysis
      • uterus and bil adnexa
        • Uterus: 12x8x5 cm
        • corpus – adenomyosis-like with some uterine myomas
        • cervix – seemed free of cancer invasion
        • right adnexa –
        • ROV 15x14cm tumor with large solid and cystic contents, containing chocolate fluid 600 c.c
        • Frozen section of ROV–malignancy
        • right tube – np
        • left adnexa: normal-looking
        • bowels, omentum, liver– seemed free of cancer invasion
        • Bilateral pelvic iliac and obturator LNs was removed
        • left iliac LNs
        • left obturator LNs
        • right iliac LNs
        • right obturator LNs
        • CDS: no ascites (washing cytology was sent) but pelvic adhesion was noted between right adnexa, pelvis, peritoneum and bowels s/p enterolysis A 7mm JP drain was placed in CDS
  • chemoimmunotherapy
    • 2022-11-17 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-10-27 paclitaxel 175mg/m2 268mg 3hr + carboplatin AUC 5 600mg 2hr
    • 2022-10-06 paclitaxel 160mg/m2 240mg 3hr + carboplatin AUC 5 600mg 2hr (paclitaxel first time 160, next 175)

[assessment]

  • The lab results (2022-11-17) were grossly normal and should be considered satisfactory for the scheduled chemotherapy.
  • The currently used [paclitaxel + cisplatin] regimen is preferable since carboplatin produces equivalent response rates and survival outcomes to cisplatin and is associated with less toxicity, while paclitaxel is less myelosuppressive than docetaxel. There is, however, a higher risk of neuropathy, myalgias, and weakness associated with paclitaxel in comparison with docetaxel, which should be monitored regularly.
  • The underlying condition of viral hepatitis B is appropriately managed with Vemlidy (tenofvir alafenamide).

701262855

221117

{drug identification}

requesting drug identification for 6 items.

the 5 items are identified as following while the other 1 item remains unknown.

Indershin (indomethacin 25mg) Anrokin (chlorzoxazone 200mg) Leflo (levofloxacin 500mg) Ketofen (ketoprofen 50mg) Decan (dexamethasone 0.75mg)

The drugs were packaged as one dose in an opaque bag, which was opened irreversibly. The checked drugs will not be returned to the ward due to the possibility of contamination.

700399143

221116

  • exam findings
    • 2022-11-03, -10-30, -10-27 CXR
      • Massive right side Pleura effusion causing mediastinum shift to left side.
      • There are patchy opacity on right lung and nodular opacity projecting in left lung. Please correlate with CT.
    • 2022-10-27 CT - chest
      • Indication: Malignant neoplasm of right main bronchusLung cancer, clinical trail
      • Findings
        • Huge soft tissue mass at right lung up to 16.cm with massive right pleural effusion is found. In enlargement.
        • Left lung nodules are found up to 1.7cm in largest dimension is found. In comparison with CT dated on 2022-09-12, the lesion enlarged markedly.
        • Marked paraseptal Emphysematous change over both lungs more on upper lobes is found.
        • Right axillary lymphadenopathy is found.
      • Imp:
        • Huge right lung cancer with lung to lung meta, right axillary lymphadenopathy, in progression.
    • 2022-10-06 ROS1 FISH
      • Result
        • Number of invasive tumor cells counted: 50
        • Number of cells (%) classified as negative: 49 (98%)
        • Number of cells (%) classified as positive: 1 (2%)
      • Interpretation
        • Rearrangement of ROS1 gene is NOT detected. Patients with NO ROS1 gene arrangement may not benefit from therapy with ROS1-targeted inhibitors.
    • 2022-10-06 ALK IHC
      • ALK immunostaining result: Negative
      • The immunostaining of the section slide labeled S2022-15576, using ALK antibody D5F3 along with a Ventana autostainer system, revealed no staining in tumor cells.
    • 2022-10-04 MRI - brain
      • No intracranial metastatic lesion.
    • 2022-09-27 Tc-99m MDP whole body bone scan with SPECT
      • Mildly increased activity in some L-spines and sacrum. Degenerative change may show this picture. Please correlate with other imaging modalities for further evaluation.
      • Some hot and faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders and hips, compatible with benign joint lesions.
    • 2022-09-22 PD-L1 (22C3)
      • PD-L1 immunostaining result
      • Tumor Proportion Score (TPS) assessment: >= 50%
      • Tumor Proportion Score (TPS): 85%
    • 2022-09-22 EGFR mutation
      • Result: No mutation was detected at exons 18 (G719X), 19 (Deletions), 20 (T790M, S768I, Insertions), 21 (L858R, L861Q) of EGFR gene in this specimen.
    • 2022-09-15 Patho - bronchus biopsy
      • Lung, RLL, CT-guide biopsy — poorly differentiated non-small cell carcinoma, origin?
      • Sections show large pleomorphic tumor cells infiltrating in a fibrotic stroma with marked tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CK5/6(-), GATA3(+), CDX2(focal weak +), TTF-1(-), Napsin A(-), CD56(-), and p40(-). Please correlate with the clinical presentation and image study to exclude other tumor origin.
    • 2022-09-12 CT - chest
      • Imaging Report Form for Lung Carcinoma
      • Impression (Imaging stage): T:T4(T_value) N:N2(N_value) M:M1a(M_value) STAGE:____(Stage_value)
    • 2022-09-12 CXR
      • Huge mass lesion over right lung. Suggest check CT scan.
    • 2022-08-01 T-spine AP + Lat.
      • Large patchy consolidation over RUL.
  • chemoimmunotherapy
    • 2022-11-03 - pembrolizumab 100mg 1hr
    • 2022-10-31 - carboplatin AUC 2 300mg 2hr D1 + paclitaxel 80mg/m2 120mg 1hr D2

[assessment, not posted]

  • There were no mutations or arrangements detected for EGFR, ALK, or ROS1. There is a tumor proportion score of 85% greater than 50% for PD-L1. In this case, the [carboplatin + paclitaxel + pembrolizumab] regimen is appropriate.

700016065

221115

  • diagnosis - 20221114 admission note
    • Malignant neoplasm of esophagus, unspecified
    • Chronic viral hepatitis B without delta-agent
    • Chronic hepatitis, unspecified
    • Unspecified cirrhosis of liver
  • past history - 20221114 admission note
    • HBV and alcohol related to liver cirrhosis, Episode hepatic encephalopathy times on 2009
    • Hemorroid bleeding on 2009.05
    • Reflux esophagitis, gastric ulcer, duodenal ulcer and esophageal varices history for years
    • CAD under medication treatment for months
  • exam findings
    • 2022-11-08 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Poor echo window due to inter-position of colon between liver and abdominal wall
      • Collateral vessels, splenic hilum
    • 2022-09-22 Miniprobe Endoscopic Ultrasound
      • Esophageal cancer, middle and lower esophagus, T3 (suspicioius N1) Mx
    • 2022-09-21 Tc-99m MDP whole body bone scan with SPECT
      • Faint hot spots in both rib cages, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in the maxilla, mandible, some C-, T- and L-spine, bilateral sternoclaviculr junctions, shoulders, S-I joints, hips, and left knee.
    • 2022-09-06 Patho - esophageal biopsy
      • Esophagus, 30 cm below incisor, biopsy — modertaely differentiated squampus cell carcinoma
      • Microscopically, section shows moderately differentiated squamous cell carcinoma consisting of nests of squamous tumor cells in infiltrative growth pattern. The tumor cells have abundant eosinophilic cytoplasm, round to oval nuclei, prominent nucleoli, pleomorphism, hyperchromasia, higher necleus to cytoplasm ratio and mitiotic activity.
    • 2022-09-05 Panendoscopy
      • Esophageal cancer, middle esophagus, s/p biopsy
      • Advance esophageal lesion, middle and lower esophagus
      • Reflux esophagitis, lower esophagus, LA classification, grade B
      • Superfical gastritis, antrum
    • 2022-03-07 CT - abdomen
      • Indication
        • Alcoholic + HBV related, Liver cirrhous with hepatic encephalopathy
        • 2021/12/20: echo and lab stable, follow up 3 months later by lab and CT
      • Findings
        • Severe splenomegaly and Irregular hepatic surface with parenchymal nodularity indicate liver cirrhosis.
        • Significant splenic varices formation with splenorenal shunt is also noted.
      • Imp
        • Liver cirrhosis with varices formation and splenorenal shunt
        • No evidence of hepatic tumor in the study.
    • 2021-06-29 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Colleteral vessels, LUQ of abdomen
    • 2021-04-05 CT - abdomen
      • Liver cirrhosis with portal hypertension, left splenorenal shunt and splenomegaly.
      • Much stool retention in colon.
    • 2020-05-06 CT - abdomen
      • Liver cirrhosis with splenomegaly and varices formation.
      • No evidence of hepatic tumor in the study.
    • 2019-11-19 SONO - abdomen
      • Cirrhosis of liver
      • Part of right lobe masked by gas
      • Splenomegaly, mild
    • 2019-08-27 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
      • Spleno-renal shunt
    • 2019-05-31 CT - abdomen
      • Liver cirrhosis and portal hypertension.
      • Splenomegaly.
    • 2019-03-19 SONO - abdomen
      • Cirrhosis of liver
      • Splenomegaly, mild
    • 2018-07-05 CT - abdomen
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2017-08-02 CT - abdomen
      • Liver cirrhosis with portal hypertension and splenomegaly.
    • 2017-02-17 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (118 - 31) / 118 = 73.73%
        • M-mode (Teichholz) = 73
      • Septal hypertrophy with Gr I LV diastolic dysfunction; dilated LA.
      • Normal LV and RV systolic function.
      • Mild MR; mild TR.
      • VPC bigeminy.

[assessment]

  • Metoclopramide is recommended to be given at a dose of 5 mg four times daily (maximum dose: 20 mg) for patients with moderate or severe hepatic impairment (Child-Pugh class B or C). The medication is currently prescribed in both oral and IV forms, with a dose of 3.84mg PO TIDAC and 10mg IVD PRNQ6H.
  • As far as morphine for patients with hepatic impairment is concerned, the manufacturer’s labeling does not provide any dosage adjustments. Pharmacokinetics remain unchanged in mild liver disease; substantial extrahepatic metabolism may occur. There may be a need to adjust the dosage in patients with cirrhosis due to increases in half-life and AUC.
  • A dose adjustment is not required for any other drug in the active prescription.

700054842

221115

  • exam findings
    • 2022-11-09 CT - abdomen
      • Indication: liver mass
      • CC:
        • Nausea and diarrhea for 2 weeks. Dizziness.
        • Abdominal fullness and passage of black stools for 2 weeks.
        • Tea-colored urine was noted. Tense leg edema for 10 days.
      • Past history:
        • An oral caner patient and received operations and RT since 2013/2/15. He has sleeping problem and abnormal taste in his mouth after operation and RT. He quit betel nut chewing and smoking in his past years. He had been received induction chemotherapy, operations and adjuvant RT due to oral cancer at his left lower gum since 2011/11.
      • This patient did not receive IV contrast administration. Small visceral, intra-abdominal and retroperitoneal lesion may be difficult to detect. Either vascular patency or organ pefusion status can not be determined without IV contrast.
      • Findings:
        • There is hepatomegaly (the greatest cranial-caudal dimension measuring 21.2 cm) and infiltrative hypodense masses on both hepatic lobes.
          • Metastases on both hepatic lobes are highly suspected.
          • The tumor margin is hard to define in non-enhanced CT. Please correlate with contrast enhanced dynamic CT or non-enhanced MRI.
          • In addition, There is minimal dilatation of right lobe inferior segment IHDs that may be tumor compression.
          • Please correlate with serum alk-p and bilirubin level.
        • There is a soft tissue lesion in left para-aortic space, 2.2 cm in size that may be metastatic node (Srs:201 Img:26) .
        • There is ascites.
        • There is lack of subcutaneous fat that may be cachexia status and hypoalbuminemia.
        • A renal cyst measuring 1.9 cm in right middle pole is noted.
        • There is no hyper-or hypodense lesion in the gallbladder, , pancreas, spleen & left kidney.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • IMP:
        • Metastases on both hepatic lobes are highly suspected.
        • Metastatic node in left para-aortic space 2.2 cm.
        • Ascites
    • 2022-11-04 SONO - abdomen
      • Diagnosis
        • Liver tumor, right lobe, suspicious HCC with main and right portal vein encasement.
        • Liver hemangioma, S2
        • Renal cyst, right
        • Ascites, mild
      • Suggestion
        • arrange liver dynamic CT and correlate with tumor markers.
    • 2022-08-16 KUB and lateral L-spine
      • Degenerative change of the thoracic and lumbar spine with spurs formation and narrowed intervertebral disc spaces.
    • 2019-05-28 MRI - nasopharynx
      • Post OP at left oral cavity and mandible, stationary.
    • 2018-08-03 MRI - nasopharynx
      • Prominent soft tissu in the right lower gingiva. Nature?
    • 2017-11-24 MRI - L-spine
      • mild retrolisthesis at L2-3.
      • herniated discs in the L2/3 and L3/4 discs
      • annulus tears in the L4/5 and L5/S1 discs
    • 2017-11-23 MRI - nasopharynx
      • Post flap reconstruction surgery at left anterior lower buccal-gingival region, mandible and submental region with sof-tissue tissue defect, and retention of surgical clips. As compared with previous study on 2017/04/11, there was no interval change. No focal mass or nodule.
      • Post LNs dissection with clips retention with metallic artifact and/or soft tissue or muscle defect, left.
    • 2017-04-11 MRI - nasopharynx
      • Post flap reconstruction surgery at left anterior lower buccal-gingival mandible regions with left neck LNs dissection. No evidence of tumor recurrence.

700312743

221115

{gastric signet-ring cell carcinoma}

  • exam findings
    • 2022-11-13 CXR
      • Consolidations in both lung fields
      • Normal heart size and configuration
      • Suspect left pleural effusion
    • 2022-11-09 SONO - chest
      • Finding
        • Left-side of thorax
          • Irregularly thickened pleurae was noted along with moderate free and anaechoic effusion LLL consolidaiton and atelectasis
        • Right-side of thorax
          • no pleural effusion
          • No active lung lesion
      • Echo diagnosis:
        • Pleural effusion, moderate, left
        • atelectasis, LLL
        • Pleural nodules, left
    • 2022-11-08 Pelvis & Lt. Hip Lat
      • Avascular necrosis of right femoral head is highly suspected. please correlate with clinical condition and MRI.
      • There is no identifiable osteoblastic or osteolytic bony lesion recognized in the current radiography. Please correlate with clinical condition or CT.
    • 2022-11-08, -10-31 CXR
      • Atherosclerotic change of aortic arch
      • Spondylosis of the T-spine
      • Blunting of left costal-phrenic angle is noted, which may be due to pleura effusion ?
      • Peri-bronchial wall thickening of the right and left lower lung zone is noted, which may be due to inflammatory process. Please correlate with clinical history and symptom.
    • 2022-11-04 CT - chest
      • Bil. pleural effusion with adjacent lung collapse.
      • No evidence of pulmonary embolism.
    • 2022-10-28 Panendoscopy
      • Diagnosis
        • Esophageal mucosal oozing, s/p hemostasis with APC
        • Reflux esophagitis LA Classification grade A
        • Superficial gastritis, remnant stomach
        • c/w s/p antrectomy with B-II anastomosis
      • Suggestion
        • High dose PPI * 3 days
    • 2020-10-26 CT - abdomen
      • History:
        • 20200729 BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
        • 20200729 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging: cT4aN2M0, cSTAGE:III
        • 20200810 S/P subtotal gastrectomy: Tumor present at greater omentum. Surgeon suggests tumor seeding and c/w distant metastasis. pT4aN3aM1, pstage IV
      • Indication: LUQ pain persist in recent months
      • Findings:
        • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
          • In addition, There are multiple enlarged nodes in paratracheal space, subaortic space, bilateral hilum and subcarina space that are c/w metastatic nodes.
        • S/P subtotal gastrectomy
        • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
          • The differential diagnosis include metastatic nodes. Follow up is indicated.
        • There are several hepatic cysts in both lobes and the largest one 1.3 cm in size at S7.
        • There is no focal abnormality in the gallbladder, biliary system, pancreas, spleen & both kidney.
        • There is no evidence of lymphadenopathy.
        • There is no bowel wall thickening, and no bowel obstruction.
        • The abdominal aorta and IVC are grossly unremarkable.
        • There is no evidence of intrinsic or extrinsic bladder mass. There is no focal lesion over the mesentery and omentum.
      • Impression:
        • There is left side Pleura effusion with suggstive thickening at the parietal pleura that may be pleura tumor seeding. Please correlate with pleura biopsy and pleura effusion cytology.
        • Metastatic nodes in the mediastinum are noted.
    • 2022-10-12 Patho - pleural/pericardial biopsy
      • Pleura, left, biopsy — metastatic signet-ring cell carcinoma, consistent with gastric origin
      • Section shows skeletal muscle fibers and fibroadipose tissue with metastatic signet-ring cell carcinoma.
      • The immunojostochemical stains reveal CK(+), CDX2(+), Calretinin(-), and TTF-1(-). The results are consistent with gastric origin.
      • The immunohistohcmeical of Her-2/neu (Ab) is done and shows Negative (0).
    • 2022-10-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (89 - 27) / 89 = 69.66%
        • LVEF (%) = 70
        • M-mode (Teichholz) = 70
      • Normal LV systolic function with normal wall motion.
      • Impaired LV relaxation.
      • Normal RV systolic function.
      • Mild MR; moderate TR; mild PR; aortic valve sclerosis.
      • Possible mild pulmonary hypertension, estimated PASP: 36 mmHg.
      • Flat IVC and tachycardia; consider hypovolemia.
      • Left pleural effusion.
    • 2022-09-24 CT - abdomen
      • Indication
        • [ICD10CM] Malignant neoplasm of pyloric antrum
        • [ICD10CM] Malignant neoplasm of stomach, unspecified
      • Findings
        • s/p partial gastrectomy.
        • The GB is well distended without soft tissue lesion
        • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
        • The urinary bladder is well distended without soft tissue lesion.
        • There is no evidence of destructive bone lesion.
        • Non-specific bowel gas at abdominal cavity is found.
        • Dilated CBD is found. Stationary.
        • Massive left pleural effusion is found.
        • Normal heart size.
        • The lung fields are clear.
      • Imp:
        • s/p partial gastrectomy.
        • Minimal soft tissue mass around the celiac trunk is found. In comparison with CT dated on 2022-07-18, the lesion is stationary.
    • 2022-07-18 CT - abdomen
      • s/p subtotal gastrectomy.
      • Soft tissue mass surrounding the celiac trunk is found. In comparison with CT dated on 2022-04-20, the soft tissue is stationary in size and extention.
      • Increased intestinal gas is found. The intestines are wall dilated. Post op. change is favored.
    • 2022-04-28 MRI - T-spine
      • The thoracic spine shows normal alignment and vertebral contour.
      • The thoracic disk spaces show no disk bulging, extrusion or protrusion.
      • The thoracic spinal cord shows normal size and signal intensity without evidence of compressive edema, ischemia or myelomalacia. There is no extrinsic compresson of the cord.
      • The neural foramina of the thoracic spine are patent. No impingement is seen.
    • 2022-04-27 Whole body PET scan
      • Glucose hypermetabolism in the LUQ of abdomen, compatible with S/P subtotal gastrectomy.
      • Glucose hypermetabolism in the soft tissue in the left supra-renal region and in the pre-vertebral space of T12 spine, the nature is to be determined (reactive nodes, metastatic lymph nodes or others ?), suggesting further investigation.
      • Glucose hypermetabolism in the right submandibular lymph nodes, the nature is to be determined also (reactive nodes or others ?), suggesting further investigation.
      • No prominent abnormal focal FDG uptake is noted elsewhere.
    • 2022-04-25 SONO - abdomen
      • Findings
        • Anechoic nodules, 1.19x0.65cm and 1.29x0.96cm in left lobe, 1.2x0.68cm and 1.07x0.85cm in right lobe, suspected liver cysts.
        • Normal appearance of gallbladder without stone.
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Impression
        • Liver cysts.
    • 2022-04-20 CT - abdomen
      • S/P subtotal gastrectomy.
      • Prior CT identified Mild soft tissue density lesion in the celiac trunk surrounding area is noted again, stationary that may be normal variation.
      • The differential diagnosis include metastatic nodes.
    • 2022-03-31 MRI - L-spine
      • Thoracicolumbar spondylosis with diffuse spinal canal stenosis and neuroforaminal narrowing, es T10-11-12 (with left OYL) and L4-5 (with Gr I spondylolisthesis).
    • 2022-01-27 CT - abdomen
      • S/P gastric operation. No evidence of tumor recurrence.
    • 2022-01-26 Tc-99m MDP whole body bone scan
      • Faint hot spots in the left fronto-parietal region of skull and right hip joint, respectively, the nature is to be determined (post-traumatic change or other nature ?), suggesting follow-up with bone scan in 3-6 months for investigation.
      • Suspected benign lesions in the maxilla, mandible, some T- and L-spine, bilateral shoulders, and knees.
    • 2021-11-08 SONO - abdomen
      • Findings
        • Anechoic nodules, 1.22x0.7cm, 1.29x1.16cm and 1.14x0.98cm in left lobe, 0.96x0.51cm and 1.47x0.85cm in right lobe, could be due to liver cysts.
        • Normal appearance of gallbladder without stone.
        • Patency of PV, HVs, IVC and aorta in hepatic portion.
      • Impression:
        • Liver cysts.
    • 2021-08-16 CT - abdomen
      • S/P gastric operation. No evidence of tumor recurrence.
      • Liver cysts (up to 1.1cm).
    • 2021-03-09 CT - abdomen
      • s/p subtotal gastrectomy.
      • No evidence of recurrent/residual tumor in the study.
    • 2020-08-11 Patho - stomach subtotal/total (tumor)
      • Addendum:
        • Tumor present at greater omentum. Surgeon suggests tumor seeding and compatible with distant metastasis in clinico-pathologic conference.
        • AJCC pathologic staging is revised to pT4aN3aM1, stage IV
      • PATHOLOGIC DIAGNOSIS
        • Stomach, subtotal gastrectomy — Signet-ring cell carcinoma
        • Margins, bilateral cutting ends, ditto — Free of tumor
          invasion
        • MCA, ditto — Free of tumor metastasis (0/1)
        • Greater omentum, omentectomy — Tumor present
        • Lymph node, LN 1, dissection — Negative for tumor metastasis (0/1)
        • Lymph node, LN 3, ditto — Tumor metastasis (4/8) without extracapsular extension (0/4)
        • Lymph node, LN 4, ditto — Tumor metastasis (3/6) with extracapsular extension (2/3)
        • Lymph node, LN 5, ditto — Negative for tumor metastasis (0/4)
        • Lymph node, LN 6, ditto — Tumor metastasis (4/5) with extracapsular extension (1/4)
        • Lymph node, LN 7, 8, 9,12, ditto — Negative for tumor metastasis (0/3)
        • Lymph node, LN 11p, ditto — Negative for tumor metastasis (0/1)
        • Lymph node, LN 14, ditto — Tumor metastasis (3/3) with extracapsular extension (2/3)
        • AJCC Pathologic staging — pT4aN3a (if cM0), stage IIIB
      • MICROSCOPIC EXAMINATION
        • Histologic type: Signet-ring cell carcinoma
        • Histologic grade: Grade 3
        • Depth of tumor invasion: visceral peritoneum
        • Lymph nodes: tumor metastasis (14/31) with extracapsular extension (5/14) in total number
        • Omentum: Tumor present
        • AJCC Pathologic Staging: pT4aN3a
        • Bilateral Margins: Free of tumor invasion
        • Additional pathologic findings: intestinal metaplasia, focal mucin production
        • Immunohistochemical stains: CK(+), Her2(-, Dako score 0) for tumor cells
        • Perineural invasion: present
        • Lymphovascular space invasion: present
    • 2020-08-04 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 35) / 112 = 68.75%
        • M-mode (Teichholz) = 69
      • Dilated LA, Ao
      • Adequate LV,RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild TR, AR
    • 2020-07-29 Patho - stomach biopsy
      • Stomach, biopsy — Adenocarcinoma
      • Section shows fragments of gastric tissue infiltrated by isolated neoplastic cells.
    • 2020-07-29 CT - abdomen
      • History and Indication:
        • BW loss 6 Kgs in recent 6 months, postprandial epigastric discomfort and poor appetie for 3 months
        • 2020/07/29 Gastroscopy: Borrmann type II gastric cancer in the antrum. CT staging
      • FINDINGS:
        • There is lobulated wall thickening in the gastric antrum and low body and the maximal wall thickness measuring about 2.2 cm that is compatible with adenocarcionoma.
        • There are at least 4 enlarged nodes in the dorsal aspect mesentery of the perigastric antrum area (Srs:302, Img:38,43) that may be metastatic nodes in station 4 and 6.
        • Ascites in the pelvis is noted, nature?
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T4a(T_value) N:N2(N_value) M:M0(M_value) STAGE:III (Stage_value)
    • 2020-07-29 Panendoscopy
      • big gastric ulcers. A2, highly suspected gastric cancer Bormman type II; antrum
  • consultation
    • 2022-10-17 ENT
      • Q
        • for hoarse throat days
        • This 67-year-old man, a patinet of gastric cancer with Gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810 & post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T finishing in Oct 2020 & post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 11 finishing in May 2021. He was admitted due to dyspnea S/P pig-tail drainage inserted. He complained of hoarse throat for days. WE need expertise to evaluate his condition thanks!
      • A
        • Scope: smooth nasopharynx, oropharynx, hypopharynx. Fair vocal cord movement.
        • Impression: favor functional dysphonia.
        • Plan: May give Broen-C 2# TID.
        • ENT OPD follow-up after discharge.
    • 2022-08-12 Nephrology
      • Q
        • for hyponatremia,thanks
        • This 65-year-old male, a pt of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p Op & HIPEC on 20200810, suffered from initial presentation of marked weight loss of 6kg from Feb 2020.
        • Surgical pathology with stomach, subtotal gastrectomy (20200810) proved signet-ring cell carcinoma.
        • Subtotal gastrectomy, BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC with oxaliplatin 360mg/m2 (650mg) 42C for 60 min, on 20200810.
        • He was referred to our hemato-oncologic clinic on 20200901 for post-Op adjuvant CCRT & C/T.
        • We explain to pt & his wife about the indication & risk / benefit of post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T then post-CCRT adjuvant C/T wt Oxaliplatin / HDFL IV Q2W x 12.
        • HBsAg, anti-HCV (20200901): negative.
        • #1 R/T to gastric tumor bed on 9/14 20
        • #1 post-Op adjuvant CCRT wt 5-FU 24 hr QD x 5 per wk x 6 plus R/T on 9/16~9/18 20, #2 on 9/28 20, #3 on 10/12 20.
        • #1 post-Op adjuvant CCRT with Oxaliplatin / HDFL IV Q2W x 12 on 11/17 20, #2 on 12/14 20, #3 on 12/28 20, #4 on 1/11 21, #5 on 1/25 21, #6 on 2/22 21, #7 on 3/15 21, #8 on 3/29 21, #9 on 4/12 21, #10 on 4/27 21, #11 on 5/11 21
        • The whole abdominal CT (3/9 21) showed s/p subtotal gastrectomy. No evidence of recurrent/residual tumor in the study.
        • Painless gastroscopy (4/1 21): Erosive reflux esophagitis LA Classification grade A
        • S/p subtotal gastrectomy with B-II anastomsis, superficial gastritis, remnant stomach.
        • Followed CXR & abd sono (11/8 21): negative but liver cysts.
        • Followed Abd CT (8/16 21) (1/27 22) revealeds/p gastric Op. No evidence of tumor recurrence.Liver cysts (up to 1.1cm).
        • Followed Abd CT (4/20 22)revealed s/p subtotal gastrectomy.Prior CT identified Mild soft tissue lesion in the celiac trunk noted again, stationary that may be normal variation. D/D include mets nodes.
        • PET scan (4/27 22) showed negative.
        • Followed Abd CT (7/18 22) revealed s/p subtotal gastrectomy.Soft tissue mass at the celiac trunk, compared wt CT on 4/20 22, the soft tissue is stationary in size and extention. c/o L lower chest wall pain. Dr Wu did bone scan.
        • Bone scan (1/26 22) showed negative. (2/8 22).
        • He complained of back pain & left lower abdominal discomfort, Dr Wu consult Dr Chang for CCRT on 7/26 22. Palliative R/T to recurrnet LAPs for 3500cGy/14 fractions is suggested for pain control. Suggest concurrent chemotherapy.The radiotherapy started on 8/5 22
        • This time ,he was admitted for #1 CCRT wt 5-FU 24 hr QD x 5 per wk x 3 on 8/9 22
        • However, hyponatremia was noted during CCRT.3% NACL 15ml/hr was administered. Followed the thyroid function and pending. We need your epertise for further management,thanks
      • A
        • This 65 years old male patient had underlying history of gastric adeno CA of antrum, cT4aN2N0 stage III, pT4aN3aM1, stage IV, s/p subtotal gastrectomy BII anticolic anastomosis, D2 dissection, with T-colectomy and HIPEC on 20200810 , post-Op adjuvant CCRT. Consult for hyponatremia.
        • Lab data:
          • WBC: 2.76, Hb: 11.9,Plt: 182
          • Na: 132-> 128-> 126-> 125(8/9)-> 115(8/12)
          • K: 4.3, Ca: 2.42, Albumin: 4.6, Ca: 2.14, Mg: 1.7
          • BUN: 16, Cre: 0.75
          • Uric acid: 1.6, T bil: 1.03, D bil: 0.21, GOT :31
          • E4V5M6, BW 67.15kg
        • Assessment :
          • Severe acute hyponatremia
        • Suggetsion:
          • Supplementation with 3% NS run 20ml per hr for one day
          • Follow up serum Na Q4hr and not more than 8-10mmol/L per day
          • Check plasma osmolality, urine osmolarity and urine Na, FeNa, Fe uric acid (serum uric acid, urine uric acid, serum Cr, urine Cr) , TSH, Free T4, ACTH, cortisol
          • We will follow up this case.
        • Follow up (20220813)
          • Lab
            • Na: 117
            • Urine uric aicd : 21.7
            • Urine osmolarity: 377
            • Plasma osmolality : 236
            • Uric acid: 1.6
          • Assessment: suspect SIADH
          • Suggestion:
            • Keep 3% NS 20ml per hr for 2 days
            • Fluid restriction
            • Follow up Na Q4h or Q6h
            • Lasix 1 amp IV st
  • surgical operation
    • 2020-08-10
      • Surgery
        • Subtotal gastrectomy with D2 LNdissection
        • mesocolon resection
        • HIPEC with Oxaliplatinum 360mg/M2 650 mg T 42 C for 60 mins
        • B-II anticolic anastomosis
      • Finding
        • huge gastric ulcerative mass at greater cuvature with direct invasion to moesocolon
        • small nodular seeding at greater omentum
        • ascite(-)
  • chemoimmunotherapy
    • 2022-10-25 - irinotecan 160mg/m2 270mg 1.5hr + leucovorin 400mg/m2 670mg 1.5hr + fluorouracil 2800mg/m2 4700mg 46hr
    • 2022-08-22 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
    • 2022-08-15 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
    • 2022-08-09 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
    • 2021-05-11 - oxaliplatin 85mg/m2 160mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • 2021-04-27 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 740mg 2hr + fluorouracil 2800mg/m2 5200mg 46hr
    • 2021-04-12 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-03-29 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-03-15 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-02-22 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5100mg 46hr
    • 2021-01-25 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2021-01-11 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2020-12-28 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 5000mg 46hr
    • 2020-12-14 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2020-11-17 - oxaliplatin 70mg/m2 120mg 2hr + leucovorin 400mg/m2 700mg 2hr + fluorouracil 2800mg/m2 4900mg 46hr
    • 2020-10-12 - fluorouracil 200mg/m2 350mg 24hr D1-D5 (CCRT)
    • 2020-10-01 - fluorouracil 200mg/m2 350mg 24hr D1 (CCRT)
    • 2020-09-28 - fluorouracil 200mg/m2 350mg 24hr D1-D3 (CCRT)
    • 2020-09-15 - fluorouracil 200mg/m2 350mg 24hr D1-D4 (CCRT)
    • 2020-08-10 - [cisplatin 360mg/m2 650mg + gentamicin 40mg + sodium bicarbonate 7% 60mL] IP 1hr for HIPEC at OR

[assessment]

  • As the patient reported bilateral lower limb edema after taking Lyrica (pregabalin), so the pregabalin has been held for the moment. As part of discharge preparations, gabapentin could be prescribed as a substitute for pregabalin for the patient’s neuropathic pain with less than half the risk of edema. (ref: UpToDate)

700900195

221114

  • exam findings
    • 2022-11-08 CT - brain
      • No ICH. Brain atrophy. Old left anterior basal ganglia lacunar infarcts.
    • 2022-08-22 MRI - c-spine
      • Cervical spondylosis, retrolordotic change, subluxation, mild spinal canal stenoses.
    • 2022-01-07 CT - c-spine
      • Cervical spinal kyphosis.
      • Degenerative spinal and disc disease.
      • Severe right C4-5, C5-6 neuroforaminal narrowing.
    • 2021-05-11 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (54 - 13) / 54 = 75.93%
        • M-mode (Teichholz) = 76
      • Preserved LV and RV systolic function with normal wall motion
      • Grade 1 LV diastolic dysfunction
      • Mild AR, TR
    • 2021-05-11 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.

[assessment]

  • Following the last cholesterol total measurement in April 2021 (275 mg/dL), there has been no further follow-up. It might be beneficial to collect the reading again to determine whether a statin agent is required (Zulitor (pitavastatin 4mg) 1# QN has been used in the past).

701447350

221114

  • exam findings
    • 2022-10-31 Pelvis & Bilat. Hip Lat
      • There is an osteolytic or osteopenic lesion in the lesser trochanter of right femur. Please correlate with CT to R/O bony metastasis.
    • 2022-10-05 Tc-99m MDP whole body bone scan
      • A hot area in the right iliac bone and increased activity in the sternum, malignancy with bone metastases should be considered, suggesting further investigation.
      • Increased activity in the sacrum, left humerus, and left hip, the nature is to be determined (bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for evaluation.
      • Suspected benign lesions in some C-, T- and L-spine, bilateral shoulders, and right femoral trochanter.
    • 2022-10-04 Patho - liver biopsy
      • Liver, CT-guided biopsy — Adenocarcinoma, poorly differentiated, compatible with cholangiocarcinoma
      • The sections show adenocarcinoma, poorly differentiated, composed of nests of large pleomorphic neoplastic cells, arranged in solid pattern with desmoplastic stromal reaction. Subtle glandular formation is present.
      • IHC, tumor cells reveal: CK7(+), CK20(-), Hepa-1(-) and Arginase-1(-).
    • 2022-09-14 CT - abdomen
      • Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.
      • Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space.
      • Bony metastases.
  • consultation
    • 2022-11-02 Radiation Oncology
      • A
        • A: Intrahepatic cholangiocarcinoma with multiple metastases.
        • P: Radiotherapy is indicated for this patient with the following indicators: bone metastases.
          • Goal: palliation
          • Treatment target and volume: metastatic right ilium, sacrum, and right lesser trochanter lesions
          • Technique: IMRT
          • Preliminary planning dose: 3000cGy/12 fractions of the metastatic right ilium, sacrum, and right lesser trochanter lesions.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his wife. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 1330, 2022-11-07.
    • 2022-10-28 Rheumatology
      • Q
        • This 64-year-old man, a patient of being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC & bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza x 7 times) and bone met S/P R/T x 6 times was noted later. He was admitted for C/T. He complained of whole body skin rash & icthing did not improve for days. The ANA:1:80, IgE: 425. We need expertise to evaluate his condition thanks!
      • A
        • History review was performed. Patient was admitted due to HBV-related HCC & for C/T. I was consulted for generalized itching sensation.
        • RIA condition:
          • Allergic rhinitis Hx(+)
          • multiple small papules over four limbs
          • WBC/Hgb/PLT:4550/8.1/49K; Eosinophils:1.1%
          • IgE:425
          • ANA:1:80(s)
        • Suggestion:
          • Treatment as current your expert’s management.
          • Please check cryoglobulin, Panel 5 specific allergen test.
          • Keep allegra 1#BID & add chlorpheniramine 1# prn HS.
    • 2022-10-03 Dermatology
      • Q
        • for skin rash & icthing over whole body
        • This 64-year-old man, Being diagnosed to have HBV-related HCC several years ago (3-4 yrs) post TAE at SYKCC . Bililary ca was diagnosed later and received further chemotherapy (cisplatin and gemza )and bone met was noted later. The abdominal CT (9/14 22) showed Hepatocholangiocarcinoma is highly suspected. The differential diagnosis include cholangiocarcinoma and metastases? Biopsy is indicated.Multiple metastatic nodes in hepatoduodenal ligament, para-aortic space and para-cava space,Bony metastases. He complained of skin rash & icthing over whole body for days. We need expertise to evaluate his condition thanks!
      • A
        • This patient suffered from erythematous papules on limbs for 2 wks. and dyskeratoticnails for yrs.
        • Imp:
          • Subacute dermatitis
          • Tinea unguim
        • Suggestion:
          • Please check CBC. ANA. TSH. IgE
          • Dexamethason * 1 /Qd
          • Topsym cream * 4 tubes/bid
          • Excelderm soln * 2 Bt/Bid
  • chemoimmunotherapy
    • 2022-10-31 - oxaliplatin 85mg/m2 150mg 2hr + leucovorin 400mg/m2 750mg 2hr + fluorouracil 2800mg/m2 5300mg 46hr

700132355

221110

[assessment]

  • The trough value of vancomycin was reported on 2022-11-10 at 25.4 mcg/mL.

  • A blood draw time of “2022-11-10 00:00” has been recorded, this should be due to an invalid entry, please confirm that the concentration is actually a “trough”.

  • Redraw the value if it is not truly a “trough”.

  • In the event that the value is a real “trough”, then it is recommended to hold vancomycin and perform a renal function test.

700161803

221103

  • exam findings
    • 2022-11-02 CT - abdomen
      • Findings:
        • There are multiple enlarged lymph nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, mesentery, para-aortic space, para-cava space, and bilateral common iliac chain.
          • Metastatic nodes are highly suspected.
          • The differential diagnosis include lymphoma.
          • In addition, thrombosis in right superficial femoral vein is noted.
        • There is diffuse wall thickening at the low body and antrum of the stomach. Please correlate with gastroscopy.
        • Prior CT identified a poor enhancing Soft tissue tumor, 4cm in the uterus, is noted again, stationary. Myoma is suspected.
          • In addition, There is a homogeneous soft tissue mass measuring 2.8 x 1.8 cm in left adnexa, near the uterine fundus, that also may be myoma.
        • Bilateral renal cysts, up to 2.6cm.
        • There are massive bilateral Pleura effusion.
      • Impression:
        • Multiple Metastatic nodes are highly suspected.
          • The differential diagnosis include lymphoma.
          • In addition, thrombosis in Rt superficial femoral vein is noted.
    • 2021-05-15 CT - abdomen
      • Imaging Report Form for Gastric Carcinoma
        • Impression (Imaging stage): T:T2(T_value) N:N0(N_value) M:M0(M_value) STAGE:I(Stage_value)
    • 2021-05-11 Patho - stomach biopsy
      • Stomach, GC-PW of middle body, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of tubular adenocarcinoma, moderately differentiated, composed of gastric mucosal tissue with columnar to cuboidal neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic reaction.

[assessment]

  • Low molecular weight heparin (LMWH) is probably superior to unfractionated heparin (UFH) in reducing mortality in the initial treatment of venous thromboembolism (VTE) in people with cancer (2022-11-02 CT: thrombosis in right superficial femoral vein). Also, there are additional advantages of LMWH related to subcutaneous administration and outpatient management. (ref: Anticoagulation for the initial treatment of venous thromboembolism in people with cancer. Cochrane Database of Systematic Reviews 2021, Issue 12. Art. No.: CD006649. DOI: 10.1002/14651858.CD006649.pub8). For most patients with active malignancy and acute VTE who have a reasonable life expectancy and adequate renal function (CrCl >=30 mL/minute), LMWH is the preferred agent for initial anticoagulation, rather than other agents.

701035130

221103

  • diagnosis - 2022-11-02 adminssion note
    • Unspecified abdominal pain
    • Malignant neoplasm of unspecified part of left bronchus or lung
    • Malignant neoplasm of esophagus, unspecified
    • Chronic viral hepatitis C
    • Malignant neoplasm of upper lobe, left bronchus or lung
    • Malignant neoplasm of middle third of esophagus
    • Alcohol dependence, uncomplicated
    • Secondary malignant neoplasm of bone
    • Calculus of bile duct with cholangitis, unspecified, with obstruction
  • exam findings
    • 2022-10-06 Tc-99m MDP whole body bone scan with SPECT
      • The scintigraphic findings suggest multiple bone metastases.
      • Increased activity around right hip prosthesis. The nature is to be determined (infection or inflammation? other nature?). Please correlate with other clinical findings.
      • Mildly increased activity in the right knee. Arthritis may show this picture. Please also correlate with other clinical findings for further evaluation and to rule out other possibilities.
    • 2022-10-05 Patho - pleural/pericardial biopsy
      • Lung, left upper lobe, CT-guide biopsy — small cell carcinoma
      • Sections show large nests of small hyperchromatic tumor cells with scanty cytoplasm and marked crushing artifact.
      • The immunohistochemical stains reveal CK7(+), CK20(-), TTF-1(-), Napsin A(-), Synaptophysin(-), Chromogranin A(-), CK5/6(-), p40(-), GATA3(focal +), SALL4(-), OCT4(-), and beta-hCG(-). The morphology is the same as S2022-16555.
    • 2022-09-30 MRI - pancreas
      • History: 20220924 CC: abdomen pain
        • 20220924 CT: A mass (2.6x5.4cm) at LUL and left pulmonary hilum. Some LNs at mediastinum, hepatic hilum, and retroperitoneum. Some hypodense lesions (up to 4.7cm) in both hepatic lobes.
          • Suspected lung cancer at LUL with LNs and liver metastases
        • 20220927 CA199: 19090 U/mL (< 35), CEA and AFP: normal.
        • 20220928 liver biopsy: neuroendocrine carcinoma
    • 2022-09-28 Patho - liver biopsy needle/wedge
      • Liver, CT-guided biopsy — Poorly differentiated carcinoma,compatible with neuroendocrine carcinoma
      • The sections show nests of medium to large-sized, poorly differentiated neoplastic cells with marked apoptosis, in fibrous stroma. Neither squamous nor glandular differentiation can be identified.
      • IHC shows: CK(+), p40(-), TTF1(-), CD56 (+), and Synaptophysin(-). The findings favor neuroendocrine carcinoma.
    • 2022-09-28 Patho - stomach biopsy (middle esophagus)
      • Labeled as “middle esophagus”, biopsy (B) — squamous cell carcinoma.
      • IHC stains: CK5/6 (+), p63 (+).
    • 2022-09-26 SONO - abdomen
      • Diagnosis
        • Liver tumors, favor metastatic tumors
        • liver parenchymal disease
        • mild GB wall thickening
      • Suggestion
        • correlate with other image study such as contrast-enhanced CT scan or MRI
    • 2022-09-24 CT - chest
      • Suspected lung cancer at LUL with LNs and liver metastases. Suggest tissue study.
  • consultation
    • 2022-11-02 Family Medicine
      • Q
        • This is a 51-year-old man with past history of
          • Squamous cell carcinoma involved middle esopahgus
          • Nueroendocrine carcinoma of liver, poor differentiated, multiple metastatic lymph nodes
          • Small cell carcinoma of lung
          • Tc99m: multiple bone metastasis
          • Left hip AVN, alcoholism related, s/p left THR in 2013 at WanFang Hospital.
          • Left distal tibial fracture and lateral malleolar fracture by trauma, s/p ORIF with plate fixation in 2017/07
          • Left THR acetabular component loosening, s/p left hip revision THR in 2017/12
          • Right hip s/p bipolar hemiarthoplasty s/p infection, s/p ROI and antibiotic cement beads insertion in 2020/04
          • Hepatitis C under Maviret treatment since 20221021.
        • According to family, the patient developed chest tightness, abdominal pain, and severe right knee pain for several days. Productive cough with difficult swallowing were also noted. So he visited our ER for help. He managed to talk oriently and was able to eat by himself then.
          • Vital sign at ER revealed BP:117/76 mmHg; HR:102 bpm; BT:35.6 celsius degree; RR:18 /min ; GCS:E4V5M6. Laboratory data revealed leukocytosis, elevated CRP and direct/total bilirubin. Icteric appearance was noted. Cefataxime was prescribed at ER. However, he became lethargy and confused this morning. Though his eyes opened spontaneously, he could not answer questions properly or obey order. Productive cough was also noted. Under the impression of (1) squamous cell carcinoma involved middle esopahgus (2) Nueroendocrine carcinoma of liver (3) Small cell carcinoma of lungs (4) altered mental status (5) pneumonia, the patient was admitted for further evaluation and management. Due to difficult swallowing and altermental status, NG tube was inserted today.
        • Considering the irreversible end stage cancers and his family decided not to accept advanced treatment, we need your expertise for this patient’s hospice care. Thank you very much!!
      • A
        • After discussion, I decided to arrange hospice combine care for this patient. Thanks for your consultation.
        • Current condition: 51 y/o Esophageal cancer, bone mets
        • Indication for hospice combine care: Advanced esophageal cancer
    • 2022-10-03 Hemato-Oncology
      • Q
        • This is a 51-year-old man, who was admitted for GI bleeding. PES was done and his vital signs is stable now. Further investigation revealed 1. Esophageal Ca, r/o lung cancer and liver neuroendocrine carcnioma were noted.
        • We would like to request your expertise upon further management of the condition.
      • A
        • This 51-year-old man was consulted and evaluated for liver tumor and esophageal cancer.
        • History and medical records reviewed and patient interviewed at bedside.
        • Recommendation:
          • lung biopsy to R/O small cell carcinoma of lung
          • chemotherpay with cisplatin based regimen is suggested after the lung tumor pathology is elucidated.
          • check bone scan
          • suggest to consult the radiation oncologist for possible of CCRT
        • I will follow up this patient, Thank you for the referral.
    • 2022-09-27 Thoracic Medicine
      • Q
        • This is a 51-year-old patient, he came to our ward since GI bleeding.
        • On 20220924, chest x ray shows: Mass like lesion at left upper lobe is found.
        • on 20220924, CT shows: A mass (2.6x5.4cm) at LUL abutting mediastinum and left pulmonary hilum.
        • Meanwhile, abdominal sonography shows multiple liver tumors, metastatic suspected.
        • We would like to consult to Dr. we wonder if there’s any advices, or would you recommand surgical intervention for the patient?
        • Please insight us. Thanks for your time and reply.
      • A
        • This 51-year-old man without chronic disease was admitted due to GI bleeding and CXR showed incidental finding of lung tumor.
          • Chest CT revealed multiple liver hypodense tumor with LUL mass near hilum with multiple LD at retroperitonium, and mediastinum. Therefore, we were consulted for further evaalution and management.
        • Lab:
          • CA19-9: 19090, AFP, CEA: normal
          • Anti-HCV: (+)
          • smoking, alcohol, and betel nut history: (+)
          • Panendoscopy revealed esophageal lesion post biopsy, GU post biopsy, and DU scar.
        • Impression:
          • Lung tumor with multiple liver tumor and LN with esophageal lesion, primary origin?
          • Gastric ulcer, with esophageal lesion s/p biopsy
        • Suggestion:
          • Pending biopsy report
          • Could ask the interventional radiologist for CT guided biopsy (liver tumor first due to lower risk) if negative findings of esophageal lesion.
            • If interventional radiologist refuse, we could arrange bronchoscopy to see whether we could approach the mass lesion.
          • could also check other tumor marker - SCC for evaluation.
          • Treat Gi bleeding as your expertise.
          • We will closely follow up the patient.
        • Thanks for your consultation
    • 2022-09-26 Rehabiliation
      • A
        • Right knee:
          • No erythermatous change, no swelling, no heating, no tenderness over his right knee
          • Lockman test: negative; McMurray test: Positive
          • Pain when flexion and extension ROM, relief after resting
        • Right knee sonogram: mild effusion in suprapatellar
        • Assessment
          • Right knee internal derangement
        • Plan
          • Arranged right knee sonogram (done, pending report)
          • Knee IA with low dose steriod injection
          • Please arrange right knee X-ray, and MRI
          • Please arrange rehab OPD after discharge for follow up if his right knee is still pain

[assessment]

  • Tube feeding is possible for all oral medications in the active prescription.
  • It is recommended that the patient-carried medication Maviret (glecaprevir 100mg + pibrentasvir 40mg) be taken with food (cum cibos) and the frequency should be amended to QDCC.

701458197

221031

{drug identification}

requesting drug identification for 1 item.

the item is identified as Serenal (oxazolam 10mg/cap).

the drug will be sent back to ward by an in-hospital porter.

701272100

221028

  • diagnosis 2022-06-24 discharge
    • Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with lymph node dissection on 2021/03/29 s/p concurrent chemoradiotherapy
    • Chronic viral hepatitis B without delta-agent
  • exam finding
    • 2022-09-09 CT - abdomen
      • FINDINGS:
        • Prior CT identified several metastatic nodes in para-aortic space and left common iliac chain are noted again, decreasing in size that may be metastatic nodes S/P C/T with partial response .
        • S/P Whipple operation and S/P cholecystectomy.
          • Mild dilatation of the IHDs on both lobes are noted.
          • Please correlate with serum alk-p and bilirubin level.
        • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
        • There is a enlarged node measuring 1.8 x 1.1 cm in the para-tracheal space that may be metastatic node.
      • IMP:
        • Metastatic nodes in para-aortic space and left common iliac chain S/P C/T show partial response. Follow up is indicated.
        • Metastatic node in paratracheal space measuring 1.8 x 1.1 cm is highly suspected.
    • 2022-07-15 Tc-99m MDP whole body bone scan
      • Mildly increased activity in the lower C- and lower L-spines. Degenerative change may show this picture.
      • Increased activity in the maxilla and mandible. Dental problem may show this picture.
      • Some faint hot spots in bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
      • Increased activity in bilateral shoulders, hips, knees and feet, compatible with benign joint lesions.
    • 2022-06-21 SONO - neurology
      • Minimal atherosclerosis in bilateral CCA bifurcations.
      • Normal extracranial carotid, vertebral, and intracranial basal cerebral arterial flows.
    • 2022-06-16 MRI - brain
      • No abnormal enhancing lesion within brain parenchyma.
      • Mild periventricular small vessel disease. NO acute ischemic infarct.
    • 2022-05-25 CXR
      • Atherosclerotic change of aortic arch
      • Enlargement of cardiac silhouette.
    • 2022-05-25 CT - abdomen, pelvis
      • Findings:
        • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
        • S/P Whipple operation and S/P cholecystectomy.
        • Mild pneumobilia on both lobes IHDs are noted.
        • There is a poor enhancing lesion 1.1 cm in S6 liver that is c/w cyst.
      • Imp:
        • There are several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
    • 2022-03-28 Patho - soft tissue biopsy/simple excision (non lipoma)
      • Skin and soft tissue, abdominal wall #1, excision — Fat necrosis
      • Soft tissue, abdominal wall #2, excision — Fat necrosis
    • 2022-03-01 Patho - soft tissue debridment
      • Labeled as “abdominal wall tumor around the scar region”, clinical history of pancreatic ductal carcinoma, needle biopsy — fibrosis.
      • IHC stains: CD68 highlights many histiocytes. CK (-): no carcinoma.
    • 2022-02-25 CT - abdomen, pelvis
      • S/P Whipple operation and S/P cholecystectomy. There is no evidence of tumor recurrence.
      • Mild pneumobilia on both lobes IHDs are noted.
    • 2021-10-14 CT - abdomen, pelvis
      • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
    • 2021-07-27 MRI - MR Cholangiography, MRCP
      • Pancreatic cancer s/p operation. No evidence of tumor recurrence.
    • 2021-07-07 CT - abdomen, pelvis
      • Findings
        • S/P Whipple operation and S/P cholecystectomy.
        • There is mild fatty stranding and suspicious mild fluid collection at the anastomosis area of the pancreaticojejunostomy that may be post-operative change. The differential diagnosis include partial leakage? please correlate with clinical condition.
        • There is a round, encapsulated lesion in the subcutaneous fat layer of the midline incisional wound with a central area of predominantly fat attenuation, a finding indicative of encapsulated fat necrosis.
        • Mild ascites in the pelvis is suspected.
        • Fatty liver, grade 4, is noted.
      • IMP:
        • Post-operative change at the anastomosis area of the pancreaticojejunostomy is suspected. The differential diagnosis include partial leakage? please correlate with clinical condition.
        • Encapsulated Fat necrosis in the subcutaneous fat layer of the incisional wound is suspected.
    • 2021-03-30 Patho - gallbladder (benign lesion)
      • Gallbladder, cholecystectomy — Chronic cholecystitis
      • The sections show a picture of chronic cholecystitis, composed of congestion, mild chronic inflammatory cells infiltration, mild mural fibrosis, and scattered Rokitansky-Aschoff sinuses.
    • 2021-03-30 Patho - liver partial resection
      • pathologic diagnosis
        • Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18)
        • Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1)
        • Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1)
    • 2021-03-30 Patho - pancreas total/subtotal resection
      • pathologic diagnosis
        • Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated
        • Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44)
        • Pathologic Staging: pT2N2; Stage III if cM0
      • macroscopic examination
        • Specimen Type: Whipple operation
        • Venous (Large Vessel) Invasion: Absent
      • microscopic examination Representative parts are taken for section and labeled as: A1=
        • Histologic Type: Ductal adenocarcinoma
        • Histologic Grade: Moderately differentiated (G2)
        • Tumor Extension: Tumor invades peripancreatic soft tissue
        • Lymphvascular Invasion: Present
    • 2021-03-12 Patho - pancreas biopsy
      • Labeled as “pancreatic tumor”, EUS guided FNA/B of Pancreas — adenocarcinoma.
      • IHC stain: CK highlights small irregular infiltrative neoplastic ducts.
      • Section shows cores of markedly necrotic tissue with atypical mucinous gnads.
    • 2021-03-12 Cell block
      • cytologic diagnosis
        • Atypia
      • gross description
        • 32 cc, light orange, turbid
      • microscopic description
        • Smears an cell block show scant atypical hyperchromatic epithelial cells. The speicmen may not be representative for low cellularity.
    • 2021-03-12 Endoscopic Ultrasonography, EUS
      • Diagnosis
        • Suspected Pancreatic head cancer s/p CH-EUS & EUS/FNB
        • Pancreatic cystic lesions, pancreatic body, suspected IPMN
        • Peri-pancreatic lymphadenopathy
        • Shallow duodenal ulcer, bulb
      • Suggestion
        • F/u pathology
        • PPI use for ulcer
    • 2021-03-11 Abdominal Ultrasonography
      • Diagnosis
        • Pancreatic tumor, uncinate process
        • Pancreatic cystic lesions, body
        • Main pancreatic duct dilatation
        • Liver cysts, three, S3 and S6
        • Suspected renal stone, left kidney
      • Suggestion
        • correlated wtih other images and tumor markers
  • consultation
    • 2022-06-15 ENT
      • Q
        • For dizziness when turn the neck for 1 week.
        • This 64-year-old female has past history of gastric ulcer. According for her statement, she noted for pancreatic tumor for 3 years with regular follow up at other hospital. However, health examination revealed pancreatic lesion by abdomen MRI which showed a 2.2cm sized progressive rim enhancing lesion is noted at uncinate process of the pancreas, with high signal intensity on T2WI, diffusion restriction, nature to be determined. suspect of pancreatic cancer, solid pseudopapillary tumor. She came to our OPD for further management. EUS was also performed and showed 1) R/o Pancreatic head cancer s/p biopsy. 2) Pancreatic cystic lesions, pancreatic body, r/o IPMN. 3) Peri-pancreatic lymphadenopathy. 4) Shallow duodenal ulcer, bulb. Tumor marker of CEA: 2.05ng/ml, CA-199: 469.32U/ml on 2021/03/16. She referred to our GS OPD for further treatment.
        • Now, she is admitted for Abraxane and Gemcitabine on 2022-06-14, she complaints dizziness when turn the neck for 1 week, so we need tour help, thanks a lot!!
      • A
        • PE: Bil. Dix-Hallpike test negative, no spontaneous nor motional nystagmus
        • According to her statement, favoring resolved BPPV, unspecific ear
        • However, still have to r/o tumor metastasis
        • May prescribe Diphenidol for her remaining dizziness
    • 2021-08-20 Infectious Disease
      • Q
        • This 63-year-old is a case of Pancreas adenocarcinoma, pT2N2(cM0); Stage III status post pylorus-preserving pancreaticoduodenectomy with LN dissection s/p CCRT. This time, for abdominal wound casr with pus in 2021/07 with antibiotic Metrozole 1# po QID and Amoxicillin 2# po Q8H theraoy. But, Pus/C showed normal. Now, for evaluate antibiotic therapy. Thank you.
      • A
        • A 63-year-old woman of pancreas adenocarcinoma. Wound/pus culture revealed no growth. The common infecting bacteria of deep wound infection including Streptococci, Staphylococci, and gram negative-negative enteric bacteria possible. MRSA has been reported to account for up to 21% of nosocomial skin infections. Vancomycin typically is the drug of choice for methicillin-resistant coagulase-negative and coagulase-positive staphylococcal infections. It is also useful against penicillin-resistant streptococcal infections. Anti-microbiologic coverage as with parenteral Vancocin 500 mg or + - (plus Fortum 1.0 gm) q12h is recommended.
    • 2021-04-10 Hemato-Oncology
      • Q
        • For further chemotherapy
        • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. Now, her condition improve and appetite fair. We need your expertise for further chemotherapy. Thanks for your times.
      • A
        • A case MD pancreatic ductal adenocarinoma, post PPPD and LND, pT2N2(8/44)M0, Stage III, was noted.
        • My suggestion would be:
          • The adjuvnat treatment is mandatory. May consider CCRT followed by C/T
          • Please check HBV (HBs Ag, Anti-HBs Ab, Anti-HBc Ab) and HCV (Anti-HCV) status during this admission, or I will check in my OPD
          • If possible, please check CA199/CEA, or I will check in my OPD
          • If MBD, please arrange my OPD
          • Please arrange Port-A if possible.
        • Thanks for your consultation. Any problem, please let me know.
    • 2021-04-09 Radiation Oncology
      • Q
        • For further radiotherapy
        • This 64 y/o female a case of pancreatic head cancer s/p PPPD + LND on 20220329. The final pathology revealed ductal adenocarcinoma, moderately differentiated, lymph nodes metastatic (8/44), Staging: pT2N2M0; Stage III. We need your expertise for further radiotherapy. Thanks for your times.
      • A
        • The patient’s history was reviewed and patient was examined.
        • S:
          • For postoperative radiotherapy due to pancreatic cancer.
          • PI: Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection on 2021-03-29.
          • Family history: (father: prostate cancer, elder brother: esophageal cancer)
          • Cancer site specific factors: Alcohol (-); Smoking (quit); Betel nut (-).
          • Personal Hx: DM(-); HTN(-)
          • Other disease: (-)
          • Previous RT Hx: (-)
        • O:
          • ECOG: 1
          • PE: neck and bil SCF: neg; abdomen: surgical scar and status during drainage.
          • CXR (2021-03-09): Essential negative findings
          • Abd sono (2021-03-11): pancreatic tumor, uncinated process; pancreatic cystic lesions, body; main pancreatic duct dilatation; liver cysts, three, S3 and S6; suspected renal stone, left kidney.
          • CA199 (2021-03-16): 469.32
          • Operation (2021-03-29): PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
          • Pathology (S2021-04713, 2021-04-01): 1. Lymph nodes, LN 7, 8, 9, 11p, 12, dissection — Metastatic adenocarcinoma (1/18). 2. Lymph node, J1, dissection — Metastatic adenocarcinoma (1/1). 3. Lymph node, SMV, dissection — Metastatic adenocarcinoma (1/1).
          • Pathology (S2021-04715, 2021-04-01): 1. Pancreas, Whipple operation — Ductal adenocarcinoma, moderately differentiated. 2. Lymph nodes, regional, Whipple operation — Metastatic carcinoma (8/44). 3. Pathologic Staging: pT2N2; Stage III if cM0. Uncinate margin: Uninvolved by invasive carcinoma, 1 mm from closest margin.
        • A:
          • Ductal adenocarcinoma, moderately differentiated of the pancreas, pathologic Staging: pT2N2(cM0); Stage III, s/p PPPD with LN 5, 6,7,8,9,11p,12, 14a & v dissection.
        • P:
          • Radiotherapy is indicated for this patient with the following indicators: Staging: pT2N2(cM0); Stage III, and close margin.
          • Goal: curative
          • Treatment target and volume: pancreatic tumor bed, peripheral, to regional lymphatic area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 4500cGy/25 fractiobns
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and her brother’s son. They understand and agree to receive radiotherapy. The treatment planning of radiotherapy will be started at 11AM, 2021-04-22.
  • surgical operation
    • 2021-03-29
      • Surgery
        • PPPD with LN 5, 6, 7, 8, 9, 11p, 12, 14a & v dissection
      • Finding
        • 2 x 2.0cm tumor at uncinate process with SMV partial invasion
        • multiple LN palpable at proximal SMA to J1
        • P-duct 3mm with soft pancreas
        • C-duct 1.0cm
    • 2021-03-28
      • Surgery
        • Excision of subcut tumor 4 x 2 cm
        • and 1.5 x 1.0 cm at midline abdominal wound
      • Finding
        • two subcut hard mass at upper mdiline laparotomy wound
        • 4 cm and 1.5 cm
  • radiotherapy
    • 2021-04-29 ~ 2021-06-02) - 4500cGy/25 fractions (15MV photon) of the pancreatic tumor bed, peripheral, to regional lymphatic area.
  • chemoimmunotherapy
    • 2022-10-19 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-10-05 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-28 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-14 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-09-07 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 150mg 30min
    • 2022-08-24 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-08-17 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-08-03 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-07-20 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-07-13 - gemcitabine 800mg/m2 1200mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-06-29 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-06-23 - gemcitabine 1000mg/m2 1400mg 30min + nab-paclitaxel 100mg/m2 140mg 30min
    • 2022-02-09 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2022-01-18 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2022-01-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-12-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-12-01 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-11-16 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-11-03 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-10-15 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-09-30 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 550mg 48hr + fluorouracil 2800mg/m2 4000mg 48hr
    • 2021-09-09 - gemcitabine 1000mg/m2 1600mg 30min + oxaliplatin 85mg/m2 130mg 2hr + leucovorin 400mg/m2 600mg 48hr + fluorouracil 2800mg/m2 4300mg 48hr
    • 2021-08-24 - gemcitabine 800mg/m2 1100mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 200mg/m2 280mg 48hr + fluorouracil 2000mg/m2 2800mg 48hr
    • 2021-07-19 - gemcitabine 1000mg/m2 1400mg 30min + oxaliplatin 65mg/m2 100mg 2hr + leucovorin 240mg/m2 350mg 48hr + fluorouracil 2400mg/m2 3500mg 48hr
    • 2021-06-02 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-27 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-17 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-05-07 - gemcitabine 400mg/m2 600mg 30min (CCRT)
    • 2021-04-29 - gemcitabine 400mg/m2 700mg 30min (CCRT)

[note]

  • NCCN Pancreatic Adenocarcinoma 20210225 evidence blocks p35~36
    • neoadjuvant therapy
      • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
      • Gemcitabine + albumin-bound paclitaxel +- subsequent chemoradiation
      • Only for known BRCA1/2 or PALB2 mutations
        • FOLFIRINOX or modified FOLFIRINOX +- subsequent chemoradiation
        • Gemcitabine + cisplatin (>= 2-6 cycles) +- subsequent chemoradiation
    • adjuvant therapy
      • preferred regimens
        • Modified FOLFIRINOX (category 1)
        • Gemcitabine + capecitabine (category 1)
      • other recommended regimens
        • Gemcitabine (category 1)
        • 5-FU + leucovorin (category 1)
        • Continuous infusion 5-FU
        • Capecitabine (category 2B)
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation
        • Induction chemotherapy (gemcitabine, 5-FU + leucovorin, or continuous infusion 5-FU) followed by chemoradiation followed by subsequent chemotherapy  - Gemcitabine followed by chemoradiation followed by gemcitabine -Bolus 5-FU + leucovorin followed by chemoradiation followed by bolus 5-FU + leucovorin -Continuous infusion 5-FU followed by chemoradiation followed by continuous infusion 5-FU

==========

2022-10-28

  • According to 2022-09-09 CT (compared to 2022-05-25 CT), the disease has had a partial response to the current regimen started 2022-06-23.
  • Oxacillin (currently used) or cefalotin remain the drugs of choice for treating uncomplicated cellulitis (of left lower limb) in regions where community-acquired methicillin-resistant S. aureus is infrequent.
  • The active prescription does not pose any problems.

2022-06-15

  • 2022-05-25 CT showed several newly-developed nodes in para-aortic space and left common iliac chain that may be metastatic nodes.
  • CA199 levels time series showed the biomarker has roughly tripled in the last six months.
    • 2022-06-13 88.35 U/mL
    • 2022-05-25 78.08 U/mL
    • 2022-04-29 83.18 U/mL
    • 2022-02-23 31.33 U/mL
    • 2022-01-26 28.59 U/mL
    • 2022-01-18 29.57 U/mL

701457957

221027

{colon cancer}

  • exam findings
    • 2022-10-22 CXR
      • Tortuosity of the aorta with atherosclerotic change.
      • Increased infiltration over RLL. May be active infection.

[assessment]

  • Fasting blood sugar level is highly volatile (103 ~ 419 mg/dL). Acute infections lead to difficulty in controlling blood sugar levels and infectious diseases are more frequent and/or serious in patients with diabetes mellitus. The patient has been prescribed biosynthetic human insulin.
  • Despite improvements in renal function compared to 2022-10-24, creatinine and BUN levels remain high (creatinine 2.33 mg/dL and BUN 55 mg/dL on 2022-10-27).
  • When there is no evidence of active bleeding, the pantoprazole injection might be switched to an oral PPI.

700014137

221026

{Extranodal NK/T-cell lymphoma, nasal type, Lugano stage II, PS: 0}

  • initial presentation
    • 2022-04
      • nasal stuffness and abscess discharge.
      • fever and weight loss about 4kg in 2 months and night sweats were also noted.
  • lab data
    • 2022-08-08 CMV viral load assay 39 IU/mL
    • Anti-HBc
      • 2022-06-09 Reactive 7.68 S/CO
    • EBV DNA PCR
      • 2022-06-08 2724 copies/mL
    • HBsAg
      • 2022-06-01 Negative 0.517
    • Anti-HCV
      • 2022-06-01 Negative 0.0409
  • exam finding
    • 2022-10-06 Sinoscopy
      • bil profuse otorrhea, L mucopus
    • 2022-09-19 Sinoscopy
      • nasal ca s/p CCRT
    • 2022-09-05 Nasopharyngoscopy
      • nasal cancer s/p CCRT
      • gr4 mucositis + mucopus
    • 2022-08-22 Sinoscopy
      • bil nasal synehiae (basal) + L IT synechiae lyzed after intranasal injection + L nasal packing + post nasal septal R/T mucositis, gr 3
      • post R/T mucositis, ENT local treatment done
    • 2022-08-22 Pure Tone Audiometry, PTA
      • Tymp:
        • Bil grommet
      • PTA
        • Reliability FAIR
        • Average RE 50 dB HL; LE 56 dB HL.
        • bil mild to severe mixed type HL.
        • tinnitus(+)
    • 2022-08-19 C-spine AP + Lat.
      • Degeneration and spondylosis of C-spine.
    • 2022-08-15 Nasopharyngoscopy
      • nasal ca under CCRT
    • 2022-08-02 Nasopharyngoscopy
      • crust and bloody discharge at bil nasal internal nasal valve and bil nasal septum, covered with Surgicel, smooth OPx, HPx
    • 2022-07-31 ECG
      • Sinus tachycardia
      • Left axis deviation
      • Abnormal ECG
    • 2022-07-28 Pure Tone Audiometry, PTA
      • Tymp:
        • R’t type C; L’t type B.
      • ART:
        • Bil absent.
      • PTA
        • Reliability FAIR
        • Average RE 61 dB HL; LE 54 dB HL.
        • R’t mild to profound MHL.
        • L’t moderate to severe mixed type HL.
    • 2022-07-21 Sinoscopy
      • much mucopus
      • no visible tumor
    • 2022-07-14 Nasopharyngoscopy
      • sinonasal lymphoma undergong CCRT
    • 2022-06-16 Sinoscopy
      • remove packing + R packing with Surgicel
      • 2022/6/13 fiber = R nasal cancer, bleeing spontaneous (cancer+) again after removal of nasal packing; thus, bil Merocel packing again
      • intermittent L epistaxis noted for 2 months, went to ShuangHo Hospital and Biopsy, NK/T-cell lymphoma, nasal type was diagnosed
      • went to our hospital for CCRT
      • Left epistaxis during admission, ENT was consulted, s/p L merocel packing
    • 2022-06-16 SONO - abdomen
      • Diagnosis
        • Fatty liver, moderate
        • Pancreas not shown
        • Suboptimal examination of liver due to poor echo window caused by severe fatty infiltration
      • Suggestion
        • OPD f/u
        • Follow liver function test and AFP
        • Some area of liver, especially liver dome and S1 was diffcult to approach and easy missed
        • Because of poor echo window, infiltrative lesion or small lesion may not be excluded completely. Please correlate with other image or follow sono abd every 3-6 months.
    • 2022-06-15 Nerve Conduction Velocity (NCV), Electromyography (EMG)
      • Findings
        • The ENoG study showed a facial CMAP amplitude ratio as 73% (right/left) and prolonged distal latency in bilateral facial nerves.
        • The results of blink reflex study were within normal limits.
      • Conclusion
        • The above findings may suggest bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern. Advise clinical correlation.
    • 2022-06-13 Nasopharyngoscopy
      • smooth NPx, OPx, HPx
    • 2022-06-01 CT - lung/mediastinum/pleura
      • no abnormality in the chest and upper abdomen.
    • 2022-05-30 MRI - larynx
      • Findings
        • Extensive soft tissue tumor with T1-hypointensity, T2-hyperintensity and vivid enhancement involving nasopharynx, soft palate, bilateral nasal cavities, bilateral ethmoid and sphenoid sinsues, right maxillary sinus wall, clivus and adjacent sphenoid bones.
        • No enlarged lymph node.
        • No abnormality at hypopharynx and larynx.
        • Diffuse mottled T2-hyperintensity filling in bilateral mastoid air cells, indicating amstoiditis.
        • No abnormality at parotid, submandibular and sublingual glands.
      • IMP:
        • Nasal-nasopharyngeal tumor with aforementioned involvement. D/D: lymphoma, NPC.
    • 2022-05-30 2D transthoracic echocardiography
      • Normal AV/MV with no AR/MR
      • Mild concentric LVH, normal LV wall motion
      • Preserved LV and RV systolic function
      • No PR, trivial TR, normal IVC size
    • 2022-05-30 EKG
      • Left axis deviation
    • 2022-05-28 CXR
      • Chest PA and Lat. LT view: Widening of the right upper mediastinum is suspected. Please correlate with CT.
    • 2022-05-17 PET scan (at ShuangHo Hospital)
      • c/w lymphoma involving a NP, nasal cavity, ethmoid sinus, soft palate.
    • 2022-05-03 Surgical pathology - nasal tumor biopsy (at ShuangHo Hospital)
      • extranodal NK/T-cell lymphoma, nasal type.
    • 2018-02-21 Blink Reflex Studies
      • The ENoG study showed facial CMAP amplitude ratio as 74 % (right/left). The blinking reflex study showed relatively prolonged ipsilateral R1 and R2 latency when right side stimulation and relatively prolonged contralateral R2 latency when left side stimulation. These findings may suggest right facial nerve lesion.
  • radiotherapy
    • 2022-06-22 ~ 2022-08-08 - 2000cGy/10 fractions of the nasal - nasopharyngeal, peripheral involved to bilateral neck nodal, and 5000cGy/25 fractions of the reduced nasal - nasopharyngeal, peripheral involved area.
  • chemoimmunotherapy
    • 2022-09-20 - carboplatin AUC 4 200mg/m2 300mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 1000mg/m2 1700mg 4hr D1-3
    • 2022-08-29 - carboplatin AUC 2 150mg/m2 260mg 2hr D1 + etoposide 67mg/m2 110mg 1hr D1-3 + ifosfamide 900mg/m2 1500mg 4hr D1-3 (full dose: carboplatin 200mg/m2, etoposide 67mg/m2, ifosfamide 1000mg/m2)
    • 2022-07-21 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
    • 2022-06-08 - carboplatin AUC 2 150mg/m2 270mg 2hr D1 + etoposide 67mg/m2 120mg 2hr D1-3 + ifosfamide 900mg/m2 1600mg 4hr D1-3
  • G-CSF
    • 2022-09-06 Granocyte (lenograstim) 250mg QD SC OPD 2022-09-06
    • 2022-08-03 Granocyte (lenograstim) 250mg QD SC IPD 2022-07-31

==========

2022-10-26

  • Swelling around the eyes might be caused by inflammation resulting from a variety of conditions, including infection, injury, and allergies. If this is the case, some eye drops containing steroid/antihistamine and/or antimicrobial might be beneficial.

2022-08-30

  • Pure-tone audiometry 2022-08-22 RE 50 dB HL LE 56 dB HL <- 2022-07-28 RE 61 dB HL LE 54 dB HL. There is no evidence of rapid deterioration in hearing.
  • Tamsulosin has been prescribed. Please make sure that any possible obstruction to the urinary tract has been eliminated or corrected before beginning treatment with ifosfamide.

2022-07-22

  • 2022-06-15 electromyography suggested bilateral peripheral facial nerve lesion, more severe in the right side, with demyelinating pattern.
  • The neurology related adverse reaction incidences of the drugs in current regimen:
    • carboplatin - Nervous system: Neurotoxicity (5%), peripheral neuropathy (4% to 6%)
    • etoposide - Peripheral neuropathy (1% to 2%)
    • ifosfamide - Central nervous system: Brain disease (<=15%), central nervous system toxicity (<=15%)
  • Please monitor for newly developed neuropathy as usual.

2022-06-09

  • There is no re-biopsy performed at our facility, in addition to our imaging studies and pathology results from ShuangHo Hospital.
  • An EBV positive result (lab 2022-06-08 EBV DNA PCR 2724 copies/mL) is consistent with NK/T-cell, nasal type. EBV-associated T- and NK-cell lymphoproliferative disorders (LPD), including chronic active EBV infection (CAEBV), can progress to aggressive NK-cell leukemia (ANKL).
  • For extranodal NK/T-cell lymphomas, suggested treatment regimens can be (ref https://www.cancertherapyadvisor.com/wp-content/uploads/sites/12/2018/12/nhl-extranodalnk_0318_9414.pdf )
    • combination chemotherapy regimen (asparaginase-based)
      • Modified SMILE (steroid [dexamethasone], methotrexate, ifosfamide, pegaspargase, and etoposide) x 4-6 cycles for advanced stage
      • P-GEMOX (gemcitabine, pegaspargase, and oxaliplatin)
      • DDGP (dexamethasone, cisplatin, gemcitabine, pegaspargase)
    • combined modality therapy
      • concurrent chemoradiation therapy: RT and 3 courses of DeVIC (dexamethasone, etoposide, ifosfamide, and carboplatin) <= currently applied.
      • sequential chemoradiation: For stage I, II, modified SMILE x 2-4 cycles followed by RT
      • sandwich chemoradiation: P-GEMOX x 2 cycles followed by RT followed by P-GEMOX x 2-4 cycles
  • CCRT using DeVIC is currently being applied during this hospital stay.
  • Lab results 2022-06-08 indicated liver and kidney function, CBC, WBC DC, electrolytes were grossly normal. TPR, PB is relatively stable.
  • There is a self-carried drug - amoxicillin 500mg PO Q8H - listed in active prescription for the apical infection of tooth 26 and its complicated extraction.

701049370

221025

  • diagnosis 20221003 discharge
    • B cell lymphoma, high grade, stage IV
    • Splenomegaly, not elsewhere classified
  • exam findings
    • 2022-09-30 CXR
      • Fibrosis of left upper lung are suspected. Please correlate with clinical history to R/O old inflammatory process.
    • 2022-09-19 Whole body PET scan
      • Glucose hypermetabolism lesions in bilateral cervical, bilateral axillary, celiac chain, bilateral para-aortic space, and pre-vertebral lymph nodes of lower T-spine, and spleen, highly suspected lymphoma with involvement of lymph node regions on both sides of the diaphragm.
      • Glucose hypermetabolism lesions in T9-11 spines, highly suspected lymphoma with involvement of bones and/or bone marrow.
      • Increased FDG uptake in bilateral pulmonary hilar and bilateral mediastinal lymph nodes, probably reactive nodes (priority) or lymphoma with involvement of lymph node regions, suggesting further investigation.
      • B cell lymphoma, c-stage IV (AJCC 8th ed.), by this F-18 FDG PET scan.
    • 2022-09-20 CXR
      • Interstitial pattern at LUL.
    • 2022-09-15 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Atypical lymphoid aggregates, favor reactive
      • The sections show normocellular marrow (30%). The myeloid series show good maturation. The megakaryocytes are normal in number and morphology. Scattered interstitial, mixed small and large lymphoid cell aggregates are present.
      • IHC, a mixture of CD3+ T and CD20+ B lymphocytes haphazardly arranged with slightly B cell predominant are noted. The B cells also show: BCL6(focal +), CD10(-), and CD23(-). The findings favor reactive lymphoid aggregates. Suggest bone marrow smear evaluation and clinic correlation.
    • 2022-09-01 Patho - fibrolipoma
      • Labeled as “right neck”, excisional biopsy — B cell lymphoma, high grade.
      • Section shows lymph nodes with architecture obscured by large blasts like neoplastic lymphoid cells (more than 15/HPFs) and scattered centrocytes like cells.
      • IHC stains: CK (-), CD3 (focal+), CD20 (diffuse +), CD10 (+), bcl-2 (+), bcl-6 (+), MUM-1 (focal +, 10%), Ki-67: 60%, cyclin-D1: (equivocal), c-myc (-). Vague lymphoid follicles are highlighted by IHC stains. The pattern is suggestive of follicular lymphoma, grade 3A.
    • 2022-09-01 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T10-12.
      • Portal hypertension and splenomegaly.
      • Some LNs (up to 2.0cm) at retroperitoneum.
    • 2022-03-24 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T10-12.
      • Increased soft tissue at left pubic cavity.
      • Portal hypertension and splenomegaly.
    • 2021-12-21 Patho - soft tissue nontumor/mass/lipoma/degridement
      • Soft tissue mass, left pelvic cavity, CT-guide biopsy — Suggestive of benign, reactive change
      • Microscopically, the sections show a picture of almost small to medium-sized lymphocytes infiltration with monocytoid feature.
      • Immunohistochemistry shows CK(-), CD3, CD5 and CD43 (+, diffuse), CD20(+, diffuse), CD10(+) for follicle, Bcl-2(-) for follicle, CD23(-) and Cyclin-D1(-). According to all histopathologic findings, it is suggestive of reavtive hyperplasia and less likely lymphoma. However, repeat biopsy or excision is advised for further evaluation, if malignancy is still suspected clinically.
    • 2021-12-13 CT - abdomen
      • Thickening of right posterior pleura and prevertebral tissue at T9-12.
      • Increased soft tissue at left pubic cavity.
      • Portal hypertension and splenomegaly.
    • 2021-12-07 SONO - abdomen
      • Splenmegaly, marked
  • chemoimmunotherapy
    • 2022-10-24 - rituximab 375mg/m2 600mg 8hr + cyclophosphamide 750mg/m2 1200mg 30min + doxorubicin 50mg/m2 50mg 30min + vincristine 1.4mg/m2 2mg 10min + prednisolone 60mg/m2 5mg/tab 18# 90mg QD D1-5
    • 2022-09-30 - rituximab 375mg/m2 600mg 8hr + prednisolone 60mg/m2 5mg/tab 8# 40mg BID D1-5

[assessment]

  • There is evidence of splenomegaly, portal hypertension, and high bilirubin levels (direct and total), but the cause is not yet known.
  • Interstitial pattern and/or fibrosis at LUL has been observed. Rituximab has been associated with pulmonary disease and/or pulmonary toxicity. It might be necessary to monitor the lung status on a regular basis.
  • As far as the current prescription is concerned, there is no problem.

700141460

221024

  • chemoimmunotherapy
    • 2022-09-14 - irinotecan 150mg/m2 230mg 90min + leucovorin 400mg/m2 600mg 2hr + fluorouracil 2400mg 3600mg 46hr

[assessment]

  • Coxine (isosorbide-5-mononitrate) has been prescribed for the patient’s high hs-Troponin I (241.8 pg/mL 2022-10-22) and CKMB (9.7 ng/mL 2022-10-22).
  • The most recent record of blood pressure was 100/52 (2022-10-24 08:41). The perfusion of vital organs, including the coronary arteries, might be compromised by low blood pressure. Saline 0.9% 500mL IVD PRNQD has been prescribed.
  • There is an impairment of renal function in the patient. Hemodialysis will be arranged by a nephrologist.
  • Currently, the serum potassium level is within the normal range (3.5 mmol/L 2022-10-22)
  • The blood calcium concentration of this patient is frequently below normal. The addition of some phosphate binders may be beneficial. Phosphate binders are categorized as calcium-containing and noncalcium-containing. Calcium-containing binders include calcium carbonate and calcium acetate. Major noncalcium-containing binders include sevelamer and lanthanum. Other agents include ferric citrate and sucroferric oxyhydroxide.

700511404

221024

  • past history (2022-10-22 adminnote)
    • DM
    • Hypertension
    • Left breast cancer s/p OP
    • GERD
    • Constipation
    • Hyperthyroidism
    • Breast cancer s/p C/T (bil leg numbness)
    • Multiple myeloma IgA kappa + lambda biclonce /p Ixazomib since 2022/7-2022/8 and lenalidomide 1# QOD and dexamethasone since 2022/7 to now.
  • exam findings
    • 2022-12-02 CT - brain
      • A skull defect at left temporal region. Some lucent lesions in skull.
      • Brain atrophy and lacunar infarct.
    • 2022-11-03 Myocardial perfusion SPECT with persantin
      • Probably mild myocardial ischemia at the apex.
      • Mild reverse redistribution of radioactivity to the anteroapical wall and posterior wall, either normal variant or myocardial ischemia may show this picture.
    • 2022-11-03 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (124 - 49) / 124 = 60.48%
        • M-mode (Teichholz) = 60
      • Adequate LV systolic function with normal resting wall motion
      • Trivial MR, mild AR, mild TR
      • Mild pulmonary hypertension
      • LV diastolic dysfunction, Gr 1
      • Preserved RV systolic function
      • Sinus rhythm at the exam
    • 2022-10-25 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — myeloma.
      • IHC stains: CD138: 60%; Kappa and Lambda light chains show a predominant lambda sub-population. CD34: <1 %; MPO: 30-40% (of the nucleated cells).
      • Section shows piece(s) of bone marrow with 40 % cellularity and M:E ratio of approximately 3:1. Three cell lineages are present with normal maturation of leukocytes and increase in the number of plasmacytoid cells. Megakaryocytes are adequate in number.
    • 2022-10-24 Abdomen
      • Spondylosis of the L-spine is noted.
      • Compression fracture of T12, L2, L4, and L5 are suspected.
    • 2022-10-22 CXR
      • Cardiomegaly and tortuosity of the thoracic aorta.
      • Widening of the mediastinum.
      • Engorgement of bilateral hilar regions with increased interstitial lines of both lungs.
      • Degenerative joint disease of T-spine with marginal osteophytes.
    • 2022-03-08 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Multiple myeloma
      • Microscopically, the bone marrow shows multiple myeloma characterized by hypercellularity (90%), 2:3 of M:E ratio and a proliferation of plasma cells (11~20%).
      • Immunohistocehmical stain reveals CD20(+, 15%), CD138(>10%), Kappa(-), Lambda(+), MPO(+), CD34(-), CD117(-) and CD71(+).
    • 2021-12-09 Gynecologic ultrasonography
      • Bilateral adnexae: free
      • EM: 8.3mm.
    • 2021-03-05 Patho - bone marrow biopsy
      • Bone marrow, biopsy — <2% of CD138+ cells
      • Microscopically, it shows 30% of cellularity, 1:1 of M:E ratio, occasional normal megakaryocytes and <2% of CD138+ cells.
      • Immunohistochemical stain reveals CD138(<2%), CD71(+), MPO(+), CD117(-), CD34(-), CD20 (2~3%).
    • 2021-01-25 ENT Hearing Test
      • Reliabilty Fair
      • PTA
        • R’t : 58 dB HL
        • L’t : 50 dB HL
        • Bil mild to moderately severe SNHL
      • Tymp
        • R’t : Type As
        • L’t : Type C
      • ART
        • Bil absent.
    • 2020-10-20 ENT Hearing Test
      • Tymp bil type As
      • ART bil contra and RE ipsi absent, LE ipsi reduced thretholds
      • E- tube function bil poor
      • PTA:
        • Reliability FAIR
        • Average RE 60 dB HL, LE 50 dB HL
          • RE mild to severe SNHL
          • LE mild to moderately severe SNHL
      • RE tinnirus
    • 2020-10-20 OVEMP
      • oVEMP (ocular vestibular-evoked myogenic potential)
        • Bil show no response
      • cVEMP (cervical VEMP)
        • Bil show no response
    • 2020-10-20 Electronystagmography, ENG
      • no abnormal nystagmus
    • 2020-09-28 C-spine Lat. flex. and ext.
      • Osteoporosis. Spondylosis, esp C5-6-7.
    • 2020-08-28 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Compatible with plasma cell myeloma with partial remission
      • The sections show normocellular marrow (20%). M/E ratio = 3:1. The myeloid cells show good maturation. The megakaryocytes are normal in number and morphology.
      • IHC, scattered CD138+ plasma cells in interstitium, account for <5% of marrow cells with lambda light chain restriction and negative for kappa light chain. Suggest further bone marrow smear evaluation and clinic correlation.
    • 2020-04-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (112 - 44.1) / 112 = 60.63%
        • M-mode (Teichholz) = 60.6
      • Adequate LV systolic function with no regional wall motion abnormality at resting state
      • Mild aortic, mitral and tricuspid regurgitation
      • Dilated LA, thick IVS and LVPW
      • Impaired LV relaxation
    • 2020-04-09 Long bones series
      • Few osteopenic defects at bilateral radius, bilateral humerus, bilateral femur, bilateral fibular and bilateral scapular are suspected.
    • 2020-04-07 Patho - bone marrow biopsy
      • Bone marrow, iliac, biopsy — Myeloma.
      • IHC stains: CD138 (+, 85-90% of the nucleated cells), kappa (+, 80-90%), lambda (<5%), MPO (<5%), CD117 (<1%)
      • Section shows one piece of bone marrow with 40-50% cellularity and a predominant plasmacytoid cells.
    • 2020-04-06 Patho - bone exostosis
      • Soft tissue and bone, L5 body and right upper sacrum, CT-guided biopsy — Plasma cell neoplasm, compatible with plasma cell myeloma
      • The sections show plasma cell neoplasm, composed of diffuse sheets of neoplastic round cells with abundant basophilic cytoplasm and eccentric nuclei. Occasional intranuclear inclusions (Dutcher body) can be found.
      • IHC, the neoplastioc cells reveal: CD138(+), cytokeration(-), lambda light chain(+), and kappa light chain(-). Suggest clinic correlation.
    • 2020-04-01 SONO - nephrology
      • right adrenal tumor, nature to be determined
    • 2020-03-31 MRI - L-spine
      • Small L4/5 central HIVD.
      • L2 compression fracture.
      • Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
    • 2019-06-05 Color Transcranial Sonographic, CPA (carotid phonoangiograph)
      • Mild atheromatous lesions in bilateral ICAs and carotid bifurcations.
      • Normal extracranial carotid, vertebral arterial flows.
      • Poor bilateral temporal windows for transcranial insonation.
      • Normal other intracranial and bilateral ophthalmic arterial flows.
  • consultation
    • 2020-04-10 Rehabiliation
      • Q
        • Being unable to sit up in bed
      • A
        • Assessment
          • Multiple myeloma
          • Anemia
          • Hypercalcemia, improved
          • Hypertension
          • Diabetic mellitus (2020/3/13 HbA1c 6.6%)
        • Plans
          • Please treat the myeloma and related back pain as your expertise
          • Keep back brace use except when lying down
          • Rehabilitation programs: Bedside PT rehabilitation programs
            • Goal: better sitting/standing balance, ambulate with device under support
    • 2020-04-10 Radiation Oncology
      • A
        • A: Multiple myeloma with L spine and sacrum involvement.
        • P: Radiotherapy is indicated for this patient with the following indicators: Multiple myeloma with low back pain.
          • Goal: palliation.
          • Treatment target and volume: L2~L5 and sacrum.
          • Technique: IMRT
          • Preliminary planning dose: 2800cGy/14 fractions.
    • 2020-03-31 Hemato-Oncology
      • Q
        • For MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases
        • This 73-year-old female with a past history of 1) DM 2) Hypertension 3) Left breast cancer s/p OP 4) Constipation, she had dizziness for half years, under regular Neuro OPD follow up. She was admitted due to severe low back pain, L-MRI showed Mass or nodule in anterior L5 body and right upper sacrum, suspected multiple myeloma, metastases. We need your help for further management, thanks a lot.
      • A
        • This is a case of hypercalcemia. Mass over anterior L5 vertebral body was noted. MRI sifggested D/D of myeloma and metastasis.
        • Suggest check immunoglobulin profile (IgG, A, M, kappa/lambda light chain), tumor marker screening (CEA, CA199, CA153, CA125). We’ll follow up this case, if there is abnormal immunoglobulin profile, we’ll make diagnostic BM biopsy; otherwise, do tumor survey according tumor markers and do tumor mass mass biopsy is suggested.
    • 2020-03-31 Orthopedics
      • Q
        • for severe low back pain
      • A
        • consult for low back pain radiation to bilateral buttock and lower leg, weakness and paresthesia,unable to bear weight
        • Xray showed bil SI joint OAand decreased disc space and foramen of L5-S1 level
          • suggest pain control (Arcoxia 1# QD or even Dynastat Q12H x 3 days if severe pain + Mefno 1# QD + Neurontin 1# QD)
          • suggest L-spine MRI for further evaluation
          • contact me afteer MRI was done
    • 2020-03-24 Orthopedics
      • Q
        • Due to right lower back pain was noted for days, she also mentioned she was her CVA husband main care giver, we would like to need your visit to rule out orthologic disease. Thank you very much!
      • A
        • S: low back pain, radiation to bil buttock and thigh
        • O: tenderness. knocking pain+, muscle spasm, SLRT-X: L5-S1 narrow, bil SI arthritis
        • A: lumbar spondylosis, L5-S1 narrow, degeneration
        • P: Arcoxia 1# QD, Traumacet 1# bid, Neurontin 1# HS, use waist support
  • chemoimmunotherapy
    • 2022-04-21 ~ 2022-09-01 - Ninlaro (ixazomib) 3mg QWAC
    • 2022-04-14 ~ 2022-11-25 - Revlimid (lenalidomide) 25mg QOD
    • 2022-01-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2022-01-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-12-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-12-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-11-04 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-10-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-17 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-09-09 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-08-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-08-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-05-07 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-23 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-04-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-12 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-03-05 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-02-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-02-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-01-15 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2021-01-08 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-13 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-11-06 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-30 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-16 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-10-02 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-25 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-18 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-09-11 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-07-10 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-07-03 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-06-26 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-06-19 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-27 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-20 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-28 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-21 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-04-14 - Velcade (bortezomib) 1.3mg/m2 2mg SC
    • 2020-05-13 ~ 2022-04-14 - Thado (thalidomide) 100mg QN
    • 2020-07-03 ~ on and off - Xgeva (denosumab) 120mg Q1M SC

[assessment]

  • As the patient’s serum calcium levels have dropped into the normal range, it may be appropriate to hold or discontinue Miacalcic (calcitonin) if no other considerations exist.
    • 2022-12-05 Ca (Calcium) 2.39 mmol/L
    • 2022-12-04 Ca (Calcium) 2.74 mmol/L
    • 2022-12-03 Ca (Calcium) 3.25 mmol/L
    • 2022-12-02 Ca (Calcium) 3.25 mmol/L
  • For it has been observed that multiple data points of blood sugar levels exceeding 200 mg/dL since this hospitalization under current metformin treatment, the initialization of basal insulin is recommended.

701120825

221024

  • exam finding
    • 2022-10-21 ECG
      • Sinus tachycardia
      • Right atrial enlargement
      • Rightward axis
      • Possible Anterior infarct, age undetermined
      • Abnormal ECG
    • 2022-10-21 Nasopharyngoscopy
      • Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
    • 2017-10-05 Whole body PET scan
      • Glucose hypermetabolism in a focal area in the left lower neck about level IV. A metastatic lymph node may show this picture.
      • Asymmetric FDG uptake in bilateral tonsils with a little more FDG uptake in the right tonsil. The nature is to be determined (inflammatory process? other nature?). Please correlate with other clinical findings for further evaluation.
      • Mild glucose hypermetabolism in bilateral pulmonary hilar regions, bilateral shoulders and right hip. Inflammatory process may show this picture.
    • 2017-07-17 MRI - larynx
      • A nodule or LN with central necrosis in left lower neck, level IV.
    • 2017-02-22 CT - neck, hypopharynx
      • several small lymph nodes in the right parotid space
    • 2016-04-23 CT
      • Post LNs dissection with soft tissue or muscle defect, right.
      • Small left neck LNs.
      • No obvious nasopharynx, oropharynx, hypopharynx or larynx mass..
      • No obvious abnormal enhancement after contrast medium administration.
    • 2015-04-23 pathology
      • Tonsil, right, biopsy — Negative for malignancy.
      • Lymph node, neck level I, right, neck dissection — Negative for malignancy (0/2).
      • Salivary gland, submandibular, right, neck dissection — Negative for malignancy.
      • Lymph node, neck level II, right, lymphadenectomy with frozen section — Presence of metastatic carcinoma, in favor of non-keratinizing sqaumous cell carcinoma, with extranodal extension(1/1).
      • Lymph node, neck level II, III and IV, right, neck dissection — Negative for malignancy( 0/10).
      • Tissue labelled as “internal jugular vein”, right, neck dissection — Negative for malignancy.
      • Soft tissue, sternocleidomastoid muscle, right, neck dissection — Negative for malignancy.
  • consultation
    • 2022-10-22 Family Medicine
      • Q
        • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey Hospital for supportive care. Deu to dyspnea, so she sent to our ED. Family favor hospice. We need your help. Thanks!
      • A
        • Dyspnea.
        • NOW with UFT 1# BID
        • Our share care would follow up.
    • 2022-10-21 ENT
      • Q
        • The 64 y/o woman has head and neck non-keratinizing sqaumous cell carcinoma, with extranodal extension, regular at Mackey for supportive care. Due to suspect air obstruction, we need your help for management.
      • A
        • Oral cavity: trismus with <1 FB.
        • Neck: stiffness, previous OP wound over right neck, an about 3cm tumor over rigt post-auricular region.
        • Scope: Tumor involving soft palate, bilateral palatine tonsil, tongue base, epiglottis, supraglottic region and nasopharyngeal roof. Bilateral vocal fold immobility with airway narrowing.
        • Impression: Head and neck malignancy with diffuse involvement.
        • Plan: Since the patient has signed DNR consent, palliative therapy is suggested for the patient.
  • surgical operation
    • 2015-04-23
      • Surgery
        • Radical neck dissection, right
        • Tumor mapping with right tonsil biopsy
      • Finding
        • Hypertrophy of lower pole of right tonsil, s/p biopsy.
        • 4x4cm capsulized tumor at right neck level II, severe adhesion to surrounding muscle and vessel, ruptured intra-operatively and some serous flowed out, which was sent for culture. The tumor was sent for frozen section. Frozen section = suspected squamous cell carcinoma
        • Lymphoareolar tissue at right level I, II, III, III as well as internal jugular vein, SCM were dissected out and removed. Spinal accessory nerve was preserved.

[assessment]

  • 2022-10-21 serum creatinine 0.39 mg/dL, eGFR 175, serum glucose 127 mg/dL. Glomerular hyperfiltration promoted by hyperglycemia? Muscle loss?
  • Celebrex (celecoxib) should be limited as short as necessary to prevent possible renal injury.

701370027

221024

[assessment]

  • eGFR was around 15 ~ 20 over the past half year (2022-04 ~ 2022-10), and the medication dosage has been adjusted accordingly.
  • There is no restriction on the use of nasogastric tubes in the administration of oral medications included in the active prescription.

700269001

221021

  • lab data
    • UGT1A1 6/7
    • Bilirubin total
      • 2022-07-14 Bilirubin total 0.70 mg/dL
      • 2022-06-16 Bilirubin total 1.30 mg/dL
      • 2022-04-21 Bilirubin total 0.60 mg/dL
      • 2022-04-07 Bilirubin total 0.98 mg/dL
      • 2022-03-31 Bilirubin total 0.98 mg/dL
      • 2022-03-22 Bilirubin total 1.18 mg/dL
      • 2022-03-09 Bilirubin total 2.15 mg/dL
      • 2022-02-24 Bilirubin total 1.44 mg/dL
      • 2022-02-09 Bilirubin total 1.22 mg/dL
      • 2022-01-26 Bilirubin total 1.27 mg/dL
      • 2021-12-30 Bilirubin total 0.98 mg/dL
      • 2021-12-25 Bilirubin total 0.78 mg/dL
  • exam finding
    • 2022-08-29 CT - abdomen, pelvis
      • Rectal cancer s/p operation. Minimal ascites in pelvic cavity.
    • 2022-07-15 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average RE 18 dB HL, LE 21 dB HL
      • bil normal to moderate SNHL
    • 2022-07-08 Pure Tone Audiometry, PTA
      • Reliability FAIR
      • Average R’t 13 dB HL, L’t 31 dB HL
      • R’t normal to mild SNHL.
      • L’t normal to moderately severe SNHL.
      • Tymp: Bil type A.
      • ART: R’t WNL.
      • L’t 500 Hz reduced thresholds.
    • 2022-07-01 Pure Tone Audiometry, PTA
      • Reliabilty Fair
      • R’t: 19 dB HL, WNL except 8k Hz
      • L’t: 45 dB HL, mild to moderately severe SNHL.
    • 2022-06-23 Hearing Test
      • Reliabilty Fair
      • PTA - Pure Tone Audiometry
        • R’t: 18 dB HL, normal to moderate SNHL
        • L’t: 46 dB HL, normal to moderately severe SNHL
      • Tymp - Tympanogram
        • Bil Type A
      • ART - Acoustic reflex threshold
        • R’t: Ipsi absent
        • L’t: Ipsi 500-1k Hz reduced, contra absent.
    • 2022-05-23 Patho - colon segmental resection for tumor
      • pathologic diagnosis
          1. Tumor, lower rectum, Robotic Abdominal Perineal Resection — Residual intramucosal adenocarcinoma
          1. Resection margins, ditto — Free of tumor
          1. Lymph nodes, mesocolic, dissection — Free of tumor metastasis (0/8)
          1. AJCC pathologic stage — ypTisN0, stage 0, if cM0
      • macroscopic examination
        • Tumor appearance: elevated mucosa
        • Depth of invasion grossly: lamina propria
      • microscopic examination
          1. Histology: residual intramucosal adenocarcinoma
          1. Histology Grade: G1, well differentiated
          1. Depth of invasion: lamina propria
          1. Angiolymphatic invasion: not identified
          1. Perineural invasion: not identified
          1. Discontinuous extramural tumor extension: absent
          1. Circumferential (radial) margin of rectosigmoid: Not involved
          1. Lymph node metastasis, mesocolic: free of tumor metastasis (0/8)
          1. Lymph node metastasis, IMA / SMA: N/A
          1. Extranodal involvement: N/A
          1. Pathological TNM Stage: ypTisN0
          1. Type of polyp in which invasive carcinoma arose: N/A
          1. TNM descriptors: y
          1. Tumor regression grading S/P CCRT: grade 2 (rare residual cancer)
    • 2022-05-23 SONO - abdomen
      • Liver calcification nodules (incomplete exam of liver)
    • 2022-05-19 ECG
      • Normal sinus rhythm
      • RSR or QR pattern in V1 suggests right ventricular conduction delay
      • Borderline ECG
    • 2022-04-07 CT - abdomen, pelvis
      • History and indication:
        • Rectal cancer s/p CCRT suspected low rectal cancer at anterior; 1.5*1.5 cm with ulceration and bleeding at 3 cm from AV
      • IMP:
        • Mild regression of rectal cancer.
    • 2022-04-07 Colonoscopy
      • Findings
        • The scope reach the S-colon.
        • Rectal cancer s/p CCRT with tumor regression at anterior wall, 4cm from AV
      • Diagnosis
        • Rectal cancer s/p CCRT with tumor regression
    • 2022-03-24 Cardiac Catheterization
      • Type of arrhythmia
        • WPW
      • Ablation Diagnosis
        • Intermittent Wolff-Parkinson-White syndrome (iWPW), s/p successful cryoablation of para-Hisian accessory pathway through non-coronary cusp (NCC) approach
    • 2022-03-14 SONO - abdomen
      • suspected liver parenchymal disease, mild fatty liver
      • liver calcification nodules
    • 2022-02-17 ECG
      • Sinus rhythm with frequent Premature ventricular complexes in a pattern of bigeminy
      • Fusion complexes
    • 2022-01-28 Cardiopulmonary Exercise Testing
      • summary:
        • maximal exercise
        • normal exercise capacity ( VO2 99%, WR 118%)
        • normal stroke volume response during exercise
        • normal ventilatory function ( FVC 127%, FEV1 118%)
        • normal respiratory muscle strength (MIP 75%, MEP 89%)
      • suggestions:
        • treat underlying condition
        • survey and treat cardiac function, refer to CV for EKG with ST-T changes
        • arrange pulmonary rehab with exercise training
    • 2022-01-12 CXR
      • A calcified spot at RUQ.
    • 2021-12-28 Patho - colon biopsy
      • Colon, dentate line to 8 cm AAV at anterior wall, biopsy — Adenocarcinoma.
      • IHC stains: EGFR (+); PMS2 (+), MSH6 (+), MSH2(+), MLH1 (+).
      • Section shows pieces of colonic tissue with invasive irregular neoplastic glands.
    • 2021-12-28 Colonoscopy
      • Diagnosis
        • Highly suspected rectal cancer, 1/4 circumference, from dentate line to 8 cm AAV at anterior wall, s/p biopsy
      • Suggestion
        • F/U pathology report
      • Complication
        • No immediate complication
    • 2021-12-27 CT - abdomen, pelvis
      • Imaging Report Form for Colorectal Carcinoma
      • Impression (Imaging stage): T3N0M0, stage IIA
  • consultation
    • 2022-01-18 Psychosomatic Medicine
      • Q
        • This 57-year-old woman patient is a case of low rectal cancer arising from dentate line with broad-based villous tumor up to 8 cm from AV cT3N0M0; stage II. She was admitted for concurrent chemoradiotherapy. For evaluate anxiety with insomnia therapy. Thank you.
      • A
        • Psychiatric impression:
          • depression and anxiety
          • suspected adjustment reaction with anxiety and depression
        • Psychiatric history:
          • This 57-year-old woman patient is a case of low rectal cancer cT3N0M0; stage II was diagnosed in December 2021. This time she was admitted for concurrent chemoradiotherapy. We were consulted due to anxiety and insomnia were noted.
          • According to the patient, she suffered from low mood, anxiety and worry about the cancer treatement (enteroproctia, artificial anus). surgical treatment, fearfulness, anticipatory anxiety, negative thought, free floating anxiety, poor appetite and poor sleeplasting (1-2 hour), suicide ideation before.
          • MSE: coherent and relevent speech, fair spontaneous speech, anxiety and low mood, negative thinking, worrisome, denied panic like attack.
        • Suggestion:
          • emotional support and empthy
          • may give Mirtapine (mirtazapine) 0.5# HS and alprazolam 0.5# prn if anxiety
          • arrange psychiatric OPD (patient request W1 evening OPD)
  • radiotherapy
    • 2022-01-10 ~ 2022-02-23 - Concurrent radiotherapy 4500cGy/25 fractions of the pelvic and 5040cGy/28 fractions of the rectal tumor bed area.
  • chemoimmunotherapy
    • 2022-10-20 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-09-30 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-09-07 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-08-26 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-08-12 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-29 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-15 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr
    • 2022-07-01 - oxaliplatin 65mg/m2 100mg 2hr + leucovorin 300mg/m2 450mg 2hr + 2400mg/m2 3500mg 46hr (oral mucostatis with ulcer with pain for 2 weeks, upper and lower limbs numbness in 2022-06)   
    • 2022-04-11 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
    • 2022-03-09 - oxaliplatin 85mg/m2 120mg 2hr + leucovorin 400mg/m2 600mg 2hr + fluorouracil 400mg/m2 600mg 10min + 2400mg/m2 3600mg 46hr
    • 2022-02-14 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT
    • 2022-02-09 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
    • 2022-01-17 - Leucovorin 20mg/m2 10min D1~3 + 5-FU 400mg/m2 10min D1~3; CCRT
    • 2022-01-13 - Leucovorin 20mg/m2 10min D1~2 + 5-FU 400mg/m2 10min D1~2; CCRT

[note]

  • All You Need to Know About UGT1A1 Genetic Testing for Patients Treated With Irinotecan: A Practitioner-Friendly Guide ( https://ascopubs.org/doi/full/10.1200/OP.21.00624 )
    • Irinotecan is an anticancer agent widely used for the treatment of solid tumors, including colorectal and pancreatic cancers. Severe neutropenia and diarrhea are common dose-limiting toxicities of irinotecan-based therapy, and UGT1A1 polymorphisms are one of the major risk factors of these toxicities.
    • In 2005, the US Food and Drug Administration revised the drug label to indicate that patients with UGT1A128 homozygous genotype should receive a decreased dose of irinotecan. However, UGT1A128 testing is not routinely used in the clinic, and specific reasons include lack of access to concise information on this wide issue as well as mixed recommendations by regulatory and professional entities.
    • To assist oncologists in assessing whether and when to use UGT1A1 genetic testing in patients receiving irinotecan-based therapies, this article provided (1) essential knowledge of UGT1A1 polymorphisms; (2) an update on the impact of UGT1A1 polymorphisms on efficacy and toxicity of contemporary irinotecan-based regimens; (3) dosing adjustments based upon the UGT1A1 genotypes, and (4) recommendations from currently available guidelines from the US and international scientific consortia and major oncology societies.

[assessment]

  • FOLFOX regimen has been modified by lowering oxaliplatin dose (65mg/m2 <- 85mg/m2) and skipping fluorouracil bolus since July 2022 due to mucositis and limb numbness observed in June 2022.
  • Oral mucositis is appropriately treated with Nincort Oral Gel (triamcinolone) currently.
  • Duloxetine is recommended for the mitigation of chemotherapy-induced peripheral neuropathy (ref: Prevention and Management of Chemotherapy-Induced Peripheral Neuropathy in Survivors of Adult Cancers: ASCO Guideline Update. Journal of Clinical Oncology 2020 38:28, 3325-3348)
  • Duloxetine for chemotherapy-induced peripheral neuropathy (off-label use): Oral initial: 30 mg once daily for 1 week, then 60 mg once daily. (ref: UpToDate)

700514824

221021

[assessment]

  • Since the patient began her hospital stay, her blood sugar levels have exceeded 200 mg/dL in all data points ( with a record high 401 mg/dL) under current basal/bolus insulin therapy.
  • In this case, it is recommended to gradually increase the basal insulin by 2 or 3 units and monitor the changes in blood sugar levels to determine whether further adjustments are necessary.

700999894

221021

  • diagnosis
    • 2022-10-18 discharge note
      • Right lower lobe lung cancer, adenocarcinoma, T2bN0M0, stage IIA, status post operation, with recurrent rT4N2M1a, stage IVA with lung to lung metastasis, ECOG 1, EGFRmutation: L858R (-), exon 19 (-), ALK(-), ROS1(-)
      • Essential (primary) hypertension
      • Type 2 diabetes mellitus without complications
      • Insomnia, unspecified
      • Malignant neoplasm of lower lobe, right bronchus or lung
      • Chronic obstructive pulmonary disease
      • Chronic rhinitis
  • History
    • hypertension under regular control for 2-3years (at LMD)
    • RLL lung cancer,adenocarcinoma, pStage IIA, pT2bN0(cMx)s/p VATS RLL lobectomy + RLND on 20170904, diagnosed on 20170908 ECOG:1; EGFR mutation wild type; Alk negative; PDL1 <1%.
      • post operation adjuvent chemotherapy:
        • immunotherapy Keytruda 20171006 ~ 20190603
        • chemotherapy with C1D1D8 Navelbine (20171007 and 20171031);
        • Gemzar total 6 cycle (20171030 ~ 20180501);
        • CDDP total 4 cycle (201761103, 20171127, 20180302, 20180503);
        • Vinorelbine total 6 cycle (20180528, 20180621, 20180726, 20180821, 20180914, 20181012)
      • For lung cancer re-staging, the chest CT was performed, wich multiple nodular lesions of varying sizes in both lungs shown, favor recurrent lung tumor with lung to lung metastasis.
        • Brain MRI and whole body bone scane also done without brain or bone metastasis.
      • For tissue prove, thet thoracoscopic wedge or Partial resection of the Lung on 20190315 and the pathogen disclosed Adenocarcinoma.
        • Therefore, the progression lung cancer pT2bN0 staage IIA -> rT2bN0M1a Stage IV was diagnosed.
      • For progression lung cancer, we was re-challenge the chemotherapy to immunotherapy C1 with Tecentriq (Atezolizumab), chemotherapy C1 Alimta, C1 Avastin and C1 CDDP since 201904.
      • The chest film showed ill-defined nodular/masses lesions of varying sizes in both lungs, recurrent lung cancer with lung to lung metastases, in progression on 20220907.
    • The lung cancer treatment regimen as below:
      • 1st chemotherapy with C1 Alimta, C1 Avastin and C1 CDDP since 201904
      • 2nd chemotherapy with C1 Docetaxel since 20220913.
      • immunotherapy C1 with Tecentriq since 201904, and changed to double immunetherapy with C1 Nivo total 200mg (free) IVF on 20210304 and Ipilmumab total 50mg (charge) IVF on 20210305.
  • chemoimmunotherapy
    • 2022-10-14 - Yervoy (ipilimumab) 50mg 30min
    • 2022-10-14 - Opdivo (nivolumab) 200mg 1hr
    • 2022-10-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
    • 2022-09-15 - Yervoy (ipilimumab) 50mg 30min
    • 2022-09-14 - Opdivo (nivolumab) 200mg 1hr
    • 2022-09-13 - Nolboxol (docetaxel) 25mg/m2 40mg 1hr
    • 2022-06-30 - Yervoy (ipilimumab) 50mg 30min
    • 2022-06-29 - Opdivo (nivolumab) 200mg 1hr
    • 2022-06-28 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-06-27 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-06-08 - Yervoy (ipilimumab) 50mg 30min
    • 2022-06-07 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-06-06 - Cyramza (ramucirumab) 500mg 1.5hr
    • 2022-04-29 - Yervoy (ipilimumab) 50mg 30min
    • 2022-04-28 - Opdivo (nivolumab) 200mg 1hr
    • 2022-04-27 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-03-24 - Yervoy (ipilimumab) 50mg 30min
    • 2022-03-23 - Opdivo (nivolumab) 200mg 1hr
    • 2022-03-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-03-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
    • 2022-02-24 - Yervoy (ipilimumab) 50mg 30min
    • 2022-02-23 - Opdivo (nivolumab) 200mg 1hr
    • 2022-02-22 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-02-21 - Cyramza (ramucirumab) 10mg/mg 600mg 90min
    • 2022-01-21 - Yervoy (ipilimumab) 50mg 30min
    • 2022-01-20 - Opdivo (nivolumab) 200mg 1hr
    • 2022-01-19 - Alimta (pemetrexed) 500mg/m2 900mg 10min
    • 2022-01-19 - Cyramza (ramucirumab) 10mg/mg 600mg 90min

701356390

221021

{breast cancer with brain mets}

  • cheif complaint (2022-09-16 adminnote)
    • Gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted.
  • present illness (2022-09-16 adminnote)
    • The skin-sparing mastectomy with immediate breast reconstruction was done on 2007-11-26.
      • The pathological report showed the diagnosis of Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA, with ER (4+), PR (4+), Her-2 IHC (1+).
    • The adjuvant treatement was LHRH agonist (Zoladex) from 2007-12-27 to 2012-12-13.
    • The anti-estrogen, tamoxifen, was added from 2012-06-28 to 2013-01-10.
    • On 2018-03-21, she sustained a mass over left supraclavicular area.
    • On 2018-03-26, the whle body bone scan showed the possibility of bone mets over left anterior 1st and 2nd ribs.
    • The denosumab (XGEVA) was given from 2018-03-29 to now.
    • The palbociclib plus letrozole was given 2018-04-26 to 2018-11-06.
    • On 2018-06-27, the Chest CT scan revealed necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs, which might explain the findings of increasing tracer uptake in the whole body bone scan on 2018-06-27 and later on 2018-08-21.
      • It indicated the recurrence of invasive lobular carcinoma over mediastinum, The treatment was at SD, based on the findings of CT on 2018-10-16.
    • On 2018-10-26, the PET-CT demonstraged: 1. a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invsding sternum in the anterior mediastinum; 2. several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
    • The sono-guided biopsy on 2018-11-02 disclosed metastaic poorly differentiated carcinoma, with ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
    • On 2018-12-25, the thyroid sonography revealed bilateral multinodular gioter, without evident malignancy by aspiration cytology. The weekly eribulin for 2 weeks every 3 weeks was given from 2018-11-07 to 2019-10-09.
    • The letrozole from hospital and palbociclib from outside hospital were resumed from 2019-12-04 to now.
    • On 2019-03-14, the follow-up PET-CT showed marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
    • To maximize the anti-cancer effect, the radiotherapy to the anterior mediastinal mass was given with 45 Gy/18Fx was given from 2019-04-02 to 2019-04-25.
    • On 2019-09-18, the follow-up PET-CT showed partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
    • On 2020-04-01, the follow-up CT showed the metastases of mass and LAP in PR.
    • On 2021-04-26, the follow-up PET-CT showed the metastases of mass and LAP in PR.
    • She suffered from lower limbs weakness, and visited our ER on 2022-01-10. Brain CT on 2022/01/10 showed c/w brain metastasis and midline shift, 8mm. Brain MRI on 2022-01-10 showed intra-axial lesions, R/O brain metastasis.
    • Brain CT on 2022-01-12 showed multiple brain metasatses with mass effect. S/P markers for stereostatic surgery. Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor on 2022-01-13
      • CSF pathology suspicious for adenocarcinoma,
      • Brain pathology showed metastatic carcinoma, breast origin ,
        • Immunohistochemistry shows CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
    • Abdominal CT on 2022-02-11 showed 1. S/P Mastectomy, left. There is soft tissue swelling at the left upper anterior mediastinum, nature? please correlate with clinical condition. 2. Detailed findings, please see description.
    • Whole body bone scan on 2022-02-14 showed two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?).
    • Plan to deliver 30 Gy/ 10 fractions to the whole brain from 2022/01/24~2022/01/28 for 15 Gy/ 5 fractions.
    • Xgeva 1pc SC on 2022/01/27, 2022/02/24, 2022/03/24, 2022/04/19.
    • Received palliative chemotherapy with Q3W Adriamycin(60mg/m2)/Cyclophosphamide(600mg/m2) on 2022/02/24(C1), 2022/03/16(C2), 2022/04/07(C3), 2022/04/27(C4), 2022/05/17(C5), 202206/07(6).
    • Chemotherapy with QW Docetaxel(35mg/m2) on 2022/06/30(C1), 2022/07/14(C2), 2022/07/28(C3), 2022/08/11(C4),2022/09/01(C5).
    • Brain MRI on 2022/08/10 showed 1.unremarkable change in the intraventricular and extraventricular CSF spaces; 2.solid and rim-enhnaincg lesions in the left frontal lobe, 22mm; left cindulate gyrus,14.8mm; right cerebellar hemisphere, 5.7mm. right parieto-occipito-temporal lobe, 42.3mm. The small one in the left parietal lobe on the previous study on 20220510 was missing. The solid nodule in the left frontal lobe was increased in size; 3. unremarkable change in the skull base.
    • She suffered from gait disturbance within recent half month, headedness, headache, poor memory, left hand tremor also noted. She came to NS OPD for help on 2022/09/09.
    • Brain CT was done showed: 1.mild dilated intraventricular and extraventricular CSF spaces, 2.two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe, 3.unremarkable change in the skull base.
    • Now, she was admitted to ward for radiotherapy evaluate and change chemotherapy regimen for disease progression.
  • past history
    • Breast cancer s/p about 15 year ago, s/p OP and radiotherapy with bone and lymph node metastases s/p chemotherapy with brain metastasis s/p radiotherapy
    • Left lymph node s/p biospy, about 2 year ago. under Hormones and Targeted Therapy. Re-follow CT show Left lymph node and clavicle metastasis.
    • Hypertension for 10 years with Novrasc 1# po QD and Bisoprolol 1.25mg 1# po QD
    • Diabetes for 10 years with Glimet(glimepiride 2mg+metformin 500mg) 1# po QD.
  • exam finding
    • 2022-10-20 CT - abdomen
      • Partial consolidation at LLL suspected pneumonia.
      • Colon diverticula. Fat stranding abutting S-colon suspected diverticulitis.
      • Left ovary cyst (5.2cm).
    • 2022-10-07 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (99.8 - 21.7) / 99.8 = 58.82%
        • M-mode (Teichholz) = 78.3
      • Adequate LV,RV systolic function with normal wall motion
      • Mild PR
      • Impaired LV relaxation
    • 2022-09-09 CT - brain
      • mild dilated intraventricular and extraventricular CSF spaces
      • two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.
      • unremarkable change in the skull base
    • 2022-08-19 CT - chest
      • Left breast cancer with chest wall meta s/p left mastectomy, C/T and R/T. The chest wall meta is stationary .
    • 2022-08-10 MRI - brain
      • multiple brain metastasis with some stationary; one missing ; the solid one, increase in size.
    • 2022-08-01 Tc-99m MDP whole body bone scan
      • No strong evidence of bone metastasis.
      • Suspected benign lesions in the skull, both rib cages, sternum, lower L-spine, sacrum, bilateral shoulders, S-I joints, hips and knees.
    • 2022-05-24 Tc-99m MDP whole body bone scan
      • In comparison with the previous study on 2022/02/25, the previous two hot spots in the skull are a little less evident. However, no prominent change is noted in the lesions in the sternum.
      • Suspected benign lesions in lower L-spines, sacrum, bilateral shoulders, S-I joints, hips and knees.
    • 2022-05-19 CT - chest
      • Left anterior chest wall soft tissue lesion. Stationary.
      • S/P mastectomy at left side.
      • Radiation pneumoniitis at left upper lobe
    • 2022-05-10 MRI - brain
      • At least 7 intra-axial lesions, mixed solid and cystic components, in bilateral cerebral hemispheres and right cerebellar hemisphere. 5.6mm of the largest one in right posterior temporal lobe. Enhancement of the solid part after contrast administration.
      • compatible with breast cancer with brain metastases.
    • 2022-02-25 Ventricular ejaction fraction and wall motion study
      • The RVEF and LVEF were 63% and 65% respectively.
      • Normal wall motion of the LV.
    • 2022-02-24 transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (121 - 51.2) / 121 = 57.69%
      • Adequate LV,RV systolic function with normal wall motion
      • Thick IVS, Impaired LV relaxation
      • Mild PR,TR
    • 2022-02-14 Tc-99m MDP whole body bone scan
      • Two hot spots in bilateral fronto-parietal region of the skull, respectively, and increased activity in the sternum, the nature is to be determined (post-traumatic change, early bone mets or other nature ?), suggesting follow-up with bone scan in 3 months for further evaluation.
      • Suspected benign lesions in lower L-spine, sacrum, bilateral shoulders, S-I joints, and hips.
    • 2022-02-11 CT - whole abdomen, pelvis
      • S/P Mastectomy, left.
      • There is soft tissue swelling at the left upper anterior mediastinum, nature?
    • 2022-01-13 Patho - brain biopsy
      • Brain tumor, r’t frontal area, frozen section and biopsy - Metastatic carcinoma, breast origin
      • IHC: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal) for tumor cells, compatible with metastatic breast carcinoma.
        • There is NO amplification of HER2 detected by FISH assay in Taipei Institute of Pathology
    • 2022-01-13 Frozen section
      • Tumor, brain, frozen section - Malignancy, poorly-differentiated.
    • 2022-01-12 CT - Brain for navigator
      • Multiple brain metasatses with mass effect. S/P markers for stereostatic surgery.
    • 2022-01-10 MRI - Brain for navigator
      • Intra-axial lesions, suspected brain metastasis
    • 2022-01-10 CT - Brain
      • c/w brain metastasis
      • Midline shift, 8mm
    • 2021-04-26 PET
      • metastases of mass and LAP in PR.
    • 2020-04-01 CT
      • metastases of mass and LAP in PR.
    • 2019-09-18 PET
      • partial regression of the anterior mediastinal mass and invisibility of those aforementioned LAPs.
    • 2019-03-14 PET
      • marked regression of prepericardial and left intercostal LAPs, mild regression of the anterior mediastinal mass.
    • 2018-12-25 Sonography - thyroid
      • bilateral multinodular gioter, without evident malignancy by aspiration cytology.
    • 2018-11-02 Patho - sono-guided biopsy
      • metastaic poorly differentiated carcinoma
      • ER (30%), PR (-), Her-2 (<10%), Ki-67 (<3%)
    • 2018-10-26 PET
      • a huge hypermetabolic mass wiht central necrosis, abunting anterior chest wall and possible invading sternum in the anterior mediastinum
      • several hypermetaboic nodes in the left supraclavicular, left para-sternal and left lower pleura, indicating nodal metastases or pleural seeding.
    • 2018-10-16 CT
      • SD - stable disease
    • 2018-08-21, -06-27 Whole body bone scan
      • increasing tracer uptake
      • it indicated the recurrence of invasive lobular carcinoma over mediastinum
    • 2018-06-27 CT - chest
      • necrotized mass over the left uper anterior mediastinum with direction invasion to left antirior 1st and 2nd ribs
    • 2018-03-26 Whole body bone scan
      • possibility of bone mets over left anterior 1st and 2nd ribs.
    • 2018-03-21 Presentation
      • she sustained a mass over left supraclavicular area.
    • 2007-11-26 Patho - skin-sparing mastectomy
      • Invasive Lobular Carcinoma. The stage was pT2N0M0, Stage IIA,
      • IHC: ER (4+), PR (4+), Her-2 (1+).
  • surgical operation
    • 2022-01-13 Stereotactic biopsy and aspiration for right PO cystic lesion and left frontal deep tumor; breast cancer history (+);
      • finding
        • OP 1:
          • Two pieces white-grayish soft tumor was harvest at left forntal deep brain.
          • Frozen section: Tumor, brain, frozen section - Malignancy, poorly-differentiated.
        • OP 2:
          • Xanthochromic then light reddish fluid about 40cc was apirated at right PO area.
          • sent for cytology/culture and CSF profile.
    • 2007-11-26 skin-sparing mastectomy with immediate breast reconstruction
  • radiotherapy
    • 2022-02-07 medrec plan to deliver 30 Gy/ 10 fx to the whole brain.
    • 2022-01-24 ~ 2022-01-28 - the whole brain 15 Gy/ 5 fractions?
    • 2019-04-02 ~ 2019-04-25 - 45 Gy/18Fx to the anterior mediastinal mass
  • chemotherapy
    • 2022-10-21 ~ 2022-10-24 - Granocyte (lenograstim) 250mg QD SC
    • 2022-10-20 - G-CSF (filgrastim) 150mg ST SC
    • 2022-10-07 - Lipo-Dox (liposome doxorubicin) 50mg/m2 80mg 2hr
    • 2022-09-01 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-08-11 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-07-28 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-07-14 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-06-30 - Nolbaxol (docetaxel) 35mg/m2 50mg 1hr
    • 2022-06-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-05-17 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-04-27 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-04-13 ~ 2022-04-15 - Granocyte (lenograstim) 250mg QD SC
    • 2022-04-07 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-03-21 ~ 2022-03-23 - Granocyte (lenograstim) 250mg QD SC
    • 2022-03-16 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2022-02-24 - cyclophosphamide 600mg/m2 900mg 1hr + doxorubicin 60mg/m2 90mg 1hr
    • 2019-12-04 ~ undergoing ? palbociclib + letrozole
    • 2018-11-07 ~ 2019-10-09 - weekly eribulin for 2 weeks every 3 weeks
    • 2018-04-26 ~ 2018-11-06 - palbociclib + letrozole
    • 2018-03-29 ~ on-and-off - Xgeva (denosumab)
      • 2022-01-27, 2022-02-24, 2022-03-24, 2022-04-19, 2022-05-17, 2022-06-16, 2022-07-28, 2022-08-13, 2022-09-16
    • 2012-06-28 ~ 2013-01-10 - anti-estrogen tamoxifen
    • 2007-12-27 ~ 2012-12-13 - LHRH (luteinising hormone releasing hormone) agonist Zoladex (goserelin)

==========

2022-10-21

  • Grade 4 neutropenia (2022-10-21 WBC 20 cells/uL) is observed. The patient has been received lenograstim and filgrastim.
  • As the disease itself and its metastases evolve, their characteristics are changing
    • 2007-11-26 patho - mastectomy: ER(4+), PR(4+), Her2(1+).
    • 2018-11-02 patho - sono-guided biopsy: ER(30%), PR(-), Her2(<10%), Ki-67(<3%)
    • 2022-01-13 patho - brain biopsy: CK(+), GATA-3(+), ER(-), PR(-) and HER2(2+, equivocal)
  • A brain MRI on 2022-08-10 revealed that a solid mass had increased in size. Researchers have demonstrated that trastuzumab deruxtecan had a high intracranial response rate in patients with active brain metastases associated with HER2-positive breast cancer (ref: Trastuzumab deruxtecan in HER2-positive breast cancer with brain metastases: a single-arm, phase 2 trial. Nat Med 28, 1840–1847 (2022). https://doi.org/10.1038/s41591-022-01935-8). Upon confirmation that Her2 is positive, trastuzumab deruxtecan may be considered as a treatment option.
  • The blood sugar level records showed a monotonic increase (331 <- 265 <- 208 mg/dL). In addition to current used Galvus Met (metformin and vildagliptin), acarbose, glimepiride or basal insulin is recommended. The SGLT2i would not be preferred for her since she recently experienced a UTI event.

2022-10-13

  • During this hospital stay, all data points of serum glucose before meal were above 220mg/dL and a 368mg/dL peak record was observed.
  • Metformin/vildagliptin is currently being taken by the patient. There is a recommendation to add alpha-glucosidase inhibitors, e.g., acarbose, SGLT-2 inhibitors, such as canagliflozin, dapagliflozin (use SGLT2i if no more UTI concern), or a basal insulin therapy.

2022-09-19

  • This patient had received doxorubicin/cyclophosphamide (6, 2022-02-24 ~ 2022-06-07) and docetaxel (5, 2022-06-30 ~ 2022-09-01)

  • Brain MRI (2022-08-10) showed one solid mets increased in size and brain CT (2022-09-09) showed mild dilated intraventricular and extraventricular CSF spaces and two cystic lesions with fluid-fluid levels, about 20mm and 9.4mm in the left frontal lobe and about 44mm in the right parietotemporal lobe.

  • Pathology (2022-01-13) comfirmed breast cancer brain mets triple negative. Neither trastuzumab and its biosimilars/ADC(antibody drug conjugates) nor CDK4/6 inhibitors (e.g., ribociclib, palbociclib) might likely to show effective.

  • National Health Insurance covers PARP (poly ADP-ribose polymerase) inhibitors like olaparib and talazoparib for metastatic triple negative breast cancer with BRCA1/2 mutations since 2022-08-01.

  • For patients with triple-negative brain metastases from breast cancer (BCBM), two chemotherapy regimens seem to show specific CNS activity:

    • the anti-vascular endothelial growth factor agent bevacizumab plus paclitaxel in a small Phase 2 study (70% ORR but only 6 patients with triple negative MBC) and the microtubule inhibitor eribulin in case reports.
    • A Phase 2 trial presented at ASCO 2013 highlighted a combination of bevacizumab plus carboplatin in the treatment of BCBM. In this study, 38 patients were treated with bevacizumab plus carboplatin, and trastuzumab was added if the tumour was HER2+. The composite brain ORR was 63% and the global ORR was 45%.
    • For these HER2– patients, therefore, standard chemotherapy comprising capecitabine, eribulin or carboplatin plus bevacizumab can be used for progressive BM after local treatment.
    • ref: Bailleux, C., Eberst, L. & Bachelot, T. Treatment strategies for breast cancer brain metastases. Br J Cancer 124, 142–155 (2021). https://doi.org/10.1038/s41416-020-01175-y

2022-04-08

  • The patient has TNBC with brain mets and is being treated with doxorubicin and cyclophosphamide as from late February 2022.
  • In lab results reported on 2022-04-06, liver and kidney functions were normal, and no obvious abnormalities were noted in the CBC or WBC levels.
  • If the current regimen fails to produce satisfactory outcome, capecitabine might be a subsequential alternative.
  • Olaparib or talazoparib might be an optional add-on if the BRCA1/2 mutation germline sequencing result is positive.
  • Phase III KEYNOTE-355 trial demonstrated the benefits of pembrolizumab added to chemotherapy in locally advanced or metastatic triple-negative breast cancer.

2022-03-17

701450829

221021

  • exam findings
    • 2022-10-20 CT - abdomen
      • Cecal cancer with colostomy, peritoneal seeding, LNs, liver and lung metastases. Compression fracture of T12.
    • 2022-10-20 KUB
      • Lumbar spondylosis.
      • T12 compression fracture.
    • 2022-10-20 CXR
      • Increase bilateral lung markings.
      • Mild cardiomegaly.
      • Thoracic spondylosis and scoliosis.
      • T12 compression fracture.
    • 2022-10-05 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (109 - 32.2) / 109 = 70.46%
        • M-mode (Teichholz) = 70.5
      • Normal chamber size
      • Adequate LV and RV systolic function
      • Possibly impaired LV relaxation
      • Calcified mitral annulus with mild MR, mild TR and PR
      • AV sclerosis with mild AR , trivial AS
      • Possibly mild pulmonary HTN
      • No regional wall motion abnormalities
    • 2022-10-04 ECG
      • Sinus rhythm with Fusion complexes
      • T wave abnormality, consider inferior ischemia
    • 2022-10-04 CXR
      • Multiple nodules at bil. lungs.
    • 2022-09-26 Patho - colon biopsy
      • Colon, hepatic flexure, biopsy — Adenocarcinoma, moderately differentiated
      • The sections show a picture of adenocarcinoma, moderately differentiated, composed of columnar neoplastic cells, arranged in glandular and cribriform patterns with desmoplastic stromal reaction.
      • IHC, tumor cells reveal: EGFR(+), MLH1(+), PMS2(+), MSH2(+), and MSH6(+).
    • 2022-09-23 Colonoscopy
      • One tumor mass (4-5 cm in size) was noted in thehepatic flexure withlumen narrowing (80 cm from anal verge).
    • 2022-09-16 CT - abdomen
      • History: Mild epigastric discomfort and fullness, acid reflux, weight loss due to decrease intake, microcytic anemia was noted at OPD post transfusion
        • 20220915 sono: A 71.8x57.8 mm hypoechoic heterogeneous mass lesion at the RT lobe liver. Suspected HCC
        • 20220916 CA125: 97.2 U/mL (<35), CA199: 1896 U/mL (<35), AFP: normal.
      • Findings:
        • There is circumferrential asymmetrical wall thickening at the cecum, proximal ascending colon, ileocecal valve, and terminal ileum with irregular contour, measuring 4.7 x 6.8 cm in size.
          • Cecal cancer (T4a) is highly suspected. Please correlate with colonoscopy.
          • In addition, there are several enlarged nodes in the adjacent mescolon (T2a).
        • There are heterogeneous poor enhancing masses in S5 and S6 of the liver and the largest one measuring 8 cm in size. It is c/w liver metastasis.
          • In addition, there are two soft tissue nodules in LLL and LUL of the lung that are c/w lung metastases.
          • There are two small soft tissue nodule in the omentum of RMQ and lower pelvis that may be tumor seeding (M1C).
        • There is mild ascites in the cul-de-sac.
        • A renal cyst measuring 2.9 cm in left upper pole is noted.
      • Imaging Report Form for Colorectal Carcinoma
        • Impression (Imaging stage): T:T4a (T_value) N:N2a (N_value) M:M1c (M_value) STAGE:IVC(Stage_value)
    • 2022-09-15 Sonography - abdomen
      • hepatic tumor favor HCC
      • susp. parenchymal liver disease.
  • consultation
    • 2022-10-21 Family Medicine
      • Q
        • The 85 y/o woman has ascending colon cancer with liver, peritoneal seeding, LNs, liver and lung metastases, stage IVc (cT4aN2aM1c) status post laparoscopy with loop-ileostomy on 20221006. Family need information for hospice care. Thanks! 64749陳宣妃
      • A
        • DNR(-) The patient is unaware of the situation?
        • Our share care would follow up.

700997286

221020

{ovarian cancer s/p debulking surgery}

  • discharge diagnosis
    • 2022-07-22
      • 1: Ovarian cancer s/p Debulking surgery (bilateral salpingo-oophorectomy + omentectomy + peritoneal tumor excision + bilateral inguinal mass excision) on 2021/11/09, pT3cN0M1b, Stage IVB s/p chemotherapy with Taxaol/Carboplatin(from 2021/12/15~2022/03/16 for 9 cycles), PD
      • 2: Major depressive disorder, single episode, severe with psychotic features
      • 3: Delusional disorders
      • 4: Hypomagnesemia
  • drug allergy
    • Ibuprofen Injection 100mg/ml,4ml/amp: angioedema
    • Voren 12.5mg/supp (diclofenac sodium): angioedema
  • exam finding
    • 2022-08-04 CT - abdomen, pelvis
      • S/P hysterectomy.
      • Progression of peritoneal/abdominal wall seeding, retroperitoneal and pelvic recurrence.
      • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
    • 2022-06-10 Patho - lymph node region resection
      • Lymph node, left inguinal, excision — metastatic ovarian high-grade serous adenocarcinoma (2/2)
      • Section shows pieces of lymph nodes with metastatic papillary tumor cells.
      • The immunohistochemical stains reveal PAX8(+), WT-1(+), and p53 (aberrant expression).
      • The results are in favor of metastatic ovarian high-grade serous adenocarcinoma.
    • 2022-06-02 ECG
      • Minimal voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2022-04-25 ECG
      • Sinus rhythm with Premature atrial complexes
      • Incomplete right bundle branch block
      • T wave abnormality, consider anterior ischemia
      • Prolonged QT
    • 2022-04-25 CT - abdomen, pelvis
      • Findings
        • S/P hysterectomy. Some soft tissue masses in retroperitoneum and pelvic cavity.
        • Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region.
        • Some fluid at operative wound site.
        • Left renal stone (2mm).
      • Impression
        • S/P hysterectomy. Recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site.
    • 2022-04-14 2D transthoracic echocardiography
      • Adequate LV, RV systolic function with normal wall motion
      • Impaired LV relaxation
      • Mild MR,TR,PR
      • Mild Pulmonary HTN
    • 2022-03-23 CT - abdomen, pelvis
        1. Recurrent serous adenocacinoma in left inguinal area.
        1. Metastatic nodes in para-aortic space, aortocaval space, Lt common iliac chain, and Lt external iliac chain.
        1. There are lobulated cystic lesions in the pelvis and smuddgy appearance of the omentum that may be residual tumor seeding (carcinomatosis)?
    • 2021-12-13 Pure Tone Audiometry, PTA
      • Reliabilty Fair
      • R’t : 15 dB HL
      • L’t : 10 dB HL
      • Bil WNL.
    • 2021-11-09 Patho - soft tissue tumor, extensive resection
      • Pathologic diagnosis
        • Ovary, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
        • Ovary, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade.
        • Fallopian tube, right, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        • Fallopian tube, left, salpingo-oophorectomy —- serous adenocarcinoma, high grade. By seeding.
        • Uterus — absent – post hysterectomy
        • Omentume, omentectomy —- serous adenocarcinoma, high grade.
        • Douglous pouch mass, tumor excision — serous adenocarcinoma, high grade.
        • Para-rectal mass, tumor excision — serous adenocarcinoma, high grade.
        • Omentum mass x 2, tumor excision — serous adenocarcinoma, high grade.
        • Right inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        • Left inguinal mass, tumor excision — serous adenocarcinoma, high grade.
        • An addendum report of the consensus pathological stage will be followed after tumor board meeting.
        • The consensus pathology tumor staging of gynecology tumor board meeting on Nov. 18, 2021: pT3c pNx pM1b, FIGO stage: IVB.
      • Microscopic examination
          1. Histologic type: serous adenocarcinoma
          1. Histologic grade: high grade
          1. Contralateral ovary involvement: present
          1. Tumor side ovarian surface involvement: present
          1. Contralateral ovary surface involvement: present
          1. Right tube involvement: present (on serosa)
          1. Left tube involvement: present (on serous and in parenchyma)
          1. In situ adenocarcinoma in right and/or left fallopian tube: absent
          1. Right adnexa soft tissue involvement: present
          1. Left adnexa soft tissue involvement: present
          1. Pelvic soft tissue involvement: present: 3). central pelvic mass; 4). Douglous pouch mass; 5). para-rectal mass x 2)
          1. Uterine serosa involvement: non-applicable (previous hysterectomy; no uterus received)
          1. Omentum involvement: present.
          1. Uterine Cervix involvement: not received
          1. Endometrium involvement: not received
          1. Myometrium involvement: not received
          1. Appendix involvement: not received
          1. Largest Extrapelvic Peritoneal Focus - Macroscopic (2 cm or less)
          1. Peritoneal/Ascitic Fluid-Not submitted.
          1. Regional Lymph Nodes: No lymph nodes submitted
          1. Other organs or specimens involvement: present. 7). right inguinal mass; 8). left inguinal mass.
    • 2021-09-22 Patho - ovary (tumor)
      • Pelvic mass, CT-guide biopsy — Adenocarcinoma
      • Microscopically, the sections show a picture of adenocarcinoma characterized by pleomorphic and hyperchromatic tumor cells arranged in papillary or soild pattern.
      • Immunohistochemistry shows CK7(+), CK20(-), PAX-8(+, focal), WT-1(+) and calretinin(-) for tumor cells, serous carcinoma originating from adnexa maybe first considered. Please check GYN condition and clinical correlation is advised.
    • 2021-06-17 CT - abdomen, pelvis
      • S/P hysterectomy. Some soft tissue masses (up to 6.2cm) in peritoneal cavity (esp. pelvic cavity) suspected peritoneal seeding. Suspected liver metastases.
    • 2021-05-13 Gynecologic ultrasonography
      • pelvis mass 57x50mm, RI:0.22, ATH
      • suspect pelvis mass
  • consultation
    • 2022-05-06 Plastic and Reconstructive surgery
      • Q
        • The 61 y/o woman has ovary cancer with recurrent tumors in retroperitoneum and pelvic cavity. Enlarged LNs (up to 2.1cm) at retroperitoneum and left inguinal region. Some fluid at operative wound site. We confirm GYN, who suggested debridement, so we need your help. Thanks!
      • A
        • I will check on her next Monday. Thanks.
    • 2022-05-05 Infectious Disease
      • Q
        • The 61 y/o woman has ovarian cancer with peritoneal sign and fistula with fungating. Due to spiked fever noted, so we hold Tapimycin and shift to Meropenam and Targocid for infection control. We need your agree. Thanks!
      • A
        • keep present antibiotic Rx, and adjust to culture data later
        • monitor CRP
  • chemoimmunotherapy
    • 2022-10-19 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
    • 2022-09-13 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
    • 2022-08-18 - topotecan 1.2mg/m2 1.5mg 90min D1-D5
      • topotecan dosing
        • package insert: Ovarian cancer and SCLC:
          • Initial Dose: The recommended dose of topotecan is 1.5 mg/m2 body surface area/day administered by intravenous infusion over 30 minutes daily for 5 consecutive days with a 3 week interval between the start of each course.
          • Subsequent Dose: Preconditions: Neutrophil >= 10^9/L, PLT >= 100*10^9/L, HGB >= 9 g/dL
        • UpToDate: Ovarian cancer, metastatic: IV: 1.5 mg/m2/day for 5 consecutive days every 21 days, continue until disease progression or unacceptable toxicity (ten Bokkel Huinink 2004) or (off-label dosing) 1.25 mg/m2/day for 5 days every 21 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011) or (weekly administration; off-label dosing) 4 mg/m2 on days 1, 8, and 15 every 28 days until disease progression or unacceptable toxicity or a maximum of 12 months (Sehouli 2011).
    • 2022-07-21 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-06-22 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-04-14 - liposome doxorubicin 40mg/m2 50mg 1hr + carboplatin AUC 5 600mg 2hr
    • 2022-03-16 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 220mg 2hr
    • 2022-03-09 - paclitaxel 80mg/m2 100mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-02-23 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-02-16 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 190mg 2hr
    • 2022-01-19 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2022-01-12 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2022-01-05 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2021-12-22 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
    • 2021-12-15 - paclitaxel 80mg/m2 90mg 1hr + carboplatin AUC 2 280mg 2hr
  • lab data
    • WBC
      • 2022-10-19 WBC 7.13 *10^3/uL
      • 2022-09-08 WBC 4.19 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-09-20,21,22
      • 2022-08-19 WBC 7.81 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-08-25,26,27
      • 2022-08-16 WBC 5.49 *10^3/uL
      • 2022-08-09 WBC 1.92 *10^3/uL
      • 2022-08-02 WBC 2.73 *10^3/uL
      • 2022-07-21 WBC 4.34 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-07-27,28,29
      • 2022-07-14 WBC 3.21 *10^3/uL
      • 2022-07-07 WBC 1.18 *10^3/uL
      • 2022-06-22 WBC 9.33 *10^3/uL
      • 2022-06-20 WBC 9.86 *10^3/uL
      • 2022-06-02 WBC 10.30 *10^3/uL
      • 2022-05-09 WBC 3.54 *10^3/uL
      • 2022-05-02 WBC 7.09 *10^3/uL
      • 2022-04-29 WBC 1.11 *10^3/uL Granocyte (lenograstim) 250mg SC 2022-04-29,30,2022-05-01,02
      • 2022-04-25 WBC 2.31 *10^3/uL
      • 2022-03-30 WBC 4.38 *10^3/uL
      • 2022-03-16 WBC 4.55 *10^3/uL
      • 2022-03-09 WBC 8.12 *10^3/uL
      • 2022-02-23 WBC 3.27 *10^3/uL
      • 2022-02-16 WBC 3.12 *10^3/uL
      • 2022-02-09 WBC 2.45 *10^3/uL
      • 2022-01-19 WBC 2.91 *10^3/uL
      • 2022-01-12 WBC 3.56 *10^3/uL
      • 2022-01-05 WBC 4.00 *10^3/uL
      • 2021-12-22 WBC 5.48 *10^3/uL
      • 2021-11-29 WBC 10.34 *10^3/uL
      • 2021-11-10 WBC 10.67 *10^3/uL
      • 2021-11-07 WBC 8.92 *10^3/uL
      • 2021-10-04 WBC 6.82 *10^3/uL
      • 2021-09-13 WBC 5.54 *10^3/uL
      • 2021-08-05 WBC 6.03 *10^3/uL
      • 2021-04-28 WBC 5.37 *10^3/uL

[assessment]

  • Grade 2 neutropenia (ANC <1.5 *10^3/uL) has not been observed since mid-August 2022 as a result of the administration of G-CSF in late August and September 2022.
  • The use of electrolyte supplements is appropriate in the treatment of hypokalemia (3.1 mmol/L 2022-10-19) and hypomagnesemia (1.6 mg/dL 2022-10-19).

2022-08

  • WBC and regiemn:
    • 2022-08-09 WBC 1.92 *10^3/uL <– 2022-07-21 liposome doxorubicin + carboplatin
    • 2022-07-07 WBC 1.18 *10^3/uL <– 2022-06-22 liposome doxorubicin + carboplatin
    • 2022-04-29 WBC 1.11 *10^3/uL <– 2022-04-14 liposome doxorubicin + carboplatin
  • During the 2 to 3 weeks after receiving [liposome doxorubicin 40 mg/m2 + carboplatin AUC 5], severe neutropenia was observed, whereas during the prior nine cycles of [paclitaxel 80 mg/m2 + carboplatin AUC 2], there was no such severe neutropenia observed.

700335277

221018

{DLBCL, diffuse large B-cell lymphoma}

  • past history
    • Systemic disease: CAD (coronary artery disease), 2VD s/p POBA (plain old balloon angioplasty) + DES (drug eluting stent) at prox to mild LAD (left anterior descending artery) and POBA to distal LCX (left circumflex artery) on 20210906, paroxysmal atrial fibrillation and atrial flutter, hypertension, benign prostatic hyperplasia  
  • exam finding
    • 2022-10-02 ECG
      • Atrial fibrillation
      • Minimal voltage criteria for LVH, may be normal variant
      • Abnormal ECG
    • 2022-09-21 MRI - larynx
      • An enhancing lesion (9 mm) at C2 vertebral body. Stationary as compared with MRI on 20220316. Suggest regular follow-up.
    • 2022-09-04 ECG
      • Sinus rhythm with 1st degree A-V block
      • Moderate voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2022-08-22 CXR
      • Borderline cardiomegaly
    • 2022-08-08 ECG
      • Atrial flutter with variable A-V block
      • Abnormal ECG
    • 2022-08-03 ECG
      • Atrial fibrillation
      • Nonspecific ST abnormality
    • 2022-08-01, 2022-07-29, 2022-07-26 CXR
      • Borderline cardiomegaly
    • 2022-07-26 2D transthoracic echocardiography
      • LVEF(%) = 65
      • Conclusion:
          1. Normal LV systolic function with normal wall motion.
          1. Concentric LVH, severely dilated LA; LV diastolic dysfunction Gr 2.
          1. Normal RV systolic function.
          1. Aortic valve sclerosis with no AS, moderate AR; moderate MR; mild to moderate TR; mild PR.
          1. Possible mild pulmonary hypertension, estimated PASP: 37 mmHg.
          1. Mildly dilated ascending aorta.
    • 2022-07-25 ECG
      • Sinus rhythm with 1st degree A-V block
      • Early repolarization
    • 2022-07-24 ECG
      • Atrial fibrillation with a competing junctional pacemaker
    • 2022-07-24 CXR
      • Essential negative findings of the air way, mediastinum, heart, lungs, pleura, diaphragm and thoracic cage. Suggest clinical correlation.
    • 2022-06-23 CXR
      • S/P port-A implantation. Otherwise, there is no significant abnormality of the chest.
    • 2022-05-17 CXR
      • Elevation of both hemidiaphragms
      • Skin fold over Rt hemithorax
      • Crowding of vascular markings and/or reticular opacities over lung fields
    • 2022-03-22 EKG
      • Normal sinus rhythm
      • Voltage criteria for left ventricular hypertrophy
      • Abnormal ECG
    • 2022-03-16 Patho - bone marrow biopsy
      • Bone marrow, biopsy — Hypercellularity (50%)
      • Microscopically, the bone marrow shows hypercellularity with hemopoietic components accounting for about 50% of the marrow space, M/E ration of 1~2: 1 and presence of trilineage component. Megakaryocytes are occasionally seen.
      • Immunohistochemical stain reveals MPO(+), CD34(-),CD117(-), CD138(<5%), CD20 (focal+, <3%), Bcl-2(-), Bcl-6(-), CD71(+).
    • 2022-03-14 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-03-14 2D transthoracic echocardiography
        1. Normal AV with moderate AR
        1. Normal MV with mild MR
        1. LV septal hypertrophy
        1. Preserved LV and RV systolic function
        1. Mild PR, mild TR, normal IVC size
        1. Dilated LA
    • 2022-02-24 Whole body PET scan
      • There was increased FDG uptake involving the left tonsil and some left upper neck lymph nodes.
      • The FDG PET findings are compatible with lymphoma involving the left tonsil and some left upper neck lymph nodes.
    • 2022-02-22 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
    • 2022-02-16 Tc-99m MDP whole body bone scan
      • Several hot or faint hot spots in the left lower temporal region of the skull, right rib cage, right S-I joint, L/3, and right acetabulum, respectively, the nature is to be determined (post-traumatic change or othr nature ?), suggesting further investigation and follow-up with bone scan in 3 months.
      • Suspected benign lesions in some middle to lower C-spine, L4 spine, L-S junction, bilateral shoulders, elbows, left knee, and left foot.
    • 2022-02-14 Patho - tonsil and/or ademoid
      • Tonsil tumor, left, biopsy — Diffuse large B-cell lymphoma
      • Histology type: diffuse large B-cell lymphoma shows large atypical lymphoid cells with nucleoli and focal tumor necrosis
      • Immunohistochemistry: CK(-), P16(-), P63(+, scatter), CD3(-), CD20(+, diffuse), Bcl-2(+), CD30(-), CD10(-), Bcl-6(+), C-MYC(+, 20-30%) tumor.
    • 2022-02-11 CT - neck
      • Imaging Report Form for Oropharynx Carcinoma
      • Impression (Imaging stage): T2N0M0, stage II
    • 2022-02-11 Neck Soft Tissue
      • Film(s) of neck soft tissue shows:
        • Degeneration and spondylosis of C-spine.
        • A calcified spot at left neck.
    • 2022-02-11 ECG
      • Sinus rhythm with 1st degree A-V block
      • Otherwise normal ECG
    • 2022-02-11 Nasopharyngoscopy
      • smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
    • 2021-09-07 ECG
      • Sinus rhythm with 1st degree A-V block
      • Otherwise normal ECG
    • 2021-09-06 ECG
      • Sinus bradycardia with 1st degree A-V block
    • 2021-09-06 Cardiac Catheter
      • Intervention Summary
        • LAD P-M, Pre-DS = 70%
          • MLD/RVD=/3.5 mm mm → /3.5 mm, Post Balloon DS = 50%%.
            • Guiding catheter: Boston 6F CLS3.5.
            • Guide Wire: Terumo Runthrough Floopy.
            • Guide Wire2: Asahi SION BLUE.
            • Balloon: B Braun NSE alpha balloon. 3.5 X 13mm mm. Pressure: 12 atmospheres. 43 secs.
            • Balloon2: Abbott NC Trek. 3.5 X 20mm mm. Pressure: 9 atmospheres. 30 secs.
            • Balloon3: Medtronic NC Euphora. 4.0 X 12mm mm. Pressure: 22 atmospheres. 15 secs.
            • Stent: B Braun Coroflex ISAR DES. 3.5 X 28mm mm. Pressure: 14 atmospheres. 14 secs.
            • Stent-MLD/RVD=/3.5 mm Stent DS = 0% residual stenosis.
        • LCX-D, Pre-DS = 80%
          • MLD/RVD=/2.5mm mm → /2.5 mm, Post Balloon DS = 30%%.
            • Guiding catheter: Boston 6F CLS3.5.
            • Guide Wire: Terumo Runthrough Floopy.
            • Guide Wire2: Asahi SION BLUE.
      • In conclusion: CAD DVDs/p PCI with DES for proximal to mid LAD and POBA for distal LCX, successful
      • Recommendation: PCI for LAD and LCX
    • 2021-09-03 2D transthoracic echocardiography
        1. Preserved LV and RV systolic function with normal wall motion
        1. Dilated LA, grade 2 LV diastolic dysfunction
        1. Mild AR, MR, TR
    • 2021-09-01 ECG
      • Sinus rhythm with 1st degree A-V block
    • 2021-08-27 19:52 ECG
      • Atrial fibrillation
      • Abnormal ECG
    • 2021-08-27 17:26 ECG
      • Atrial flutter with variable A-V block
      • Abnormal ECG
    • 2021-08-01 ECG
      • Atrial fibrillation
      • Abnormal ECG
    • 2021-05-31 ECG
      • Sinus bradycardia with 1st degree A-V block with Premature supraventricular complexes
    • 2021-04-14 Vestibular Evoked Myogenic Potential, VEMP
      • oVEMP Interaural Amplitude Asymmetry ratio 22.78 %,WNL
      • cVEMP Interaural Amplitude Asymmetry ratio 8.98 %, WNL
    • 2021-04-06 C-spine AP + Lat.
      • Radiograph of the cervical spine (AP and lateral):
        • Osteoporosis.
        • Spondylosis, esp C4-5-6-7.
    • 2020-07-28 Myocardial perfusion SPECT with persantin
      • Probably mild to moderate myocardial ischemia with possible a portion of severe ischemia at the inferolateral wall and posterior wall and mild myocardial ischemia at the apical lateral wall.
    • 2020-07-17 CXR
      • Spondylosis of the T-spine
      • Atherosclerotic change of aortic arch
    • 2020-07-17 ECG
      • Sinus rhythm with 1st degree A-V block
      • Minimal voltage criteria for LVH, may be normal variant
      • Borderline ECG
    • 2019-12-20 KUB
      • The psoas shadow is clear.
      • Degenerative change of the bony structure with marginal osteophyte formation is identified.
      • Increased intestinal gas is found.
      • Phlebolith at pelvic cavity is also found.
      • Suggest clinical correlation
    • 2019-12-10 Surgical pathology Level III
      • Clinical diagnosis: Other cellulitis & absess, leg, except foot
      • Pathologic diagnosis
        • Benign
        • Skin and soft tissue, right lateral calf, regional fasciectomy — necrotizing inflammation
    • 2019-12-10 Surgical pathology Level III
      • Clinical diagnosis: Benign neoplasm of connective and other soft tissue, unspecified
      • Pathologic diagnosis
        • Benign
        • Tumor, chest, excision — Neurofibroma
    • 2017-11-14 Knee Bilat. standing
      • Moderate osteoarthritis of both knees with varus configuration
      • Ahlback calcification: grade 3, 3
  • consultation
    • 2022-06-29 Cardiology
      • Q
        • for hypertension poor control
        • This 78-year-old male, a pt of DLBCL, Lungano stage II, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022. He was admitted due to port-A infection for anti treatment. Owing to hypertension poor control (SBP:200-206)/DBP(90) was noted during admission. We need expertise to evaluate his condition thanks!
      • A
        • S:
          • He also suffered Zoaster with neuropathic pain in T4-6 dermatome region from back to chest with large surface area, now in healing stage, but neuropathic pain remains but can tolerate. He also has port A removal site pain. He felt headache when in hypertension. He also has mild right ankle joint pain but not inflammed on inspection.
          • Denied of chest and abdominal pain. shortness of breath.
        • O
          • BP: near control till 20220627 then elevated upto 200/90 in 2022/06/27-28.
          • HR: average 70
          • Bed side BP during visit: 155/78-169/81
          • Current medication
            • po candesartan 1# qn
            • po atenolol 1# qd
            • po lasix 1# qd
          • Lab
            • Renal and electrolyte : normal
        • Impression
          • Elevated blood pressure in prior HCVD patient suspected neuropathic and post op pain related.
          • Port A infection with psuedomonas infection
        • Suggestion
          • please add po norvasc 1# qd for BP and hold If SBP < 140mmHg (observe ankle swelling which could be worsen due to norvasc side effect)
          • educate patient if home BP is relatively lower than 140mmHg. and also, if recurrent zoaster infection, then visit dermatologist for UV radiation that fasten healing and reduce neuropthic pain.
          • Adequate pain control.
    • 2022-05-10 Dermatology
      • Q
        • For herpes zoter
        • This 78-year-old man, a patient of DLBCL (triple-hit lymphoma) at L tonsil, Lungano stage II, IPI: 1, non-GCB subtype, Dx in Feb 2022, suffered from initial presentation of enlarged neck near thyroid in Jan 2022 S/P C/T. He was admitted for C/T. He complained of pain & herpes zoter over right chest, armpit, back for 3 days. We need expertise to evaluate his condition thanks!
      • A
        • This patient suffered from grouped vesicels on R’t trunk for 3 days.
        • Imp: Herpes zoster
        • Suggestion:
            1. Famvior 1 / Tid
            1. Lyrica * 1 /Bid
            1. ZnO* 1 tube/bid
    • 2022-02-11 ENT
      • Q
        • Sore throat > blood pressure or heartbeat is different from the patient’s usual value, however hemodynamics is stable, tonsils are suppuration, and there is no improvement after visiting local clinics.
          • throat pain noted for days
          • no fever
          • odynophagia(+)
          • no vomiting
        • PH: HTN; Af ; CAD
        • NKA
        • s/p 2nd Moderna last Dec.
      • A
        • S
          • Odynophagia, VAS 4-5 for a week.
          • Fever(-) Dypsnea(-)
        • O
          • PE:
            • Oral: swelling of left tonsil with exudate, swelling of left soft palate s/p aspiration(no pus)
            • Scope: smooth NPx, moderate obstruction at velum level, smooth OPx, HPx, airway mild compromised
        • Imp: Suspect left peritonsillar abscess
        • Plan:
            1. Neck CT with/without contrast (last meal: 20220211 11:40)
            1. OA to ENT, IV Curam + Genta
            1. Monitor airway
  • chemoimmunotherapy
    • R-DA-EPOCH, Dose-adjusted EPOCH-R ([etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin] + rituximab). Titration up: etoposide, doxorubicin, cyclophosphamide
    • 2022-10-18 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
    • 2022-09-19 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1285mg 30min D5 + prednisolone 60mg/m2 tmg/tab 20# QD D1-5
    • 2022-08-22 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 10mg/m2 17mg 24hr D1-4 + vincristine 0.4mg/m2 0.7mg 24hr D1-4 + cyclophosphamide 750mg/m2 1300mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-07-26 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5 (vincristine not available then)
    • 2022-05-03 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-04-12 - rituximab 375mg/m2 600mg 8hr + etoposide 50mg/m2 80mg 24hr D1-4 + doxorubicin 9mg/m2 15mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5
    • 2022-03-17 - rituximab 375mg/m2 640mg 8hr + etoposide 40mg/m2 68mg 24hr D1-4 + doxorubicin 6mg/m2 10mg 24hr D1-4 + vincristine 0.4mg/m2 0.6mg 24hr D1-4 + cyclophosphamide 600mg/m2 1000mg 30min D5 + prednisolone 60mg/m2 5mg/tab 20# QD D1-5

==========

2022-09-19

[drug identification]

One drug for identification.

  • It is identified as Doudart (dustasteride 0.5mg + tamsulosin 0.4mg).
  • In men, it is used to treat the signs of an enlarged prostate.

The drug will be sent back to ward by the in-hospital porter.

2022-08-23

  • During this hospitalization, the blood pressure was around (180+-30)/(85+-10) with prescribed Norvasc (amlodipine 5mg) 1# QD, Blopress (candesartan 8mg) 1# QN and self-carried Urosin (atenolol 100mg) QD. If HTN still becomes symptomatic, thiazide diuretics such as Tricozide (trichlormethiazide 2mg/tab) 1# QD or Natrilix (indapamide 1.5mg/tab) 1# QD might be also considered.
  • Renal denervation is another BP-lowering strategy in hypertensive patients with high CV risk, such as resistant or masked uncontrolled hypertension, established ASCVD, intolerant or nonadherent to antihypertensive drugs, or features indicative of neurogenic hypertension after careful clinical and imaging evaluation (COR IIa, LOE B).

2022-07-25

  • There is a history of cardiovascular disease in the patient, 2022-03-14 2D transthoracic echocardiography showed: Mild PR, mild TR, Dilated LA, grade 2 LV diastolic dysfunction.
  • There were elevated levels of hs-Troponin I and NT-proBNP in the lab data that might indicate cardiovascular conditions.
    • hs-Troponin I
      • 2022-07-24 58.3 pg/mL
      • 2022-07-24 59.4 pg/mL
      • 2022-02-11 36.3 pg/mL
    • NT-proBNP
      • 2022-07-24 847 pg/mL
      • 2020-12-31 194 pg/mL
  • Doxorubicin was initialized at 6mg/m2 (2022-03-17) and titrated up to 9mg/m2 (2022-04-12), this is a relatively conservative and robust way of administration, last dose was administered on 2022-05-03.
  • Control of blood pressure was better than last hospitalization for there was no event of a SBP exceeding 200 mmHg and/or a DBP exceeding 100 mmHg.

2022-03-25

[drug identification]

Two drugs need identification.

the 2 identified items has been shown as following:

  • Duodart (tamsolosin 0.4mg, dutasteride 0.5mg)
  • Urosin (atenolol 100mg)

these drugs will be sent back to ward by an in-hospital porter.

700805995

221018

{Endometrioid carcinoma, grade 2, of the uterine endometrium, AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB, s/p Laparoscopic gynecologic oncology staging surgery.}

  • exam finding
    • 2022-10-18 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (93 - 12) / 93 = 87.10%
        • LVEF (%) = 87
        • M-mode (Teichholz) = 87
      • Normal LV systolic function with normal wall motion.
      • LV diastolic dysfunction Gr 2.
      • Normal RV systolic function.
      • Mild MR; mild TR; aortic valve sclerosis
    • 2022-09-16 CXR
      • Scoliotic alignment of the thoracolumbar spine is noted.
    • 2022-09-16 Peripheral Vascular Test - AV fistula
      • adequate size of RUV
    • 2022-08-23 Patho - uterus with or without SO
      • PATHOLOGIC DIAGNOSIS
        • Endometrium, uterus, LSC staging surgery — Endometrioid carcinoma, grade 2
        • Myometrium, uterus, ditto — Tumor invasion, more than half thickness
        • Uterus, cervix, ditto — Free of tumor, 5.2 cm away from tumor
        • Ovary, right, ditto — Tumor invasion
        • Fallopian tube, right, ditto — Free of tumor
        • Ovary, left, ditto — Free of tumor
        • Fallopian tube, left, ditto — Free of tumor
        • Lymph node, left iliac, dissection — Free of tumor metastasis (0/9)
        • Lymph node, left oburator, ditto — Tumor metastasis (1/6) with extracapsular extension (1/1)
        • Lymph node, right iliac, ditto — Free of tumor metastasis (0/9)
        • Lymph node, right oburator, ditto — Free of tumor metastasis (0/14)
        • Omentum, omentectomy — Tumor invasion
        • AJCC Pathologic stage — pT3aN1aM1, stage IVB / FIGO stage IVB
      • MICROSCOPIC EXAMINATION
        • Histology type: Endometrioid carcinoma
        • Histology grade: Grade 2
        • Depth of invasion: more than half thickness of myometrium
        • Lymphovascular invasion: Present
        • The cervical stroma involvement: Absent
        • Resection margins of the cervix: Free, 5.2 cm away from tumor
        • Additional pathologic findings: focal tumor necrosis and focal squamous differentiation
        • Lymph nodes: tumor metastasis (1/38) with extracapsular extension (1/1) in total number
        • Uterine cervix: Free of tumor, chronic cervicitis
        • L’t ovary: corpus albicans and free
        • R’t ovary: tumor invasion
        • Bilateral fallopian tubes: Free of tumor
        • Omentum: tumor invasion characterized by scant tumor measured less than 0.1 cm with stromal inflammation. Immunohistochemistry of CK(+) for tumor
    • 2022-08-22 Body fluid cytology - ascites
      • diagnosis
        • Malignancy
      • macroscopic examination
        • 40 cc grey-orange cloudy ascites
      • microscopic examination
        • The smears show lymphocytes, reactive mesothelial cells and some hyperchromatic atypical epithelial cell clusters, compatible with metastatic carcinoma. Clinical correlation and confirmatory biopsy is advised.
    • 2022-08-18 MRI - pelvis
      • Imaging Report Form for Endometrial Carcinoma
      • Imaging stage : T:T1b(T_value) N:N1a(N_value) M:M0(M_value) STAGE: IIIc(Stage_value)
      • Imperssion: Uterine tumor with lymph nodes, suspected endometrial malignancy with lymph nodes metastasis, cstage T1bN1aM0, IIIc.
    • 2022-08-08 Patho - endometrium curretage/biopsy
      • Uterus, endometrium, D&C — endometrioid adenocarcinoma, grade 1.
      • IHC stains: ER (+, 100% strong intensity), PR (+, 90%, strong intensity), vimentin (+), P53 (wild type), Napsin-A (-), CK20 (-).
  • surgical operation
    • 2022-08-08
      • Surgery
        • D&C, theraputic and diagnostic, vaginal bleeding 
        • Pathology: pending
      • Finding
        • Uterus: Anteversion, 7 cm.
        • Some endometrial tissue were curetted out.
        • Estimated blood loss: 10 mL
        • Blood transfusion: nil
        • Complication: nil.  
  • radiotherapy
    • 2022-09-28 ~ undergoing? 1980cGy/11 fractions of the pelvic area.
  • chemoimmunotherapy
    • 2022-10-17 - doxorubicin 50mg/m2 77mg 30min + cisplatin 50mg/m2 77mg 2hr (Q3W)
    • 2022-09-21 - paclitaxel 160mg/m2 250mg 3hr + carboplatin AUC 5 490mg 2hr (Q3W, paclitaxel first 160mg/m2, full 175mg/m2)
      • After admission, she took pre-medication as Dorison 20mg at 20220920 2300 and 20220921 0500. She received Taxel (Initial 160mg/m2) and Carboplatin AUC 5 on 20220921.
      • When the Taxel drip around 11 ml, she has dyspnea and mild SOB. We stopped chemotherapy and IVF hydration.
      • Under the stable condition, she can be discharged on 20220922. OPD follow up is arranged.

700866748

221014

  • diagnosis
    • Adenocarcinoma, moderately differentiated, of the esophagus, EG junction, stage IV, pT3N1(pM1), s/p thoracoscopic esophagectomy, radiotherapy, UFUR, and TS-1, with left mediastinal lymph nodes metastases and suspicious right lung metastases, s/p radiotherapy and status during chemotherapy with brain metastases, s/p radiotherapy.
    • EG junction adenocarcinoma s/p adjuvant CCRT (4860 cGy and UFUR) followed by adjuvant C/T with TS-1, with recurrent adenocarcinoma over middle and lower third trachea, s/p palliative C/T of docetaxel with or without 5-FU /Folinic Acid, s/p R/T with 5760 cGy, in progression, s/p CAL056, with progression of lung metastasis s/p palliative C/T with FOLFOX with brain metastasis s/p whole brain R/T and palliative C/T with FOLFIRI from 2022/08/10
    • Chronic obstructive pulmonary disease, unspecified
    • Gout, unspecified
    • Insomnia, unspecified
  • past history
      1. Gout from 2002 to now
      1. Limping gait from 2006 to now
      1. Benign prostatic hyperplasia from 2010 to now
      1. Herniated Intervertebral Disc from 2010-06-10 to now
      1. Bilateral renal cysts from 2010-06-10 to now
      1. Mitral regurgitation Gr 1 from 2010-06-12 to now
      1. Tricuspid regurgitation Gr 1 from 2010-06-12 to now
      1. Degenerative change of the thoraco-lumbar spine with narrowed intervertebral disc spaces and spurs formation from 2012-04-13 to now
      1. Superimposed bilateral lumbosacral radiculopathy from 2013-08-26 to now
      1. Spondylosis from 2013-09-03 to now
      1. Onychomycosis from 2017 to now
      1. Obstruction sleep apnea from 2017-01-31 to now
      1. Fatty liver from 2017-01-13 to now
      1. Insomnia Gr 1 from 2017-02-07 to now
      1. Productive cough Gr 1 from 2017-06 to now
      1. Chronic obstructive pulmonary disease from 2017-07-14 to now
      1. Chronic allergic rhinitis Gr 1 from 2017-07-14 to 2020-10-21, Gr 2 from 2020-10-22 to now
      1. Gastroesophageal reflux disease Gr 2 from 2018-01-04 to now
      1. Hyperlipidemia Gr 1 from 2018-04-24 to now
      1. Hiatal hernia from 2018-10-16 to 2022-02-06
      1. Superficial gastritis from 2019-12-30 to 2022-02-06
      1. Marginal spurs of multiple vertebral bodies from 2020-07-28 to now
      1. Esophageal shallow ulcers (above ECJ) from 2020-08-05 to now
      1. Hemoptysis, intermittently from 2021-08 to 2021-09-28
      1. Anemia Gr 1 from 2020-08-25 to now
      1. Atherosclerotic change of aortic arch from 2020-10-16 to now
      1. Bilateral carpal tunnel syndrome from 2020-11-17 to now
      1. Retrolordotic curve change of the spine 2020-11-23 to now
      1. Gallbladder stones from 2021-04-13 to now
      1. Reflux laryngitis from 2021-05-13 to now
      1. Mild posterior pericardial effusion from 2021-08-04 to now
      1. Bilateral pleura effusion from 2021-08-04 to now
      1. Platelet count decreased Gr 1 from 2021-12-14 to now
      1. Blood-stinged sputum, intermittently from 2022-01-28 to now      
  • exam finding
    • 2022-09-15 Patho - bronchus biopsy
      • Lung, LB8 endobronchial tumor, bronchoscopic biopsy — adenocarcinoma, consistent with metastatic tumor
      • Sections show neoplastic glandular cells infiltrating in a fibrotic stroma with focal tumor necrosis.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are consistent with metastatic adenocarcinoma from esophagogastric junction (cardiac cancer of stomach).
    • 2022-09-15 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was severely narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was normal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment: patent and the mucosa was normal .
      • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • Trachea: no tumor recur
        • RML/RLL carina submucosal lesion, without airway mucosal invasion
        • RLL orifice two submucosal lesions, without airway mucosal invasion
        • LB 8 endobronchial tumor with total occlusion
      • Under fluoroscent bronchoscopy:
        • Trachea: no tumor recur
        • RML/RLL carina submucosal lesion, without airway mucosal invasion
        • RLL orifice two submucosal lesions, without airway mucosal invasion
        • LB8 endobronchial tumor with total occlusion, s/p biopsy
      • After RB8 tumor biopsy by 15C biopsy forceps and snare-loop, tumor bleeding was noted, electrocautery with 25W/25W to 35W/35W with heat-probe was done for bleeding control.
    • 2022-08-11 MRI - brain
      • Known a case of EG junction adenocarcinoma s/p CCRT. One enhancing nodular lesion (3.7cm) over right cerebellar lobe, favor a metastatic lesion.
      • Prominent peritumoral edema.
      • The intracranial vessels are normally signal-void.
      • The paranasal sinuses and mastoid air cells are aerated.
      • The globes, optic nerve and extraoccular muscles are sketchyily intact in the non-FatSat images.
    • 2022-07-08 CT - abdomen, pelvis
      • Findings
        • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
        • Pleura reaction in bilateral posterior basal CP angle.
        • Few calcified gallstones are noted.
        • There are several renal cysts on both kidney and the largest one measuring 3.6 cm in size at left middle pole.
          • In addition, both kidney show mild irregular contour that may be old inflammatory process or normal variation.
        • s/p distal esophagectomy, cardiectomy and esophagogastrostomy.
          • There is no evidence of tumor recurrence.
        • There is no focal abnormality in the liver, biliary system, pancreas, and spleen.
          • There is no evidence of ascites or lymphadenopathy.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
          • There is no focal lesion over the mesentery and omentum.
      • Impression
        • Prior CT identified several metastases in both lung are noted again. Most of then show stable in size. However, two metastases in RLL and LLL of the lung show increasing in size.
    • 2022-06-16 Bronchial Washing
      • Positive for malignancy
    • 2022-06-15 CXR
      • Bilateral pleural effusions
      • Atherosclerotic change of aortic arch
      • Coarse reticular opacities or Platelike lung atelectasis over Lt Rt lower lung zones
      • Marginal spurs of multiple vertebral bodies.
    • 2022-04-08 CT - abdomen, pelvis
      • Lung metastases show mild increasing in size.
    • 2022-02-07 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Reflux esophagitis, LA-A (minimal)
        • Postoperative status of partial esophagectomy and gastric tube reconstruction.
        • Much food residue retention in esophagus and stomach
        • Incomplete study
      • Suggestion
        • OPD follow-up
    • 2022-01-28 CT - abdomen, pelvis
      • Lung metastases show mild increasing in size.
    • 2022-01-06 Bronchoscopy
      • The nasal mucosa was hypertrophic.
      • The nasal lumen was severely narrowed.
      • The was copious mucoid nasal discharge retained in the nasal cavity.
      • Mucosa of nasopharynx was hypertrophic .
      • Nasopharynx was severely narrowed.
      • Mucosa of pharynx cobble-stone in shape .
      • Movement of the both. vocal cord(s) was / werenormal .
      • Bilateral arytenoid proceww was normal .
      • Trachea whole segment: patent and the mucosa was normal.
      • Main carina: sharp and movable on deep breathing.
      • Bilateral endobronchial trees:
        • RML bronchus swelling and hyperremic, easy touch bleeding.
        • No visible endobronchial lesion
    • 2021-11-22 CT - lung
      • bilateral lung and mediastinal metastases, slightly in progression as compared with previous CT study on 20210804
    • 2021-08-04 CT - lung
      • consistent with bilateral lung and mediastinal metastases, in progression as compared with previous CT study on 20210719
    • 2021-07-19 CT - abdomen
      • S/P gastric operation.
      • Small nodules at right lung suspected metastases.
    • 2021-04-13 CT - abdomen
        1. Gastric cancer s/p partial gastrectomy. Suggest follow up.
        1. Bilateral renal cysts.
        1. GB stones.
        1. Old fractures at bilateral ribs.
        1. Bilateral basal lung atelectasis.
    • 2021-02-24 ECG
      • Sinus tachycardia
      • Possible Inferior infarct, age undetermined
    • 2020-11-06 CT -lung
      • Gastric cancer s/p partial gastrectomy.
      • Right lower lobe and left lower lobe intrafissural nodule. Decreased in size.
      • Right upper lobe tiny nodule. Stable.
    • 2020-09-03 Patho - trancheal biopsy
      • Lung, side ?, bronchoscopic biopsy — adenocarcinoma, poorly differentiated, consistent with recurrence
    • 2020-08-07 Tc-99m MDP whole body bone scan with SPECT
        1. Prominently increased activity in the L3-5 spines and L5-sacrum junction. Severe degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
        1. Mildly increased activity in the lower C-spine, middle and lower T-spines. Degenerative change is more likely.
        1. Some faint hot spots in the sternum and bilateral rib cages. The nature is to be determined (post-traumatic change? other nature?). Please follow up bone scan for further evaluation.
        1. Increased activity in bilateral shoulders, bilateral sternoclavicular junctions, wrists and knees, compatible with benign joint lesions.
    • 2020-08-05 Patho - trancheal biopsy
      • Lung, ? side, bronchoscopic biopsy — adenocarcinoma, moderately differentiated, in favor of recurrence
      • Sections show bronchail mucosa with neoplastic glandular cells infiltrating in submucosa.
      • The immunohistochemical stains reveal CK7(+), CK20(-), CDX2(focal +), TTF-1(-), and Napsin A(-). The results are in favor of recurrent tumor.
      • The HER2/NEU In-Situ Hybridization Test report from Taipei Institute of Pathology is NEGATIVE. There is NO amplication of HER2 detected.
    • 2020-08-04 Esophagography
      • s/p distal esophagectomy with esophagogastrostomy
      • High grade gastroesophageal reflex
    • 2020-07-28 CT - lung
      • recurrent gastric cancer as metastatic left mediastinal LAP and suspect two metastatic Rt lung nodules.
    • 2019-08-01 Impedance Audiometry
      • Reliabilty Fair
      • PTA
        • R’t : 41 dB HL
        • L’t : 41 dB HL
        • Bil normal to severe SNHL
      • Tymp
        • Bil Type B
      • ART
        • Bil absent.
    • 2019-04-01 CT - abdomen
      • s/p distal esophagectomy and cardiectomy with esophagogastrostomy.
      • There is no evidence of tumor recurrence.
  • surgical operation
    • 2016-12-12
      • VATS with subtotal esophagectomy, cardiectomy and jejunostomy
  • radiotherapy
    • 2020-08-14 ~ 2020-09-28 - 5760 cGY/32Fx
    • 2017-05-18 ~ 2017-06-27 - CCRT with 4860 cGy/27 fractions
  • chemoimmunotherapy
    • 2022-10-06 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4800mg 48hr
    • 2022-09-21 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 4970mg 48hr
    • 2022-09-07 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-08-24 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-08-10 - irinotecan 120mg/m2 200mg 90min + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-07-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-07-06 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-06-01 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-05-18 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-05-04 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-04-20 - oxaliplatin 85mg/m2 175mg 2hr + leucovorin 300mg/m2 600mg 2hr + fluorouracil 2400mg/m2 5000mg 48hr
    • 2022-03-14 - investigational CAL056
    • 2022-02-15 - investigational CAL056
    • 2022-01-12 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-12-29 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-12-15 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
    • 2021-11-17 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2000mg/m2 4300mg 48hr
    • 2021-11-03 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-10-20 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-10-06 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-09-22 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5200mg 48hr
    • 2021-09-08 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1-2 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-08-25 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2400mg/m2 5000mg 48hr
    • 2021-08-11 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-07-28 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-07-14 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-30 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-16 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-06-02 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-05-19 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-05-05 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 2000mg/m2 4000mg 48hr
    • 2021-04-21 - docetaxel 35mg/m2 75mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-04-07 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-03-24 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-03-09 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-02-17 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-02-03 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2021-01-21 - docetaxel 30mg/m2 60mg 1hr + folinate 15mg/tab 1# QID D1 + fluorouracil 1600mg/m2 3500mg 48hr
    • 2020-12-25 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-27 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-20 - docetaxel 25mg/m2 54mg 1hr
    • 2020-11-05 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-30 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-16 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-08 - docetaxel 25mg/m2 54mg 1hr
    • 2020-10-02 - docetaxel 25mg/m2 54mg 1hr
    • 2020-09-17 - docetaxel 25mg/m2 54mg 1hr
    • 2020-09-10 - docetaxel 25mg/m2 54mg 1hr
    • 2020-08-25 - docetaxel 25mg/m2 54mg 1hr
    • 2020-08-19 - docetaxel 25mg/m2 54mg 1hr
    • 2017-08-22 ~ 2018-05-07 - TS-1 (25 mg bid of Tegafur/Gimeracil/Oteracil, 25 mg/7.25 mg/24.5 mg)
    • 2017-05-18 ~ 2017-06-27 - UFUR (2 capsules bid of Tegafur/Uracil, 100 mg/224 mg), CCRT

==========

2022-10-14

  • There is an underlying condition of COPD in this patient. The CXR taken on 2022-10-13 showed ground glass opacities in both lungs. His symptoms of SOB lasted for a week and he has been treated with tapimycin (piperacillin + tazobactam) since 2022-10-13.

2022-10-07

  • In the last two months, weight loss has exceeded 10 kilograms (86.3kg 2022-10-06 <- 99.1kg 2022-08-03) (due to reduced intake or other factor?)
  • The underlying conditions of COPD, gout, and insomnia are managed with appropriate medication and remain stable.

2022-08-11

  • As indicated by CT findings of mildly growing lung metastases, the lab tumor markers CEA and CA199 have slowly trended up since March 2022.
    • CEA
      • 2022-07-19 5.77 ng/mL
      • 2022-06-14 4.91 ng/mL
      • 2022-05-17 4.13 ng/mL
      • 2022-04-12 3.44 ng/mL
      • 2022-03-14 2.81 ng/mL
    • CA199
      • 2022-07-19 38.82 U/mL
      • 2022-06-14 29.36 U/mL
      • 2022-05-17 23.62 U/mL
      • 2022-04-12 12.43 U/mL
      • 2022-03-14 9.06 U/mL
  • Curam 1000mg/tab (amoxicillin 875mg + clavulanic acid 125mg) 1# PO BID has been prescribed since 2022-06-21. Either amoxicillin-clavulanate or a respiratory fluoroquinolone (ie, levofloxacin or moxifloxacin) are recommended for exacerbations of COPD patients who have risk factors for poor outcomes (but no increased risk for Pseudomonas infection). Elderly patients might be at increased risk of developing amoxicillin-clavulanate-induced jaundice. Prolonged treatment might increase the risk of hepatotoxicity.
  • There is a history of gout, mitral regurgitation, and tricuspid regurgitation in the patient. A recent large RCT showed that in patients with gout and major cardiovascular coexisting conditions, febuxostat was noninferior to allopurinol with respect to rates of adverse cardiovascular events. Allcause mortality and cardiovascular mortality were higher with febuxostat than with allopurinol. ( https://www.nejm.org/doi/full/10.1056/NEJMoa1710895 ). Febuxostat is currently prescribed as equivalent daily dose of 20 mg (80 mg 0.5# QOD), which should reduce the risk of cardiovascular events.

700928671

221014

  • lab data

    • 2021-12-14 Anti-HBs 7.30 mIU/mL
    • 2021-12-13 HBsAg Nonreactive
    • 2021-12-13 HBsAg (Value) 0.45 S/CO
    • 2021-12-13 HBeAg Nonreactive
    • 2021-12-13 HBeAg(Value) 0.326 S/CO
    • 2021-12-13 Anti-HBe Reactive S/CO
    • 2021-12-13 Anti-HBe Ratio 0.66 S/CO
    • 2021-12-13 Anti-HBc Reactive
    • 2021-12-13 Anti-HBc-Value 5.36 S/CO
    • 2021-12-13 Anti-HBc IgM Nonreactive
    • 2021-12-13 Anti-HBc IgM Value 0.12 S/CO
  • exam findings

    • 2022-10-12 CXR
      • Port-A catheter inserted into cavo-atrial junction via right subclavian vein.
      • small Rt hemithorax, elevation of hemidiaphgram and superior convexity of major fissure due to post operative change of RUL lobectomy
      • Subcutaneous emphysema in Rt chest wall neck in regression as compared with the previous image
      • no right pneumothorax
    • 2022-09-26 Patho - lung total/lobe/segmental
      • PATHOLOGIC DIAGNOSIS:
        • Lung, right, upper lobe, lobectomy —- pleomorphic carcinoma with squamous cell carcinoma
        • Lymph node, lobar, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/4)
        • Lymph node, right, group No.2+4, lymphadenectomy —- pleomorphic carcinoma, metastatic (6/11)
        • Lymph node, right, group No.7, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, right, group No.9, lymphadenectomy —- Negative for malignancy (0/1)
        • Lymph node, right, group No.10, lymphadenectomy —- Negative for malignancy (0/2)
        • Lymph node, right, group No.11, lymphadenectomy —- Negative for malignancy (0/2)
        • Lymph node, right, group No.12, lymphadenectomy —- pleomorphic carcinoma, metastatic (3/3)
        • AJCC 8th edition pTNM Pathology stage: pStage IVA, pT4N2(if cM1a(by CT finding)) or pStage IIIB, pT4N2(if cM0)
      • MACROSCOPIC EXAMINATION:
        • Specimen:
          • Lung, size: 12 x 7 x 4.5 cm with a piece of parietal pleura, measruing 3.3 x 3.0 cm
          • Lymph nodes, 6 bottles, group 2+4, 7, 9, 10, 11, 12; maximal size: 2.8 x 1.9 cm
        • Tumor Site: Periphery
        • Tumor Size: Multiple (Number: several), Maximal one: 8.2 x 5.5 x 5.0 cm
        • Gross tumor patterns: poorly defined, Pleural retraction with invasion to parietal pleura
        • Tissue for sections:
          • A1: bronchial and vascular resection margins; A2: parenchymal resection margin; A3: lymph node, lobar; A4: lung with satellite tumor nodules; A5: bronchus; A6-7: tumor with parietal pleura; A8-10: tumor; B1-4: lymph node, group 2+4; C: lymph node, group 7; D: lymph node, group 9; E: lymph node, group 10; F: lymph node, group 11; G: lymph node, group 12.
      • Microscopic Description
        • Tumor Focality: Separate tumor nodules of same histopathologic type (intrapulmonary metastases) in same lobe
        • Histologic Type (select all that apply): Pleomorphic carcinoma with squamous cell carcinoma; The immunohistochemical stains reveal CK7(-), CK20(-), CK5/6(+), p40(+), TTF-1(-), Napsin A(-), CD56(-).
        • Histologic Grade: G3: Poorly differentiated
        • Spread Through Air Spaces (STAS): Present
        • Visceral Pleura Invasion: Present (PL2) with invasion to parietal pleura
        • Lymphovascular Invasion (select all that apply): Present, Lymphatic
        • Direct Invasion of Adjacent Structures (select all that apply): Adjacent structures present and involved, Parietal pleura
        • Margins (select all that apply):All margins are uninvolved by carcinoma
          • Distance of invasive carcinoma from closest margin (centimeters): 0.05 cm
          • Specify closest margin: Parietal pleura
          • Bronchial resection margin: 2.5 cm
        • Treatment Effect: No known presurgical therapy
        • Regional Lymph Nodes: lobar: 3/4; group 2+4: 6/11; group 7: 0/1; group 9: 0/1; group 10: 0/2; group 11: 0/2; group 12: 3/3.
        • Extranodal Extension: Present
        • Pathologic Stage Classification (pTNM, AJCC 8th Edition)
          • TNM Descriptors (required only if applicable) (select all that apply): not applicable
          • Primary Tumor (pT): pT4: Tumor >7 cm in greatest dimension;
          • Regional Lymph Nodes (pN): pN2: Metastasis in ipsilateral mediastinal and/or subcarinal lymph node(s)
          • Distant Metastasis (pM) (required only if confirmed pathologically in this case): if cM1a (by CT finding)
        • Additional Pathologic Findings (select all that apply): None identified
    • 2022-09-20 Whole body PET scan
      • Glucose hypermetabolism in a large focal area in the upper lobe of right lung, compatible with primary lung malignancy.
      • Glucose hypermetabolism in a smal focal area in the upper lobe of right lung, compatible with a metastatic lesion.
      • Glucose hypermetabolism in the right pulmonary hilar region and in some right lower paratracheal lymph nodes. Metastatic lymph nodes may show this picture.
      • Glucose hypermetabolism in the right adrenal gland and in multiple bones as mentioned above. Adrenal metastasis and multiple bone metastases may show this picture.
      • Mild glucose hypermetabolism in the lower portion of the esophagus and in a right supraclavicular lymph node. The nature is to be determined (inflammation? other nature?). Please correlate with other clinical findings for further evaluation.
    • 2022-09-14 CT - lung/mediastinum/pleura
      • Imaging Report Form for Lung Carcinoma
      • T4N2M1a AJCC8.0
    • 2022-09-01 MRI - nasopharynx
      • C/W oral cancer s/p operation without evidence of recurrence. Right upper lung mass (67 mm), suspected infection or metastasis.
    • 2022-03-03 Patho - oral cancer (wide excision + lymph node)
      • Left buccal mucosa, partial lips and extraoral facial skin near lip conner, s/p induction chemotherapy wide excision (S2022-3441H) with frozen section (F2022-85) — Residual verrucous carcinoma.
      • Lymph node, left neck, dissection — Free
      • ypT2 ypN0 (if cM0); ypStage: II, at least.
    • 2022-03-01 MRI - nasopharynx
      • Markely regressed left buccal, oral commissure, upper lip tumors. Regressed left level I LAP.
      • Tumor, left buccal mucosa, incisoinal biopsy — Compatible with squamous cell carcinoma and ulcer
      • Microscopically, the sections show a picture of ulcer with dense inflammation and atypical squamous epithelium with hyperkeratosis, occasional mitoses and few isolated nests or buds in dense inflammatory stroma. According to clinical (7 cm big mass), MRI (T4a) and histopathologic findings, it is compatible with squamous cell carcinoma, microinvasive. However, more advanced invasion can not excluded due to limited specimen.
      • Immunohistochemistry shows CK5/6(+), CK(+, weakly), P16(-), P53(+, focal) and P63(+) for tumor.
    • 2021-12-10 Tc-99m MDP whole body bone scan
      • Increased activity in the middle C-spine, L3 and L5 spines. Degenerative change may show this picture. However, please correlate with other imaging modalities for further evaluation and to rule out other possibilities.
      • Increased activity in the maxilla. Dental problem may show this picture.
      • Increased activity in bilateral shoulders, bilateral sternoclavicular junctions and hips, compatible with benign joint lesions.
    • 2021-12-10 SONO - abdomen
      • Diagnosis
        • Fatty liver, mild
        • Left renal cyst
      • Suggestion
        • Please correlate with other image study and clinical condition
        • Regular f/u
    • 2021-12-09 MRI - nasopharynx
      • Imaging Report Form for Oral Cavity Carcinoma
      • Impression (Imaging stage): T:4a(T_value) N:1(N_value) M:0(M_value) STAGE:IVA(Stage_value)
    • 2021-11-30 Patho - gingival/oral mucosa biopsy
      • Oral cavity, left buccal mucosa to lip commissure, incisional biopsy — Verrucous carcinoma
      • Microscopically, it shows verrucous carcinoma composed of club-shaped papillae and blunt intrastromal invagination of well-differentiated squamous neoplasm with inflammatory infiltrate at the submucosa. The tumor invades the stroma with a pushing.
      • IHC stain — p16(-)
  • consultation

    • 2022-03-18 Radiation Oncology
      • A
        • A: Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0).
        • P: According to HN tumor board (2022-03-18) conclusion: postoperative CCRT is indicated for this patient with the following indicators: skin sparing conservative surgery with cosmetic and function preservation of his left lip commissure area.
          • Goal: curative
          • Treatment target and volume: left lip commissure, buccal tumor bed to bilateral neck area.
          • Technique: VMAT/IGRT
          • Preliminary planning dose: 5000cGy/25 fractions of the left lip commissure, buccal tumor bed to bilateral neck, and 6600cGy/33 fractions of the left lip commissure and buccal tumor bed.
          • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his son. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-03-24.
  • SOP

    • 2022-10-11 Radiation Oncology
      • A:
        • Squamous cell carcinoma and verrucous carcinoma of the left lip commissure to left buccal area, stage cT4aN1M0 (IVA), s/p induction chemotherapy and operation (Modified radical neck dissection of left side. Wide excision of the malignant tumor at the left buccal mucosa, partial lips and extraoral facial skin near lip conner. Complicated tooth extraction of 7 teeth. Alvealoplasty of left and right maxilla. Left ALT free flap reconstruction. ALT donor site closure using fasciocutaneous rotational flap), stage ypT2N0(cM0), s/p CCRT.
        • Pleomorphic carcinoma with squamous cell carcinoma of the lung, RUL, stage AJCC 8th edition pTNM. Pathology stage: pStage IVA, pT4N2(cM1b), s/p VATS, RUL lobectomy + RLND.
      • P:
        • Radiotherapy is indicated for this patient with the following indicators: very close surgical margin
        • Goal: palliation
        • Treatment target and volume: primary lung tumor bed and regional lymphatic area.
        • Technique: VMAT/IGRT
        • Preliminary planning dose: 5400cGy/30 fractions of the primary lung tumor bed and regional lymphatic area.
        • The treatment modality and the possible effects of radiotherapy were well explained to the patient and his sons. They understand and agree to receive radiotherapy, The treatment planning of radiotherapy will be started at 0830, 2022-10-19.
  • radiotherapy

  • chemoimmunotherapy

    • 2022-05-16 - cisplatin 40mg/m2 70mg 2hr
    • 2022-05-04 - cisplatin 40mg/m2 70mg 2hr
    • 2022-04-21 - cisplatin 40mg/m2 70mg 2hr
    • 2022-04-13 - cisplatin 40mg/m2 70mg 2hr
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 170mg in fluorouracil 900mg/m2 1700mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)
    • 2022-02-08 - docetaxel 36mg/m2 65mg 1hr + cisplatin 35mg/m2 65mg 3hr + leucovorin 90mg/m2 160mg in fluorouracil 900mg/m2 1600mg 22hr (neoadjuvant)

[assessment]

  • Pleomorphic carcinoma is a poorly differentiated non-small cell carcinoma that contains at least 10% spindle and/or giant cells or a carcinoma consisting only of spindle and giant cells.
  • There are no related molecular testing results available in HIS5 that might be considered, including: EGFR mutations, ALK, KRAS, ROS1, BRAF, NTRK1/2/3, METex14 skipping, RET, ERBB2 (HER2), PD-L1.
  • Hypercalcaemia (2022-10-14 3.86 mg/dL) and hyperuricemia (2022-10-14 8.7 mg/dL) are treated with allopurinol and zoledronic acid, respectively.

701394404

221014

{Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16}

  • last discharge diagnosis
    • 1: Gastric adenocarcinoma of antrum with gastric outlet obstruction cT3N3bM1, stage IV, ECOG 1 status post laparoscoppic gastrojejunostomy and Port-A implantation on 2022-06-16
    • 2: Postive of anti-HBc
    • 3: Anemia
    • 4: Hypertension
    • 5: Hyperlipidemia
    • 6: Hypoalbuminemia
  • lab data
    • albumin
      • 2022-07-08 2.9 g/dL
      • 2022-06-21 2.8 g/dL
  • exam finding
    • 2022-10-13 2D transthoracic echocardiography
      • LVEF = (LVEDV - LVESV) / LVEDV = (34 - 14) / 34 = 58.82%
        • M-mode (Teichholz) = 58
      • Adequate LV systolic function with normal resting wall motion
      • Septal hypertrophy
      • Trivial MR, trivial AR and mild TR and trivial PR
      • Mild to moderate pulmonary hypertension
      • Preserved RV systolic function
      • Tachycardia with E/A fusion at the exam.
    • 2022-10-12 KUB
      • marginal spurs of multiple vertebral bodies due to spondylosis.
      • Atherosclerosis of abdominal aorta and bilateral common and external iliac arteries.
      • Abdominal ascites
      • interrupted lower body of gastric air column and scanty colonic air
      • Normal shape and size of kidneys and spleen.
      • Normal appearance of psoas shadows
    • 2022-10-12 CXR
      • Thoracic aortic arch calcified atheriosclerotic plaque
      • Fullness and increased density of Rt infrhilum hila may be due to lymphadenopathy
      • Normal heart size
      • Costophrenic angles are preserved
    • 2022-10-12 ECG
      • Sinus tachycardia
      • Low voltage QRS
      • Borderline ECG
    • 2022-09-16 CT - abdomen
      • Findings:
        • There are several newly-developed poor enhancing masses on both hepatic lobes that are c/w liver metastases.
          • The largest one measuring 4.3 cm in S3.
        • There is mild ascites and soft tissue nodules in the omentum that may be carcinomatosis.
        • Prior CT identified gastric wall thickening is noted again, mild increasing in wall thickness.
        • Prior CT identified multiple metastatic nodes in the gastrohepatic ligament, hepatoduodenal ligament, celiac trunk, para-aortic space and para-cava space are noted again, mild increasing in size.
        • There is no focal lesion in both lung.
          • There are several enlarged nodes in paratracheal space.
        • Few gallstones are noted and the largest one 1.6 cm.
        • There is no focal abnormality in the biliary system, pancreas, spleen & both kidney.
          • There is no bowel wall thickening, and no bowel obstruction.
          • The abdominal aorta and IVC are grossly unremarkable.
          • There is no evidence of intrinsic or extrinsic bladder mass.
      • Impression:
        • Multiple liver metastases.
        • Carcinomatosis is highly suspected.
    • 2022-06-16 Body fluid cytology - ascites
      • 20 cc dark-brown turbid ascites — Atypia
      • The smears show lymphocytes, reactive mesothelial cells and few atypical cells show enlarged and hypochromatic nuclei with degenerative quality. Follow up.
    • 2022-06-15 Upper GI series
      • The contrast medium passage from oral cavity through esophagus to stomach smoothly without obstruction.
      • Normal contour and mucosal pattern of the esophagus. S/P NG tube indwelling.
      • Distention of stomach suspected outlet obstruction.
    • 2022-06-13 Patho - stomach biopsy
      • Stomach, antrum, biopsy — Adenocarcinoma.
      • IHC stains: CK highlights neoplastic cells. Her2/neu: negative (score=0).
      • Section shows fragments of gastric tissue infiltrated by irregular neoplastic glands.
    • 2022-06-11 CT - abdomen, pelvis
      • Imaging Report Form for Gastric Carcinoma
      • Impression (Imaging stage): T3N3M1, stage IVB
    • 2022-06-11 Esophagogastroduodenoscopy, EGD
      • Diagnosis
        • Highly suspected gastric cancer, Borrmann classification type III, with suspected gastric outlet obstruction, s/p biopsy.
        • Reflux esophagitis LA Classification grade D
        • Incomplete study due to much coffee ground content and food retention in stomach and gastric outlet obstruction
      • Suggestion
        • PPI Q12H IV
    • 2022-06-10 ECG
      • Sinus tachycardia
      • Nonspecific ST abnormality
      • Abnormal ECG
  • consultation
    • 2022-06-13 General and Gastrointestinal Surgery
      • Q
        • This is a 67-year-old male with hx of HTN.
        • This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0 -> 8.4 g/dL with f/u Hb: 6.9 -> 7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1 (lack of detailed description of metastasis).
        • Under the impression of Suspect gastric cancer, so he was admitted for urther evaluation and management.
        • We need your expertise for further evaluation for the patient’s condition of gastric cancer, and outlet obstruction, and future feeding method.
      • A
        • S: A 67-year-old male with hx of HTN. This time, he suffered from vomiting with black vomitus, dizziness, and tarry stool for 2 days. Body weight loss ~15kg in 1-2 month was noted. He was brought to our ER for help. At ER, the vital signs were generally normal with tachycardia (HR 129bpm) with BP 117/58mmHg. Lab study found Hb: 5.0g/dL, with stool OB: 2+, emergent blood transfuion with LPRBC 4U was given, and anemia improved (Hb: 5.0–>8.4 g/dL with f/u Hb: 6.9->7.6). Abdome CT showed gastric cancer with gastric outlet obstruction cstage: T3 N3b M1(lack of detailed description of metastasis). Surgical evaluation is consulted.
        • O: vital signs: stable, no fever
          • abdomen: soft, ovoid, decrease bowel sound, mild epigastric pain, no Murphy’s sign
          • lab data: see chart
        • A: gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
        • P: Suggest neoadjuvant chemotherapy for down staging first.
          • If gastric outlet obstruction related poor oral intake and malnutrition is noted, laparoscopic gastrojejunostomy may be considered.
    • 2022-06-16 Hemato-Oncology
      • Q
        • This is a 67 year-old male who has the history of hypertension with medication control. This time, he suffered from vomiting with black vomitus, dizziness, and Tarry stool for 2 days. Body weight loss ~15kg in 1-2 month, so he was brought to our ER for help. Under the impression of gastric cancer, he was transfer to GS for surgery of gastrojejunostomy on 2022/06/16. We need your help for neoadjuvant chemotherapy. Thank you so much!!
      • Q
        • Impression:
          • Suspect gastric cancer with gastric outlet obstruction cstage: T3 N3b M1, stage IV
        • Suggestion
            1. Pending pathology, if confirm gastric cancer, we will discuss with patient about neoadjuvant chemotherapy for down staging.
            1. Check anti Hbc, HbsAg, Anti HCV
        • s/p gastrojejunostomy on 2022/06/16.
        • Medical advice:
          • It will be possible to be cured only in the patient whose gastric cancer is amenable to total surgical resection (R0 resection). The local advanced gastric CA wt gastric outlet obstruction of this pt is deemed not operably subjected to total surgical resection.
          • Pre-Op neoadjuvant C/T is indicated.
            • Pre-Op neoadjuvant C/T regimen may be: Oxaliplatin / HDFL or 5-FU / LV / Oxaliplatin / Docetaxel ( FLOT ) IV Q2W x 3~4 cycles beofore / after Op.
          • If gastric tumor bleeding persists, may consider R/T to gastric tumor to cease bleeding.
  • surgical operation
    • 2022-06-16
      • Surgery
          1. Laparoscopic gastrojejunostomy
          1. Port-A insertion, L’t after L’t cephalic vein exploration        
        • Post-OP Dx: gastric antrum Ca, cT3N3M1, stage IV, ECOG 1    
      • Finding
          1. We explore and identify the L’t cephaic vein & use cutdown method to insert the 7 Fr cathter into it. We also use intra-operative EKG to check its position.        
          1. Hypertorphy and distension of stomach.
          1. No visible peritoneal wall tumor and enlarged lymph node was noted. We collect ascites for cytology.
          1. Gastric juice 2750 ml was decompressed.
  • chemoimmunotherapy
    • 2022-07-08 ~ undergoing - FOLFOX

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2022-10-14

  • 2022-10-13 2D transthoracic echocardiography showed adequate LV systolic function with normal resting wall motion and preserved RV systolic function.
  • It is possible that the rising levels of hs-Troponin I (366.4 <- 226.8 <- 134.4) are related to sepsis. The infection is currently being managed with tapimycin (piperacillin + tazobactam).

2022-07-11

  • This patient is taking two antiplatelet agents: aspirin, cilostazol (antiplatelet agent; phosphodiesterase-3 enzyme inhibitor; vasodilator); four antihypertensives: amlodipine (antianginal agent; antihypertensive; calcium channel blocker), indapamide (thiazide diurectic), spironolactone (antihypertensive; potassium sparing diurectic; mineralocorticoid (aldosterone) receptor antagonists), ramipril (angiotensin-converting enzyme (ACE) inhibitor; antihypertensive).
  • It was reported that salicylates and/or thiazides could enhance the nephrotoxic effect of angiotensin-converting enzyme inhibitors, and potassium-sparing diuretics may enhance the hyperkalemic effect of angiotensin-converting enzyme inhibitors. According to lab data on 2022-07-08, renal function and serum potassium were normal.
  • Since the afternoon of 2022-07-09, blood pressure readings have returned to normal, and no tachycardia has been observed since 2022-07-10. TPR and BP are stable currently.
  • Crestor (rosuvastatin calcium 10mg) QD might be an option if hyperlipidemia is still a medical problem.